ࡱ>  ^Cbjbj >bb;/~ ~ NN8t^2CkvD%$BBBBBBB,EHBII"kIIB"NNWB"""IrN8B"IB""<>̿S Z}=BC02C=:NI"NI4>">IIIBB"III2CNIIIIIIIIII~ :    Weekly ACNP Clinical Log CLINICAL FACULTY: Sheri Elam Student: Laura J LangenhopCourse / Quarter / Year: Spring 2015Clinical Site: The Christ Hospital Preceptor: Anne PattenWk __5_Each week, complete this document For each date, make an entry for every patient you see. There may be multiple entries for the same patient, i.e., a long-term patient in your caseload would be listed again for each date. Under comments, list any procedures performed, or other pertinent information.DateDiagnosisFMAgeComments / ActivitiesE/M Code12/1682 y.o. female who presents from the office with increased edema and weight gain. She is an 82-year-old female with a history of chronic diastolic heart failure, ejection fraction 55% to 60%, stage III kidney disease, status post pacemaker, hypothyroidism. She was admitted to the hospital with increased shortness of breath and bilateral swelling and weight gain of 11 pounds in the last 3 days, and she was admitted for management of heart failure. Her weight on admission was 201. Her weight from discharge from the hospital last month was 192. She received Lasix, but she did not have a good response, so she was started on ultrafiltration. She had a 9-pound weight loss, but she also had a bump in her creatinine, and so that was stopped after 24-48 hours. She had a right heart cath done this hospitalization which showed a right atrial pressure of 9, RV pressure 48/310, pulmonary artery pressure of 49/20/32, pulmonary capillary wedge pressure of 13. She had a cardiac index by Fick of 2.1. She states that since she has been home she has had increased SOB and edema. She also reports weight gain. She also noted to have acute left arm swelling overnight. She denies any chest pain or palpitations. She denies and syncope but does report generalized weaknessx82Increase Lasix/diuril gtt to 10 mL/hr. Lamba-Light chain blood work pending. Patient on for right heart catheterization with biopsy tomorrow at 1300 with Dr. Kong. Leave in Quad-lumen IJ for possible ultrafiltration. Patient not on BB for diastolic dysfunction/RV dysfunction. Patient not on ACE/ARB given renal insufficiency. Daily weights. Monitor I/O Q4 hours. Light chain/Lambda blood work pending. 22/17Patient is a 64 yo caucasian male with systolic heart failure (25-30%), heart failure with reduced ejection fraction, CAD, s/p 4 stents with the most recent BMS to RCA in 2013, new found A-FLutter-rate controlled, HTN, DM type 2, Diffuse Large B-Cell Stage 4 Lymphoma with liver and spleen involvement (Remission since 2012), s/p 8 cycles of RCHOP therapy for lymphoma which included Adriamycin, Thrombocytopenia of unknown etiology, CKD, s/p dialysis in 2011 following chemotherapy, and OSA. The patient was admitted from the office today with increased shortness of breath and abdominal swelling. The patient states that over the past few months he has become more short of breath on exertion and required oral lasix as needed at home. The patient denies chest pain, discomfort, N/V/D, syncope, or headache. The patient has noticed increased lower extremity swelling and he states his abdomen has increased in size over the last couple of weeks. The patient states that his "dry weight" for him is in the mid 220s and he weighed himself this morning and he was 237 lbs. Last week, the patient stated he felt more weak, had dyspnea on exertion, and has had orthopnea. The patient had a right and left heart catheterization on 2/13/2015 that revealed increased filling pressures (RA 15, RV 41/17/17, PA 52/38/45, Wedge 34, CO 4.4, CI 2.0) with 50% mid-instent stenosis of the LAD, 40% proximal Circumflex obstruction, and patent RCA with mid 30% obstruction. The patient was also found to be in A-flutter which is new. Xarelto was ordered on Friday, but the patient needed prior authorization for the medication so the medication was not started. The patient was discharged to home to start oral lasix, which the patient had not started until yesterday. Echocardiogram from 2/11/2015 showed an EF of 25-30% with g4dd, moderate MR, dilated right and left atrium, PA peak pressure 47, and Right to Left shunting across the atrial septum. Significant Laboratory Work today: INR 6.3, BUN/Cr 26/1.69, Mg 1.3, HgA1c was 8.7, AST/ATL 38/36, Total Billirubin 1.9, Direct Billirubin 0.9, Alkaline Phos 148, TSH 1.41, BNP 1150.X64Diuresis stopped r/t 14 lb weight loss in one day with diuresis. Patient euvolemic. Placed on schedule for TEE with cardioversion. 