allergies: no known allergies / adverse drug reactions attending: chief complaint: cp and sob major surgical or invasive procedure: none history of present illness: 41yo m w/ hx of dilated cardiomyopathy (ef 30%), htn, nstemi, and etoh and cocaine abuse presented to osh on complaining of worsening cp and sob over previous 48hrs. pt first developed substernal non-radiation cp he desribed as pressure. he developed sob several hrs after onset of cp. in ed, trop was (+)and ecg notable for no st changes with prev r-bundle. he was started on a hep ggt and pressure relieved with 1-inch nitro paste. utox (+) for benzos, cocaine. pt was admitted and treated for nstemi w/ hep drip and acute on chronic chf exacerbation with iv lasix 40 . following admission he beame increasingly confused and diaphoretic with a fever to 103.3 and was started on zosyn and switched to ceftriaxone/azithro. bc, uc, and legionella ag sent. legionella urine ag (+) and bg and uc no growth at 48hrs. on pt noted to be somulent and diaphoretic and thought to be in opioid withdrawl. given narcan with no response. he developed n/v thought to be narcain. he was treated with iv lasix as it was believed he was fluid overloaded. he continued to be tachypneic and tachycardic with hr over 200bpm and was cardioverted with 120j. it is uncertain which rhythm he was in at this time (discharge summ says afib w/ rvr but original signout says vt, nursing said svt, no ecg provided. he was intubated for airway protection and he was sedated with propofol. a cxr showed worsening b/l infiltrates. on transfer, pt continued to be febrile to 103, tachycardic and became hypotensive requiring phenylephrine. pt given 250cc ns bolus in transit. abg prior to transfer was 7.32/39.9/141/20. past medical history: 1. cardiac risk factors: (-)diabetes, (-)dyslipidemia, (+)hypertension 2. cardiac history: -cabg:n/a -percutaneous coronary interventions: neg cath -pacing/icd: n/a 3. other past medical history: htn chf substance abuse social history: pt lives alone in an apt that has been described as cluttered and dirty. he has a history of cocaine and alcohol abuse, has never smoked. see social work note. pt is presently unemployed and ma health application is in progress. he has an involved mother and sister. family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory physical exam: vs: t=102 bp=89/51 hr=117 rr=18 o2 sat= 100% general: intubated and sedated heent: et tube in place with visible blood. ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple. unable to assess jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. tachycardic with (+)s3. no murmurs, rubs. no thrills, lifts. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: cold to touch, b/l ecchymosis above ankle skin: no stasis dermatitis, ulcers, scars, or xanthomas. . exam at discharge: vitals - tm/tc:97.5/97.2 hr:90-100 bp:112-118/71-81 rr:20 02 sat: 96% ra in/out: last 24h: 2850/2258 with mult diarrhea last 8h: 122/700 weight: 89.7 (91.3) . heent: jvd at 12 cm cv: rrr, no m/r/g, distant hs resp: clear abd; soft, nt, pos bs extr: no edema and feet warm, pulses palpable pertinent results: admission labs: 12:17am blood wbc-11.7* rbc-4.11* hgb-12.4* hct-36.7* mcv-89 mch-30.2 mchc-33.8 rdw-14.2 plt ct-294 12:17am blood neuts-83* bands-6* lymphs-8* monos-3 eos-0 baso-0 atyps-0 metas-0 myelos-0 12:17am blood pt-14.2* ptt-60.4* inr(pt)-1.3* 12:17am blood glucose-123* urean-49* creat-4.7* na-135 k-4.4 cl-97 hco3-23 angap-19 12:17am blood alt-43* ast-131* ld(ldh)-580* ck(cpk)-738* alkphos-50 totbili-0.9 12:17am blood ck-mb-12* mb indx-1.6 ctropnt-0.48* 12:17am blood albumin-3.1* calcium-8.2* phos-3.9 mg-2.3 12:32am blood lactate-4.0* . discharged labs: 08:00am blood wbc-8.0 rbc-4.02* hgb-11.7* hct-35.4* mcv-88 mch-29.1 mchc-33.0 rdw-14.8 plt ct-721* 08:00am blood pt-30.8* ptt-150* inr(pt)-3.0* 08:00am blood urean-16 creat-0.9 na-140 k-3.9 cl-109* hco3-21* angap-14 05:15am blood alt-112* ast-71* alkphos-67 totbili-0.4 08:00am blood mg-2.1 cxr: : history: pneumonia and dilated cardiomyopathy, to assess for fluid overload. findings: in comparison with a series of films from and through , there has been progressive decrease in the bilateral pulmonary opacifications. the right lung is almost clear with only some mild residual medially at the base. there is some more diffuse opacification involving the mid and lower zones on the left. the findings are consistent with the clinical impression of clearing of pneumonia, though there may well have been some associated elevation of pulmonary venous pressure. . echo : the left atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity is severely dilated with severe global hypokinesis (lvef = 20-25 %). the basal lateral wall contracts best. there is visual dyssnchrony. no masses or thrombi are seen in the left ventricle. the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: marked left