History of present illness; Bana is a 73-year-old lady with an history of severe pulmonary AS with moderate PULMONARY HTN POST TAVI. She has also experienced a CVA-MINOR STROKE, COPD requiring home O2, ESRD (hypertensive nephropathy) and has been in hemodialysis though right perm cath started 16/3/2016.She underwent PD insertion on 9th of May, 2016.
Past medical history; In the past, she has also experienced Anemia and Aortic stenosis. Bana has gone through a number of other complications in the past. These include being at risk of falls, chronic kidney disease, stage 5 Cough, Dyslipidemia Hematoma HTN [Hypertension] Hyperkalemia and Hypertension Oliguria Historical
Medication; Earlier on, had no active inpatient medications. However at home she has been using amLODIPine, 5 mg, Oral, Daily aspirin, 81 mg, Oral, Daily calcium carbonate, 600 mg, Oral, BID ciprofloxacin, 250 mg, Oral, BID Furosemide 40mg TAB, 40 mg, 1 tab(s), Oral, BID, 2 refills lactulose, 20 gm, 30 mL, Oral, HS Lasix, 40 mg, Oral, BID Lipitor, 40 mg, Oral, Daily pantoprazole, 40 mg, Oral, Daily Refresh P.M. Eye Ointment, 1 app, Eye-Both, HS Refresh Plus, 1 drop(s), Eye-Both, q8hr sevelamer, 800 mg, Oral, TIDWM Vitamin B Complex oral tablet, and 1 tab(s).She started perm cath 16/3/2016.She also underwent PD insertion on 9th of May , 2016.She has been doing peritoneal dialysis at home. She also received Cipro 250 mg BD for 2 weeks and completed it 2 weeks ago. Also, currently she uses inpatient medication. These includeaspirin, 81 mg, 1 tab(s), Oral, Daily calcium carbonate, 600 mg, 1 tab(s), Oral, BID cefTAZidime ciprofloxacin, 250 mg, 1 tab(s), Oral, BID heparin, 5000 unit(s), 0.2 mL, Subcutaneous, q12hr Lasix, 40 mg, 1 tab(s), Oral, BID Lipitor, 40 mg, 1 tab(s), Oral, Daily multivitamin, 1 tab, Oral, Daily pantoprazole, 40 mg, 1 tab(s), Oral, Daily Refresh P.M.Eye Ointment, 1 app, Eye-Both, HS Refresh Plus, 1 drop(s), Eye-Both and q8hr
Review of system;
The earliest review indicated discoloration with foul smelling discharge around PD catheter site Physical Exam.
The patient showed signs of improvement and did not complain much. However, on 05/02/2017, the patient experienced various forms challenges such as that of PD cath site infection:
No fever, Lecucytosis, abd pain.
Ex: discoloration of the skin surrounding the PD cath exite site, could be granulatio tissue. No d/c, no tenderness, no hotness. Abd soft, not tender.
This shows that she is progressing well although with a number of challenges.
Physical examination;
On the 9th May of 2016, Bana examined thoroughly again to determine how to best deal with her conditions.
Vitals & Measurements were conducted on her on 9/05/2017 and provided the data shown below;
T: 36.6 0C (Axillary) TMAX: 36.7 0C (Oral) RR: 20 BP: 116 / 43 SpO2: 96% vitally stable, afebrile
abdomen soft and last
no signs of local infection
The lab results
The results obtained and organized in tables as shown below
The above results also indicate the specific dates in which they were obtained.
Assessment
The patient was found to be not responding well to the antibiotics. The data below obtained shows this;
Recent Assessment Pertinent to Pain Management: Pain Assessment
Primary Pain Location: Abdomen lower 12/02/2017 10:07 Quality: Aching, Discomfort 12/02/2017 10:07
Preferred Pain Tool: Numeric rating scale 19/02/2017 05:00
Acceptable Pain at Rest, Numeric: 0 = No pain 18/02/2017 16:24
Acceptable Pain with Activity, Numeric: 0 = No pain 18/02/2017 16:24
Numeric Rating Score Rest: 0 18/02/2017 16:24
Numeric Rating Score, Activity: 0 18/02/2017 16:24
The plan
As suggested by the hospital, there was to be a medical administration follow up. This is shown by the report below;
Result type:Medication Administration Follow Up-Text
Result date:19 February, 2017 22:00 AST
Result status:Auth (Verified)
Result title:Medication Administration Follow Up
Performed by:Constantino, Florence Kamil on 19 February, 2017 22:07 AST
Verified by:Constantino, Florence Kamil on 19 February, 2017 22:07 AST
Encounter info:02489142, KKUH, Inpatient, 02/02/2017 -
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