Cypress College Care Plan – Description
fill out the attachment like the example given with the information given on the patient.
DATE OF SERVICE: 6/27/2023
HOSPITAL DAY: 4
CHIEF COMPLIANT: Emesis (NV + abd distension (last paracentesis 1 week ago) + oozing abscess to R hip x approx 6 days. Hx: Mucinous
adenocarcinoma, not on chemo currently. )
Last 24 Hour/Overnight Events:
6/23/2022: Admitted (see H&P) with pertinent findings of AKI with hyperkalemia, hyponatremia, leukocytosis, and ascites noticed on physical
exam.
6/24/2022: No acute events overnight. Hyperkalemia, hyponatremia and leukocytosis resolving.
6/25/2022: Patient had referred back pain secondary to ascites overnight that responded well with lidocaine patches, IV tylenol and q3h dilaudid.
No other acute events overnight
6/26/23: Worsening hypoNa, rising BUN/Cr, pH 7.16 (metabolic). Mentation intact. Considering HD + para today.
6/27/23: Received HD at approximately 2100 on 6/26 with net negative 2L. Improvement post HD of patient’s electrolyte derangements. Continues
to have increases abdominal distention and discomfort. Plan for paracentesis on 6/27 with IR.
Subjective/Review of Systems:
Patient continues to have abdominal distension, discomfort and nausea. Has poor PO intake secondary to her nausea. No cough, fever, dysuria.
Continues to mentate well and answer all questions appropriately.
Temp: [36 °C (96.8 °F)-36.9 °C (98.4 °F)] 36.7 °C (98 °F)
Heart Rate: [77-105) 82
Resp: [16-181 16
BP: (70-118)(51-83) 109/66
NBP Mean: (64-85) 74
SpO2: [95 %-97 %] 95 %
V/O: I/O last 2 completed shifts:
1541 40087,0 6 9 91072 92 1067 9809795,1001
GENERAL: Resting in bed in no acute distress
HEENT: NCAT. EOMI.
PULM: CTAB. normal work of breathing
CV: RRR. Normal S1, S2 without murmurs, rubs, or gallops. No JVD or pedal edema.
ABD: No rebound tenderness. Mild diffuse tenderness to palpitation. More distended than 6/25 exam
EXTR: Warm and well perfused
NEURO: Grossly intact.
a 56 y.o female mucinous Adenocarcinoma of the appendix sp Folfox 4-11/2022 then chemoRT (2/15/23-3/27/23) with concurrent
Xeloda, hx of colocutaneous fistula s/p ileostomy 5/2022 presents w PO intolerance, found to have AKI, hyperkalemia and hyponatremia. Now status post HD
on 6/26 for worsening renal fxn.
Today:
– Paracentesis with IR
– discontinued lokelma since now HD
– continued bicitrix for acidemia
#AKI, pre-renal, c/f ATN
#Metabolic acidosis
Cr of 4 at admission from baseline 0.8 likely multifactorial, iso poor po intake/ emesis, third spacing and recent large volume ascites w possible urinary
retention. Per ED pt w500cc UP post foley placement, CT wo evidence of obstruction or hydronephrosis. Fena pre renal 0.2%. Ordered urine and serum osm
on 6/24 which was consistent with intravascular hypovolemia as etiology. As patient 6/24 morning creatinine did not improve, tried one more albumin + NS
bolus to increase intravascular volume on 6/24. On 6/25 patient was more acidemic with increasing creatinine to 5, worseing hyponatremia to 124 (from high
of 132 on 6/24). Nephrology was consulted and ultimately proceeded with HD on 6/26. Of note, per nephrology recommendation, renal vein ultrasound was
ordered which was without finding of renal vein thrombosis
– bicitrix 30mg TID
– s/p lokelma
– HD per nephrology (last given on 6/26)
trend VBG
– monitor electrolytes
maintain foley (placed 6/23)
– strict 1&05
A
#Hyponatremia
Patient had sodium of 127 on admission. Trended slowly to 132 over ~21 hours. On 6/25 morning cortisol resulted wnl, indicating adrenal insufficency as not a
culprit for patient’s presentaiton of hyponatremia and hyperkalemia. On 6/24 patient’s urine and serum osm indicated hypovolemic hyponatremia. On 6/25
patient’s hyponatremia worsened from peak of 132 on 6/24 to low 124 on 6/25. Most likely due to worsening renal function. Patient continues to mentate
well.