ventricular cavity dilation with severe global hypokinesis c/w diffuse process. mild-moderate mitral regurgitation. pulmonary artery hypertension. . ecg : sinus rhythm with borderline prolongation of the p-r interval. right axis deviation. left bundle-branch block. compared to the previous tracing of the heart rate has increased. other findings are similar. brief hospital course: 41yo m w/ hx of dilated cardiomyopathy (ef 30%), htn, nstemi, and etoh and cocaine abuse presented to osh with sob and cp,found to have legionella pna and ectopy with an episode of sustained vt and is s/p conversion. transferred to for further ep evaluation. . #septic shock: prior to transfer from osh, patinet became hypotensive and required phenylephrine on transfer. on arrival to , it was believed he was most likely in septic shock secondary to legionella pna. levophed and vasopressin were started for bp support. goal was to minimize levophed as pt was having ectopy in the hrs following transfer. he was sedated with fentenyl/versed as paramedics noted bp dropped very low with propofol prior to transfer. an ij central line, a-line and swan ganz catheter were placed. swan confirmed that shock most likely secondary to sepsis with low svr and normal co. on , pt received several fluid boluses with target cvp 8-12. bp responded with good urine output. vasopressin was discontinued and pt kept on levophed. . #atrial fibrillation: developed af/rvr concurrent with pressor therapy requiring cardioversion to nsr where he has remained. was initially started on amiodarone iv, then transitioned to 400mg po tid on but was eventually discontinued as pt developed a confluent rash on his back thought to be secondary to amio. he was started on warfarin with heparin bridge that was d/c'ed today for inr 3.0. warfarin dose was cut in half today and should be continued for the next 2-3 weeks depending on cardiology input. # legionella pna: on admission to osh, cxr was unremarkable. on the patient became febrile to 103 and cxr showed bilateral perihilar infiltrates. id consulted and recommended treating for cap with ceftriaxone/azithro. legionella urine ag sent and was subsequently (+). bc and uc were no growth at 48hrs. he was not treated for legionella prior to transfer. after transfer to , repeat urine ag confirmed legionella and he was started on levofloxacin. cxr was notable for b/l perihilar infiltrates. patient contined to be febrile w/ tmax of 104 and cooling blanket was used. he was given acetaminophen q8hrs. repeat cxrs showed worsening b/l infiltrates with no signs of fluid overload or pleural effusion. blood and urine cx on admission remained negative. # bacteremia: on , a routine blood culture from pt's l ij was found to be growing gram positive cocci in clusters and he was started on vancomycin. thought to secondary to central line infection and ij was discontinued. he remained normotensive throughout treatment. speciation and sensitivity showed coag negative staff sensitive to vancomycin but resistant to several other abx. he will continue a 2 week course of vancomycin, last day to be . picc line placed and needs to be removed after abx are finished. # acute on chronic systolic chf: patient was sob at osh and was intubated prior to transfer. he remained intubated with heavy sedation due to agitation. he passed an sbt on and was extubated. however, he became increasingly tachypneic and a abg showed primary respiratory alkolosis. pt began to decompensate and was reintubated on the morning of . tachypnea was thought to be secondary to pna and possible fluid overload. he was diuresed with lasix drip. benzos were weaned in hopes to imoprove ams. pt was extubated on without complication. he saturated well and did not require supplementory 02 for the remained of ccu admission. he was restarted on his home dose of lasix 60 mg daily and potassium supplementation and appears euvolemic with weight 89.7 kg at discharge. this should be considered his dry weight. he will need extensive teaching regarding low na foods and medication compliance. #arrhythmia: patient was originally transferred to following an episode of tachycardia at osh requiring cardioversion secondary to hemodynamic instability. folling transfer, the pt had numerous runs of nsvt. this has continued but inpproved with uptitration of metoprolol xl and potassium repletion. # nstemi: patient was found to have elevated troponins (.4)prior to transfer from osh with no ecg changes and treated for an nstemi. at , it was believed the elevated cardiac markers were most likely secondary to demand ischemia in setting of spesis with underlying cardiomyopathy. pt had reportedly had an unremarkable cath following an nstemi 4 years prior. heparin ggt was stopped and pt remained on asa. a repeat echo showed dilated cardiomyopathy with an ef of 20-25% with global lv hypokinesis. a bb and were held in setting of hemodynamics