allergies: penicillins / tegretol / spironolactone attending: chief complaint: fever reason for micu transfer: ams major surgical or invasive procedure: cvvhd history of present illness: this is a 72 year-old male with pmh of diastolic heart failure with an ef=65%, as s/p mechanical avr, af on coumadin, cad s/p cabg, pulmonary hypertension, 3rd degree heart block s/p ppm, severe copd, with recent prolonged hospitalization for mrsa bacteremia who was sent in from clinic with fevers. his most recent medical course dates back to / when the patient was admitted with mrsa bacteremia secondary to a picc line. hospital course complicated by left prostethic hip seeding requiring or washout and prolonged post-op course of intubation that was complicated by several infections: pseudomonal pneumonia +/- upper resp tract infection; prevotella bacteremia; and tunneling sacral wound. hospital course also c/b arf with cr peaking at 3.9. eventually the patient was extubated and d/ced to ltac with plan to continue vancomycin iv x 6weeks and then a prolonged oral course of antibiotics. rehab course was c/b worsening l hip pain with evidence of dislocation on an x-ray taken at his ltac. he was hospitalized again briefly for relocation of hip with recommendations to continue an abduction pillow between his legs until his follow up appointment on . the patient was at a routine follow up appointment at clinic when found to have fever, tachypnea and ams. per id fellow, vancomycin should be changed to linezolid with addition of colisitin and doripenem. in the ed, initial vs 100.5 hr:88 bp:115/44 resp:24 o(2)sat:98. cxr showed volume overload and worsening b/l patchy infiltrates c/w volume overload vs. infection. past medical history: -cad s/p 2v cabg -htn -hld -severe diastolic chf (ef >60% ) -pulmonary hypertension -a fib on coumadin -hx of 3rd degree block s/p ppm, currently v-paced -hx of as s/p avr with mechanical valve () -copd -hx of cva c/b seizure do, on lamictal -diet-controlled dm -chronic kidney injury -chronic lethargy and confusion with concern for dementia -focal disection of abd aorta - noted ct abdomen - unchanged from -bph (no difficulty voiding) -s/p l orif and thr social history: prior to admission he lived with wife and youngest son, , in a two story home. he is a retired newpaper journalist and english professor; he moved to the u.s.a. in , but returned to to work. he returned here permanently in . he does not currently smoke, but quit 10 years ago with an 80 pack year history. family history: per omr. there is a family history of cad. all sisters and brothers are deceased. physical exam: physical exam on arrival to : temp: 98.9 bp: 102/44 hr: 81 rr:29 o2sat 99% gen: cachectic, heent: perrl, eomi, anicteric, very drymm, poor dentition, no supraclavicular or cervical lymphadenopathy, neck vein engorged but flatten with inspiration, resp: no accessory muscle use, mildly tachypneic, good air movement throughout, rhonchi laterally at r base cv: mechanical heart sounds, regular rate, no m/r/g abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: warm, no clubbing or edema skin: tunneling sacral ulcer, venous stasis changes on bilateral distal legs neuro: drowsy, arousable to verbal stimuli, follows commands slowly, inattentive, is oriented to person and hospital, cn ii-xii intact. 5/5 strength throughout. no sensory deficits to light touch appreciated. no pass-pointing on finger to nose. 2+dtr's-patellar and biceps rectal: guaiac negative pertinent results: 06:20pm blood wbc-10.8 rbc-2.40* hgb-7.0* hct-22.7* mcv-95 mch-29.3 mchc-31.0 rdw-19.7* plt ct-324 06:20pm blood neuts-85.5* lymphs-8.5* monos-3.7 eos-2.0 baso-0.3 06:20pm blood pt-18.4* ptt-64.5* inr(pt)-1.7* 06:20pm blood glucose-165* urean-86* creat-2.6* na-143 k-5.3* cl-102 hco3-31 angap-15 06:20pm blood alt-23 ast-47* alkphos-176* totbili-1.1 06:20pm blood lipase-69* 06:20pm blood ctropnt-1.58* 03:26am blood ck(cpk)-36* 03:26am blood ck-mb-3 ctropnt-1.63* 04:49pm blood ck(cpk)-34* 04:49pm blood ck-mb-4 ctropnt-1.67* 06:20pm blood calcium-9.2 phos-3.4 mg-2.9* 07:04pm blood type-art po2-65* pco2-38 ph-7.53* caltco2-33* base xs-8 06:41pm blood lactate-2.2* k-5.3 07:04pm blood lactate-1.5 06:20pm urine color-straw appear-clear sp -1.008 06:20pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-neg 06:20pm urine rbc-0 wbc-0 bacteri-none yeast-none epi-0-2 ============= microbiology ============= - blood cx - urine cx: negative - urine legionella: negative ============= imaging ============= - cxr: semi-upright ap view of the chest: the patient is status post median sternotomy and aortic valve repair. left-sided single-lead pacemaker device is noted with lead terminating in the region of the right ventricle. a left picc tip terminates within the left distal subclavian/brachiocephalic vein. the heart remains moderately enlarged. worsening perihilar opacities with vascular indistinctness is again noted compatible with congestive heart failure, moderate in severity. worsening bibasilar opacities are also noted with small bilateral pleural effusions. no pneumothorax is present. there are no acute osseous findings. impression: 1. worsening congestive heart failure. 2. worsening bibasilar airspace opacities which may reflect atelectasis but infection is not excluded. 3. small bilateral pleural effusions. 4. left picc tip terminates within the distal left subclavian/proximal brachiocephalic vein, unchanged. brief hospital course: 72 year-old male with pmh of diastolic heart failure with an ef=65%, as s/p mechanical avr, af on coumadin, cad s/p cabg, pulmonary hypertension, 3rd degree heart block s/p ppm, severe copd, recent mrsa bacteremia, prolonged post-surgical intubation presents after recent discharge with persistent fevers and altered mental status. he was admitted to the icu for these symptoms. his heart failure continued to worsen while in the icu, and he began to undergo multiorgan failure. as his condition was refractory to treatment, his family decided to place mr. on a morphine drip. he expired on the morning of . medications on admission: patient expired discharge medications: patient expired discharge disposition: expired discharge diagnosis: patient expired discharge condition: patient expired discharge instructions: patient expired followup instructions: patient expired Procedure: Hemodialysis Venous catheterization for renal dialysis Infusion of drotrecogin alfa (activated) Diagnoses: Pneumonia, organism unspecified Acidosis Anemia, unspecified Unspecified pleural effusion Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute and subacute necrosis of liver Acute kidney failure, unspecified Unspecified septicemia Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Acute on chronic diastolic heart failure Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Other chronic pulmonary heart diseases Sepsis Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Heart valve replaced by other means Other late effects of cerebrovascular disease Long-term (current) use of anticoagulants Pressure ulcer, lower back Epilepsy, unspecified, without mention of intractable epilepsy Do not resuscitate status Abdominal aneurysm without mention of rupture Other alteration of consciousness Pressure ulcer, stage IV