-q8hr CMP check
HD as above
#Hyponatremia
Patient had sodium of 127 on admission. Trended slowly to 132 over ~21 hours. On 6/25 morning cortisol resulted wnl, indicating adrenal insufficency as not.
culprit for patient’s presentaiton of hyponatremia and hyperkalemia. On 6/24 patient’s urine and serum osm indicated hypovolemic hyponatremia. On 6/25
patient’s hyponatremia worsened from peak of 132 on 6/24 to low 124 on 6/25. Most likely due to worsening renal function. Patient continues to mentate
well.
-q8hr CMP check
– HD as above
#PO Intolerance
#Abdominal distension
CT AP on 6/23 without acute findings, low concern for SBO. Symptoms likely in setting of malignant ascites and peritoneal carcinomatosis. Differential diagnosis
includes SBP yet pt exam without tenderness to palpitation despite report of 10 days of abd pain. Patient had therapeutic paracentesis on 6/14 with ~6L fluid
drained. Seems like abdominal pain is likely in setting of reaccumulation of ascites. Patient endorses 5-6/10 patient and notes she normally has no pain. On
6/27, was in agreement with pleurx placement, will discuss with IR on inpatient vs outpatient pleurx placement.
Diagnostic/therapeutic para after
– Continue broad spectrum abx
Therapeutic paracentesis
– Possible pleurx placement
HIGOC
Patient is DR/DNI. Patient is okay with escalation of care to ICU If needed. Nephrology discussed HD with patient and per patient it would be within her goals
If it was thought to be a short term and reversible cause.
#Leukocytosis
Downtrending, Continue to monitor with CBC. Blood and urine cultures negative. Low concern for SBP as noted elsewhere. Wound culture shows rare GPCS.
MRSA nares negative on 6/27, discontinued vancomyocin.
– Continue z0syn (6/23-)
– S/p vanc (6/23-6/27)
fmetastatic mucinous adenocarcinoma of appendix c/b peritoneal carcinomatosis
vasciles, poa
S/p 12 cycles FOLFOX with partial response, last 11/2022 chemoRT to appendix and LNs with Xeloda, last 4/10/2023. Now w malignant ascites 1/s/0
progression of cancer.
#metastatic mucinous adenocarcinoma of appendix c/b peritoneal carcinomatosis
#ascites, poa
S/p 12 cycles FOLFOX with partial response, last 11/2022 chemoRT to appendix and LNs with Xeloda, last 4/10/2023. Now w malignant ascites I/s/o
progression of cancer.
– eval for SBP
–
– consider need for pleurx
Brief Oncologic history:
5/2022 Colocutaneous fistula s/p ileostomy.
6/6/2023 PET/CT scan: 1. No significant change in size of the FDG avid low density mass in the right lower quadrant adjacent to the cecum, with involvement
of the right iliopsoas musculature and two tracts leading into the right flank soft tissues.
2. Evidence of peritoneal carcinomatosis with moderate ascites, numerous FDG avid peritoneal implants, and omental carcinomatosis, stable from 6/1/2023,
but increased from 12/16/2023. 3. Low-density regional mesenteric lymph nodes with punctate calcifications and without FDG uptake are unchanged in size.
the abd wall fistula and freq paracenteses. An irinotecan-containing regimen would likely have the highest chances of success if chemotherapy is to work at
all. Bev would be a good option for her tumor type, but would possibly (likely?) make the fistula worse. One could also consider NGS to see if she has a KRAS
mutation. If not, one could use cetuximab along with the irinotecan as well*
6/14 US guided paracentesis w6 L removal
A
#colocutaneous fistula s/pileostomy
D/t malignancy. Output stable per patient
monitor output
#Urinary retention
Per ED MD patient had 550cc UP when foley placed. Patient denies urinary symptoms, UA does not show sign of infection.
– continue with foley can plan for voiding trial on 6/25
– strict I &0
Chronic/Stable/Resolved:
#GERD – home esomeprazole PRN
#hx microcytic anemia -ctm
#RLQ wound pain – home gabapentin 300 TID
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