32/17Patient is a 52 y.o. female with PMH of non-ischemic cardiomyopathy with an ejection fraction of 35%, left bundle branch block, non-obstructive coronary artery disease, and morbid obesity. She presents to the ED with complaints of shortness of breath that started over the last couple of weeks. She gets short of breath with minimal exertion. She is orthopneic. She states that her weight has increased since her office visit two weeks ago. She denies chest pain, cough, fever, or chills. No nausea, vomiting, or diarrhea. She quit smoking 3 years ago. Per ED RN, she has not been taking her medications recently. Upon arrival to ED, SpO2 84% on room air. BP 184/112. BNP 642. She has diuresed 3.5 liters with one dose of lasix 80 mg.X52Continue Lasix gtt @ 5mg/hr. Continue Diamox Q8 hours for metabolic alkalosis. Patient started on low dose Coreg today and increased Spirolactone to 50 mg PO daily. IV atbs. Changed to PO levaquin. MIC <0.5. Continue for 7 days. Consult wound care RN for dressing.42/17Patient is a 62 y.o. male with a history of CAD,s/p 3V CABG in 2007, systolic heart failure EF 25-30%, AFIB, BIV-ICD (medtronic), DM type 2, s/p repair of femoral pseudoaneurysm in 2007, COPD, and CKD. Pt was transferred from Good Sam Hospital for CHF. The patient was admitted to Good Samaritan Hospital on 2/10/15 with complaints of shortness of breath that had started the week prior to admission. The patient was found to be hypotensive and was placed on Levophed and eventually was changed to Dobutamine. The patient was also diuresed with IV lasix. The patient was transferred to the Christ Hospital today for further medical management. The patient complains of shortness of breath on exertion and orthopnea. Denies chest pain, syncope, dizziness, N/V/D, fevers, or chills. The patient has noticed his lower extremities to have more swelling. The patient is a past smoker, but currently denies use. The patient also drinks a 6-pack of beer on the weekend per his report. The patient states he follows a low-salt diet at home. The patient states his "dry weight" is 173 lbs. Today, the patient's weight was 161 lb. Laboratory work of significance from GSH today reveals: BUN 66/Cr 1.85 (normal ~1.4 to1.7), WBC 20.1, H/H 10.5/33, Mg 1.7. The patient is V-paced on the monitor with a HR of 88. Patient had an echocardiogram 2/10/15 which showed EF 20-25%, mod TR, mod MR. Last known Left heart Catheterization in 2013: Severe triple vessel CAD Patent SVG to OM and LIMA to Apical LAD, SVG RCA 100% Consider PCI of the LAD with Impella and Rotablator once his HF is well treated. LEFT MAIN: Normal LAD 80% ostial 100% distal LX: 99% mid RCA 70% mid 95% distal LVEF: 30%X6280 MG IV Lasix bid. Dobutamine gtt continued from outside hospital @ 2.5 mcg/kg/min. Right heart catheterization in the AM. Interrogate BIV-ICD for ?underlying arrhythmia. 52/19Patient is a 60 yo Caucasian male with past medical history of CAD,severe end stage SHF, ICM EF 30-35%, MR/TR, PAF, s/p BiV ICD (Medtronic upgrade 2007), Fe deficiency anemia, protein malnutrition, hyponatremia, h/o VT on Sotalol who presents As pre-op LVAD from the Cath Lab where he underwent RHC. RHC pressures revealed RA 11, RV 49/8, PAOP 46/23, MN of 32; CI 2.0/1.9. He was recently admitted in October for acute left ventricular systolic failure. At that time he was started on MIlrinone 10/11/14. He was also diuresed, received two doses of Tolvaptan, and Venofer for Iron Deficiency anemia. During the admission he underwent EGD/colonoscopy. He was found to have hiatal hernia, antral gastritis, colon polyp s/p snare caudery removal, and sigmoid diverticulosis. On 10/17, he had BRBPR, which by colonoscopy appeared to be post-polypectomy bleeding likely from distal sigmoid colon. Hemoclips were placed at the site. The patient was implanted with a heartware on 1/28. The patients post-operative course has been complicated with right ventricular failure, volume overload, and right lower lobe pleural effusion.x60Continue hydralazine for afterload reduction. Continue Sildenafil for right-sided failure/pulmonary HTN. 40 mg po Lasix BID. I/O Q4 hours. Daily weights. Send UC/UA. Blood cultures negative. CBC daily. Temperature Q4. Patient on Day 6/7 of Levaquin and Rocephin for broad-spectrum coverage. ID consulted. Continue IV venofer daily (200 mg x5 days for a total of 1 gram). Monitor CBC daily. Tranafuse for Hgb <7 g/dL Check tool occult. Consult GI if occult is positive. Colchicine added for gout/high uric acid level. 62/19The patient is a 69 African American male with a history of systolic heart failure (15-20%), Non-ischemic cardiomyopathy, HTN, Renal Insufficiency (baseline Cr. 1.4-1.6), HLD, DM type 2 that was admitted today with shortness of breath. The patient was recently admitted in October for similar complaints. The patient had a right and left heart catheterization revealing high filling pressures. The patient was diuresed to a weight of 222 lb. during admission and given prescriptions for medications and discharged on 10/8/2014. The patient never filled the prescriptions and did not attend his follow-up appointment. Today, the patient was admitted after experiencing shortness of breath, abdominal tightness, and lower extremity swelling that started over the last couple of weeks. The patient has orthopnea and is dyspneic on exertion. The patient also complains of abdominal swelling and lower extremity edema with his left