ADMITTING DIAGNOSES
1. Right lower lobe pneumonia.
2. Chronic obstructive pulmonary disease.
3. History of congestive heart failure.
4. Atrial arrhythmia.
DISCHARGE DIAGNOSES
1. Right lower lobe pneumonia- improved.
2. Chronic obstructive pulmonary disease (COPD) - stable.
3. Congestive heart failure- stable.
4. History of atrial and ventricular arrhythmias- stable.
5. Theophylline toxicity- resolved.
6. Allergic dermatitis secondary to quinidine- resolved.
7. Quinidine toxicity- resolved.
ADMITTING HISTORY AND PHYSICAL FINDINGS
The patient is an 82-year-old who had increasing shortness of breath and weakness and weight loss, and anorexia 2-3 days prior to admission. There had been evidently no change in his medications.
PHYSICAL EXAMINATION
Revealed temperature to be 100 degrees, pulse was 88. Coronary regular rate and rhythm. Lungs clear. Extremities without edema.
LAB ON ADMISSION
CBC white count 19,800 with 73 polys, 15 bands, 12 lymphs, and hematocrit 39.8. Electrolytes were within normal limits. Chest x-ray showed some blurring of the right costophrenic angle consistent with right lower lobe pneumonia. Further labs showed a digoxin level of 1.2, theophylline level of 30.4, quinidine level of 6.0.
HOSPITAL COURSE
Patient was admitted to the medical floor. The theophylline was withheld until levels dropped into the therapeutic range. Quinidine was discontinued and the patient was changed to verapamil. His pneumonia was treated with IV Kefzol. He was given oxygen by nasal cannula. Because of occasional PVCs and elevated LDH he was transferred to telemetry for monitoring while beginning verapamil therapy and having discontinued quinidine therapy. He was noted to have occasional PVCs and PACs-chronic for him. Subsequently he was noted to occasionally have multifocal atrial tachycardia with advertency versus occasional PVCs. It was very difficult to discern the nature of his arrhythmia. LDH isoenzymes failed to show any evidence of myocardial infarction. Serial cardiogram showed no acute changes. Followup chest x-ray the day before discharge showed marked improvement in right lower lobe infiltrate. The theophylline level on the 5th of April was 15.0. CBC on day of discharge showed a white count of 12,800, plus 79 polys and no bands.
DISPOSITION
Discharged home follow up in the office in 1 week. Medications: Theo-Dur 300 mg p.o. b.i.d. (admitting dose was t.i.d.) Proventil 2 puffs q.i.d., Vancenase nasal spray 1-2 sprays each nostril b.i.d. to t.i.d., digoxin 0.125 mg q.a.m., Lasix 40 mg q.a.m., Micro-K 10 mEq q.a.m., verapamil 80 mg t.i.d.
Thank you so much for your help!
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