and restarted when hemodynamics improved. . #dilated cardiomyopathy: pt has a hx of dilated cardiomyopathy most likely secondary to etoh and cocaine abuse. pt did have an elevated bnp to 7,000 at osh and was treated for acute on chronic chf exacerbation prior to transfer. echo on notable for left ventricular cavity severely dilated with severe global hypokinesis (lvef = 20-25 %). he was positive 13l since admission and was diuresed when bp improved with good urine output. he was started back on home dose 60mg of lasix. he will need social work and counseling during his rehab stay and arrangement for addiction services after discharge. #: on transfer pt's cr had doubled to 4.7. feurea was <35% indicating a pre renal vs intrarenal etiology. meds were renally dosed. his renal function greatly improved over the next 48hrs with fluid boluses. pt's renal function normal at discharge. #transaminitis: thought to be secondary to either legionella vs. shock liver. lfts trended down throughout admission. #substance abuse: pt has a history of drug and etoh abuse. u tox at outside hospital was notable for postive benzos, cocaine, and marjiuana. on transfer, pt was very diaphoretic, tachycardic, with liable bp. he displayed seizure like activity (eyes rolled back with flailing of extremities, no et biting) on several occasions thought to be secondary to etoh withdrawal. activity was controlled with versed boluses. he was transitioned to po valium as versed was weaned. benzos were stopped on and pt had no further withdrawal symptoms. . #htn: bp at goal on metoprolol and . transitions of care: 2.patient needs a pcp in the area at discharge to follow inr 3.full code medications on admission: preadmission medications listed are correct and complete. information was obtained from pharmacy osh records. 1. aspirin 162 mg po daily 2. furosemide 60 mg po daily 3. metoprolol tartrate 100 mg po bid 4. potassium chloride 40 meq po daily discharge medications: 1. furosemide 60 mg po daily 2. potassium chloride 40 meq po daily duration: 24 hours hold for k > 3. losartan potassium 50 mg po daily 4. metoprolol succinate xl 200 mg po daily hold sbp < 90, hr < 60 5. warfarin 2.5 mg po daily16 6. trazodone 50 mg po hs:prn insomnia 7. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 8. diphenoxylate-atropine 1 tab po q6h:prn diarrhea 9. folic acid 1 mg po daily 10. thiamine 100 mg po daily 11. vancomycin 1250 mg iv q 8h 12. outpatient lab work please check inr at 8am on and check vanco level before fourth dose, goal level . discharge disposition: extended care facility: - discharge diagnosis: non ischemic cardiomyopathy acute on chronic systolic congestive heart failure legionella pneumonia septic shock coag neg staph bacteremia acute on chronic kidney injury atrial fibrillation with rapid ventricular response alcohol withdrawal discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you had a pneumonia that may have been caused by mold in your apartment and an infection in your blood. you recieved antibiotics for these infections but will need to receive intravenous antibiotics for the blood infection for the next 9 days. your heart is weaker now because of your substance abuse and it is very important that you refrain from alcohol or any illegal drugs from now on to let your heart recover. the infections caused an abnormal heart rhythm called atrial fibrillation that increases your risk of stroke. because of this, we have started you on a blood thinner called warfarin to prevent blood clots. you will need to have your blood levels of warfarin monitored closely by a health care provider. had too much fluid in your lungs and needed medicines to remove the extra fluid. weigh yourself every morning, call np if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. it is very important that you do not eat salt and avoid processed or prepared foods. a list of these foods was provided to you. followup instructions: department: primary care notes: please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. department: cardiac services when: monday at 10:30 am with: dr. building: sc clinical ctr campus: east best parking: garage Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Other electric countershock of heart Arterial catheterization Pulmonary artery wedge monitoring Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Alcohol abuse, unspecified Cocaine abuse, unspecified Nausea with vomiting Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Other specified cardiac dysrhythmias Alkalosis Septic shock Old myocardial infarction Diarrhea Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Alcohol withdrawal Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Cardiac rhythm regulators causing adverse effects in therapeutic use Bloodstream infection due to central venous catheter Pneumonia due to Legionnaires' disease Unspecified erythematous condition