leg being more swollen, painful, and with open weeping ulcers. The patient denies chest pain, syncope, N/V/D, fever, chills, or palpitations. The patient states he does not exercise at all and hardly ambulates, but says "I probably can walk now that you gave me that lasix." BNP on admission was 719. Last echocardiogram was on 10/15/14 with an EF of 15-20%. The patient is in sinus tachycardia with a HR of 115, BP 123/93. Creatinine on admission was 1.55 (this is patient's baseline). H/H 19.8/62. WBC 11.9. Chest x-ray with cardiomegaly. The patient was given 60 mg IV lasix in the ED. x69Lasix gtt started @ 10 mg/hr. Endocrine consulted for diabetes management. Blood cultures/urine cultures/left leg wound cultures sent for elevated WBC. 72/20 Same as above. x69Increase Lasix gtt to 20 mg/hr for diuresis. Spirolactone added. ACE to be added tomorrow. 82/20Patient is a 62 y.o. male with a history of CAD,s/p 3V CABG in 2007, systolic heart failure EF 25-30%, AFIB, BIV-ICD (medtronic), DM type 2, s/p repair of femoral pseudoaneurysm in 2007, COPD, and CKD. Pt was transferred from Good Sam Hospital for CHF. The patient was admitted to Good Samaritan Hospital on 2/10/15 with complaints of shortness of breath that had started the week prior to admission. The patient was found to be hypotensive and was placed on Levophed and eventually was changed to Dobutamine. The patient was also diuresed with IV lasix. The patient was transferred to the Christ Hospital today for further medical management. The patient complains of shortness of breath on exertion and orthopnea. Denies chest pain, syncope, dizziness, N/V/D, fevers, or chills. The patient has noticed his lower extremities to have more swelling. The patient is a past smoker, but currently denies use. The patient also drinks a 6-pack of beer on the weekend per his report. The patient states he follows a low-salt diet at home. The patient states his "dry weight" is 173 lbs. Today, the patient's weight was 161 lb. Laboratory work of significance from GSH today reveals: BUN 66/Cr 1.85 (normal ~1.4 to1.7), WBC 20.1, H/H 10.5/33, Mg 1.7. The patient is V-paced on the monitor with a HR of 88. Patient had an echocardiogram 2/10/15 which showed EF 20-25%, mod TR, mod MR. x62Start IV Lasix gtt @ 10 mg/hr. Increase Dobutamine @ 5 mcg/kg/min for hypotension/cardiac output. Check renal panel daily. Daily weights. I/O Q4 hours. Continue conversation regarding VAD or transplant work-up. Left heart catheterization planned for Monday. 92/20This is a 51 yo male admitted in 2/18 for depression and suicidal ideations. The patient has a history of ischemic cardiomyopathy, HTN, CAD, DM, COPD, and depression. The patient was last admitted to the hospital in December for congestive heart failure. IV Lasix was given and the patient was discharged with a dry weight of 244 lbs. The heart failure team was consulted with the management of the patients cardiovascular medication regimen. The patient denies shortness of breath at rest or on exertion, chest pain or discomfort, N/V/D/, syncope, headache, dizziness, or palpitations. The patient does state he thinks his legs are a little more swollen than two days ago. The patients home medications were started yesterday and the patient states he is voiding well. The patients weight today is 248 lbs, down from 252 lbs yesterday. BNP on admission was 209. BUN/Cr 28/1.01. Chest xray on admission was negative for acute disease.x51Continue Home medications. Coreg 6.25 mg PO bid, 40 mg Lasix PO bid, Imdur 30 mg PO daily, Lisinopril 10 mg daily, Spirolactone 25 mg daily. Place on cardiac diet. Plan to see EP on discharge for BIV-ICD discussion. OK to discharge from cardiology stand-point. 101112131415 In what ways did you feel confident about your abilities this week in clinicals? Again, it is becoming more and more easier to make plans for the patient. In what areas did you feel weakest during this week of clinicals? There was a patient I was taking care of that was on the fence about having a an open heart procedure and going the route of palliative care. Though I was able to talk through this with the patient and the patients wife I dont think I exuded confidence in this kind of talk. Since I am not used to being on the end of giving the end of life talk it didnt flow and freely as what I would like it to have. List one new skill or piece of knowledge that you learned this week. I think I have stated this before, but communication is so very important when taking care of patients. I think so many times people take the short cut in giving information in what they think is explaining when the patient doesnt comprehend and then doesnt follow/adhere to the plan you set forth for them. Taking the time and sitting down and talking with patients makes a world of difference. List clinical goals for next week. Finish the last week of clinical (ever!) strong. Continue to ask questions and be open to change and learning.      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