Subjective:

CC: Community Acquired Pneumonia (CAP)

HPI: Patient is a 47-year-old male with an unknown past medical history who presented to the ED via
ambulance with fever, worsening cough, and concern for early sepsis. He was febrile, tachycardic, and
tachypneic at presentation. Patient currently in a persistent vegetative state with tracheostomy and PEG
feeding tube following a motor vehicle accident in March of this year. Patient has had multiple recent
healthcare exposures at a different medical facilities for pneumonia and sepsis.
- 05/22: Patient admitted to outside hospital for respiratory distress. Bronchoscopy completed 5/23
revealed Pseudomonas and Corynebacterium. He was started on Cefepime and Vancomycin.
Susceptibilities showed Cefepime sensitive so Vancomycin was discontinued. Patient completed 2
full courses of Cefepime. Admission continued due to complications with guardianship and post-
discharge planning.
- 06/20: Concern for persistent pneumonia on chest x-ray. CT chest and bronchoscopy completed.
Preliminary gram-negative bacilli noted from the bronchoscopy, but patient was asymptomatic with
no SIRS criteria. Treatment team suspected atelectasis vs. pneumonia and approved discharge for
06/21 without oral antibiotics.
- 06/23: Cultures from bronchoscopy showed Pseudomonas and Klebsiella. A 7-day supply of
Ciprofloxacin was sent to the patient’s pharmacy. Family reported that the patient had become
febrile and tachycardic since discharge, but the Ciprofloxacin relieved symptoms.
- 07/02: Patient returned to same hospital due to high heart rate. Sputum cultures negative. He was
afebrile. Treated empirically with Azithromycin and Vancomycin. CT Chest showed progressive
atelectasis vs. pneumonia so he was started on a 5-day course of Augmentin. Discharged home on
07/04.
- 07/11: Home Health Visit completed by Bellin PCP. No acute findings.
- 07/24: Patient presented to an outside emergency department due to hypoxia recorded at home,
but saturation was normal in route via EMS and upon arrival to facility. No signs of infection at that
time. Discharged home.

SH: Patient currently qualifies for Emergency Medicaid. Family is providing 24/7 care.

FH: Unknown

PTA Medications
Acetaminophen 500 mg capsule 1000 mg via PEG tube every 6 hours as needed for fever or
mild pain.
Albuterol-ipratropium (DuoNeb) 3-0.5 mg/3 Inhale 1 ampule (3 mL total) by nebulization 4 times daily.
mL nebulizer solution
Amantadine 100 mg tablet Take 0.5 tablet (50 mg total) via PEG tube 2 times daily.
Aspirin 81 mg Take 1 tablet once daily.
Azelastine 0.1% nose solution Instill 2 sprays into each nostril twice daily.
Baclofen 10 mg tablet Take 1 tablet via PEG tube 3 times daily.
Fluticasone Propionate nasal spray Instill 1 spray into nostrils 2 times daily.
Glycopyrrolate 1 mg tablet Take 1 tablet via PEG tube every 8 hours as needed for
increased airway secretion.
Guaifenesin 150 mg/15 mL liquid 100 mg via PEG tube 2 times daily.
Melatonin 3 mg tablet Take 3 tablets via PEG tube at bedtime.
Modafinil 100 mg tablet Take 1 tablet via PEG tube once daily.
Nutritional Supplement (Jevity 1.5) 530 mL by PEG tube every 6 hours.
 Nystatin 100,000 unit/g external ointment Apply topically 2 times daily to red areas of skin.
Polyethylene Glycol powder 17 g via PEG tube once daily.
Scopolamine 72-hour 1 mg/3 days patch Place 1 patch onto skin every 3 days.
Sodium Chloride 0.9% inhalation solution Use 3 mL in nebulizer every 8 hours as needed.
White petrolatum external gel Apply topically to eyes once daily at bedtime.

Objective:
Diagnostics Completed During Admission:
X-Ray Chest
Impression: Streaky opacity most pronounced at the right lung base could reflect underlying infiltrate.
CT Chest
Impression: No evidence of PE. Markedly elevated right hemidiaphragm with prominent atelectatic
changes at the right lung base. However there is bronchial wall thickening at the right lung base and
some heterogeneity with opacity and subsegmental bronchial occlusion at the posterior segment.
Findings could indicate a component of pneumonia and/or mucus plugging.
CT Abdomen
Impression: Mildly distended appearance of the gallbladder. Question subtle adjacent marginal
haziness. Consider correlation with right upper quadrant ultrasound. Fecal impaction. Possible
subacute fractures of the right superior and inferior pubic rami.
ECHO
Impression: Negative for valvular heart disease, vegetation, pericardial effusion. Normal right and left
ventricles. LVEF 55-60%. Normal atria, mitral, aortic, pulmonic, and tricuspid valve.

Vitals:
8/26 8/27 8/28 8/29 8/30
Day 1 Day 2 Day 3 Day 4 Day 5
BP <130/80 <130/80 <130/80 <130/80 <130/80
HR 98 – 120 88 – 119 77 – 95 75 – 88 72 – 99
Temp. 99.3 – 102.2 99.8 – 101.4 97.4 – 98.6 96.4 – 98.2 97.1 –98.2

Labs:
8/26 8/27 8/28 8/29 8/30
Day 1 Day 2 Day 3 Day 4 Day 5
Na 137 135 137 137 137
K 4.4 3.8 3.5 4.0 3.5
Mg --- --- 1.9 --- ---
Ca 9.5 8.6 9.1 8.9 9.2
WBC 8.4 7.6 7.8 7.7 7.5
Scr (mg/dL) 0.70 0.67 0.55 0.51 0.50
CrCl (mL/min) >200 >200 >200 >250 >250
Urine Output (mL) --- >1100 >1400 >2300 >4200

