Question Patient Initials: KH  Age: 60 Height: 65 inWeight: 67.13 kg HPIKH pr

Question Patient Initials: KH  Age: 60 Height: 65 inWeight: 67.13 kg HPIKH presented to the ED with c/o bug bite on L thigh that occurred about 10 days ago that has turned into an abscess “as big as a personal sized watermelon.” Patient also reported urinary burning, frequency, and urgency. The ED, WBC 37,000, glucose 317, bicarbonate 13, anion gap 25, large amount of acetone, HgbA1C 10.3. Patient was admitted to the hospital for evaluation and management of DKA, DVT, abscess, and UTI.Past Medical/Surgical History:Type 2 Diabetes MellitusPrevious tobacco use (1/2 pack per day)MVA 7/13/20: pain in pelvis and knees since accidentSignificant Clinical Events:8/23/20Wound culture: staph aureus, methicillin sensitiveBlood culture: no growth after 5 days (determined on 8/28/10)Urine analysis indicates infection and DKAInsulin drip for DKAIV antibiotics for UTI, multiple abscessesIV antifungals for multiple abscesses & topical antifungal for yeast infection8/24/20Deep muscle abscess extends to femur (visualized via CT)I&D done in OR discovered diffuse myositis & muscle necrosisS/p insulin drip for DKA treatmentWound nurse consult?Infectious disease consult8/26/20I&D done in OR on L thigh, R groin abscessPatient experience bleeding post-opSCD and TED hose prescribed for DVT8/28/20d/c Coumadin due to post procedure bleeding, switched to Lovenox8/29/20bleeding from wound, changed lovenox to heparinanemia due to blood loss s/p I&D, received 2 units packed RBCConstipation for 1 wk, senna, colace, lactulose8/30/20blood glucose 340-360 mg/dL all daypatient complains of recent onset visual disturbances (since hospitalization on 8/23/10)notify MD, increase levemir to 32 units dailyMD d/c IV antibiotic and heparin, change to PO antibiotics and coumadin Test/ResultAdmit8/23/20Sun8/29/20Mon8/30/20 Hemoglobin (g/dL)13.87.4L9.1L Hematocrit (%)42.221.1L25.8L RBC (M/uL)4.352.28L2.82L WBC (K/Ul)37.2H11.4H14.2H MCV (FL)97.1H92.591.7 MCH (PG)31.732.332.3 MCHC (g/dL)32.73535.2 RDW (%)15.1H15.8H15.5H PLT (K/uL)461H408428H MPV (FL)7.56.66.3 PT (Sec.)n/a9.710.0 INRn/a0.930.96 PTT (Sec.)n/a29.4 @ 060030.3 @ 140024.6 @ 060048.1 @ 1400 guaiac  negative BUN (mg/dL)157L6L Creatinine-mg/dl0.960.29L0.36L GFR AF54n/a>60 BNP277H   AGAP25.0H8.09.0 Chlroide (mmol/L)92L10298 CO2 (mmol/L)13L2425 Potassium (mmol/L)4.84.14.0 Sodium (mmol/L)130L134L132L Glucose (U/L)397H266H368H HgbA1C10.3H   UrinalysisColorYellowyellow   AppearanceClearHazy   Spec. Gravity1.002-1.0301.025   PH4.5-8.05.5   ProteinNegative200mg/dL   GLUNormal1000mg/dL   KetonesNegative>150   BloodNegative300   UrobilinogenNormal2mg/dL   Leuk EsterNegative500    Dx. Tests                        Date and Client Results   Gram Stain8/23/10 & 8/25/10 wound culture: gram positive cocci staph likeCultures/ Sensitivities8/23/10 blood culture: no growth after 5 days (8/28/10)8/23/10 wound culture of groin abscess: staph aureus, sensitive to methicillin, clindamycin, erythromycin, oxacillin, naficillin, amoxicillin, clavulanic acid, ampicillin, sulbactam, SXT, most parenteral and oral cephalosporins8/23/10 urine culture: >100,000 CFU/mL staph aureus sensitive methicillin, nitrofurantoin, oxacillin, SXT8/25/10 culture abscess L bottom: staph aureus (see above wound culture for sensitivities)TherapeuticDrug LevelsPT (9-11.5 sec) and INR (2.0-3.0) evaluate therapeutic drug levels of coumadin, PTT (60-70 sec) evaluate therapeutic levels of heparin. Dx. Tests                              Date and Client Results   CXR8/23/10 CXR: cardiac mediastinal silhouettes normal, lungs are clear. No pleural effusion or indication of CHF.CT/US/Nuc Med/ Spec Proc8/26/10 CT abdomen & pelvis without contrast: inflammatory mass-like density with subcutaneous of R groin containing central air bubbles presumably secondary to recent drainage/intervention. No well-organized fluid collection in region. Body wall and intra-abdominal edema. Few non-specific bubbles of air within lower anterior abdominal wall. Abscess in proximal L thigh and L buttock not imaged.8/26/10 CT pelvis with IV contrast: superficial L medial buttock abscess 5-6cm diameter extending inferiorly and connected to large deep muscle abscess, extends to femur measures 8x10cmCardiac monitoringMeasure and compare with report:PR interval:QRS:QT interval:P-P interval regular:R-R interval regular: MedicationsCefazolin (Ancef)2g/D5W 110mL IVPB q 8hrs infuse over 30 minClindamycin (Cleocin)900mg IVPB infuse over 30 minFluconazole (Diflucan)100mg PO Q 24hrsHeparin100 units/mL standard infusionWarfarin (Coumadin)NystatinTopicalInsulin Aspart0-14 units SQ 4 times daily ac/hsInsulin Detemir (Levemir)32 units SQ dailyPolyethylene glycol (Golytely)400mL PO one timeAcetaminophen (Tylenol)650mg PO q 4 hrs prnOxycodone (Oxycontin)5 mg PO Q 4 hrs prnMorphine (Duramorph)4mg IV Q 3hrs prnHydromorphone (Dilaudid)1mg IV Q 3hrs prnCalcium Carbonate (Tums) chewable500mg PO 3x daily prnPromethazine (Phenergan)6.25mg IV q 4hrs prnSennosides/ docusate sodium8.6mg/50mg 1 tablet PO BID prnTrazadone (Desyrel)25mg PO hs prn   Health Science Science Nursing NUR 235 Share QuestionEmailCopy link Comments (0)

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