Inpatient Medications During Admission (8/26 – present)

 Acetaminophen Oral Liquid
Dose: 650 mg every 4 hours PRN for fever or mild pain
Albuterol-Ipratropium 3-0.5mg/3 mL Solution
Dose: 3 mL PRN via nebulizer 4 times daily
Bisacodyl 10 mg Rectal Suppository
Dose: 10 mg daily as needed for constipation
Cefepime 1 g/50 mL Intermittent IV Duplex STARTED 8/30
Dose: 1000 mg every 8 hours
Enoxaparin 40 mg/0.4 mL Injection
Dose: 40 mg SQ once daily for DVT prophylaxis
Lactobacillus Capsule
Dose: 1 capsule daily for diarrhea
Loperamide 2 mg Capsule
Dose: 1 capsule once (8/31/23)
NaCl 0.9% Continuous Infusion
Dose: 10-25 mL/hour
Ondansetron 4 mg Injection
Dose: 4 mg every 6 hours as needed for nausea/vomiting
Piperacillin-Tazobactam 4500 mg in NaCl 0.9% 100 mL IVPB DC’d 8/30
Dose: 4500 mg q6 hours
Potassium Chloride 10 mEq/100 mL IVPB premix
Dose: 10 mEq every hour PRN
Scopolamine (72-hour) 1 mg/3 days Patch
Dose: 1 patch q72 hours
Vancomycin 1250 mg in NaCl 0.9% 250 mL IVPB DOSE/FREQ CHANGED 8/28
Dose: 1250 mg q12 hours
Vancomycin 1000 mg in NaCl 0.9% 250 mL IVPB DC’d 8/30
Dose: 1000 mg q8 hours

Pharmacokinetic Dosing
8/26 8/27 8/28 8/29 8/30
Day 1 Day 2 Day 3 Day 4 Day 5
1250 mg q12h
1000 mg q8h
Vancomycin Dose 1250 mg q12h 1250 mg q12h DC’d 1000 mg q8h
DC’d
1000 mg q8h
Vancomycin Trough --- --- 11.3 14.8 ---

Feeding/Diet
8/26 8/27 8/28 8/29 8/30
Day 1 Day 2 Day 3 Day 4 Day 5
Tube Feeding (mL) --- 1080 1440 1440 1080
Assessment/Plan:
CAP: Patient was initially treated empirically with Vancomycin and Zosyn for complicated pneumonia.
Respiratory panel and nares MRSA swab were negative. CT Chest ruled out a pulmonary embolism.
Respiratory cultures showed very few Pseudomonas and Klebsiella, both susceptible to Cefepime. ID
deescalated Zosyn to Cefepime on day 5 of admission.

Suspected Bacteremia: Blood cultures at admission came back positive for coagulase-negative
Staphylococcus and Staphylococcus epidermidis was detected by PCR. Concern arose regarding potential
contamination versus true infection leading to the collection of new blood cultures. Preliminary results on
the new blood cultures showed gram positive cocci in clusters and ID was consulted. Urine cultures were
negative. The new blood cultures later resulted with coagulase-negative Staphylococcus again. After
discussion with the microbiology lab, it was decided that the coagulase-negative Staphylococcus in the
blood cultures was more than likely a contaminant versus true bacteremia. There were multiple coagulase
negative staph colony morphologies in all positive bottles which is more consistent with contaminant than
infection. Additionally, there no clear source for bacteremia and the patient is improving clinically. ID
recommended discontinuation of Vancomycin. ID signed off of treatment team.

Pharmacokinetics: Patient was initially started on Vancomycin 1250 mg every 12 hours. A trough drawn at
an appropriate time prior to the fourth dose showed subtherapeutic trough level of 11.3. Goal trough level
is 15-20. Vancomycin was adjusted to 1000 mg every 8 hours. A repeat trough was ordered for just prior to
the new fourth dose. The trough resulted just barely subtherapeutic at 14.8, however it was drawn later
than desired, so expect the true value was closer to 15. Urine output was appropriate and kidney function
was within normal limits during the patient’s admission. Vancomycin regimen was continued at 1000 mg
every 8 hours until ID discontinued it on day 5 of admission.

Fever: Patient presented with fever and was treated with acetaminophen as needed. He remained febrile
until day 3 of admission and he remained afebrile for the rest of the admission.

Diarrhea: Treatment team ordered a C. Diff test due to watery diarrhea that started on day 4 of admission,
but it was negative. Patient started on probiotic and given one dose of loperamide.

Mild Hypokalemia: Patient was mildly hypokalemic (3.5) on day 3 and day 5 of admission. This was treated
appropriately with IV Potassium chloride. Last known potassium level was WNL.

Chronic conditions: Patient is in a persistent vegetative state due to TBI. He is tracheostomy and feeding
tube dependent. He was maintained on enteral nutrition per his home regimen while inpatient. A fresh
tracheostomy was placed during his admission without incident. His PTA amantadine, modafinil,
glycopyrrolate, guaifenesin, and baclofen were held during admission. He was given his PTA scopolamine to
help manage increased production of saliva.

IV  PO: At discharge, the patient will be switched from Cefepime to Ciprofloxacin to complete a total
course of 7 days from initiation of Cefepime. IR Ciprofloxacin tablet may be crushed and mixed with 20-60
mL of water and administered via the patient’s feeding tube. The tube should be flushed before and after
administration and spaced out from food by at least 2 hours before and 4 hours after.

Discharge: The plan is to discharge to home via ambulance on 09/01.

Kari Patterson, DPH-4 Student Pharmacist

08/31/2023