tokens: 270045381 BH 6676757 650129 10/10/1997 12:00:00 AM LEFT PROXIMAL HUMERUS FRACTURE . Unsigned DIS Report Status : Unsigned DISCHARGE SUMMARY NAME : JUNK , KACHOLERA UNIT NUMBER : 482-31-51 ADMISSION DATE : 10/10/97 DISCHARGE DATE : 10/23/97 PRINCIPAL DIAGNOSIS : Left proximal humerus fracture . ASSOCIATED DIAGNOSIS : Adult-onset diabetes mellitus x 40 years , history of silent myocardial infarction , coronary artery bypass graft ( three vessels in 1987 ) , history of chronic , stable angina pectoris , Fournier &apos;s gangrene versus necrotizing fasciitis , congestive heart failure in 03/97 while in the hospital for a rib fracture , glaucoma , diabetic retinopathy with blindness in the right eye , history of gastric stapling , left rib fracture , right femur surgery . PRINCIPAL PROCEDURE : Left shoulder hemiarthroplasty . OTHER PROCEDURES : Upper endoscopy x 2 . HISTORY OF PRESENT ILLNESS : The patient is a 65-year-old male with a past medical history of diabetes mellitus , three-vessel coronary artery bypassgraft , congestive heart failure , who presents with a humeral fracture . The patient is admitted for preoperative and orthopedic evaluations . The patient presented with a comminuted fracture of the proximal left humerus when he slipped over the stairs , about to board an airplane back to Jeglas Blvd. , Jolouisrowarlihis , Alabama 86071 . The fracture was seen by Orthopedics and was reduced . During conscious sedation , the patient developed bigeminy ( the patient was sedated , did not feel chest pain or shortness of breath ) . The patient presented to Bri Health in order to be evaluated for preoperative clearance . He was reported to have had a myocardial infarction in the past ( EKG positive for ischemia , exercise tolerance test positive , cardiac catheterization positive , the patient is now status posta three-vessel coronary artery bypass graft in 1987 ) . The patient also hada history of arrhythmia , found approximately ten years ago , unknown what type . The patient was on coumadin recently , ? whether for the arrhythmia . Coumadin was reportedly discontinued approximately six months ago secondary to planned surgery for diabetic retinopathy and glaucoma . The patient did not have chest pain until approximately 1-1/2 years ago , when he began to have chest tightness ( pressure ) approximately every three months with stress . The patient has no chest pain when walking slowly and can walk approximately 1.5 miles . He can climb approximately three flights of stairs before becoming short of breath . He does become slightly short of breath when lifting furniture . On the day of admission , when he fell , the patient was experiencing no chest pain , no shortness of breath , and had no loss of consciousness , no head trauma with fall . REVIEW OF SYSTEMS : No fevers or chills , no chest pain , no shortness of breath . The patient has stable three-pillow orthopnea and occasional paroxysmal nocturnal dyspnea . He has a chronic cough with clear sputum . No hemoptysis , hematemesis , abdominal pain , black or tarry stools , dysuria / frequency/urgency . PAST MEDICAL HISTORY : Some type of cardiac arrhythmia , diagnosed approximately ten years ago . History of coronary artery disease status post silent myocardial infarction in the past and three-vessel coronary artery bypass graft in 1987 . The patient has been experiencing chronic , stable angina pectoris over the past one to one and a half years approximately once every three months . History of congestive heart failure , diagnosed approximately eight years ago . Diabetes mellitus for approximately 40 years . Fournier &apos;s gangrene versus necrotizing fasciitis . Glaucoma . Diabetic retinopathy with the patient blind in right eye . PAST SURGICAL HISTORY : Cholecystectomy . Status post gastric stapling . Left rib fracture . Right femur surgery approximately two years ago . Righteye surgery for glaucoma in 05/97 . Laser surgery for retinopathy . MEDICATIONS ON ADMISSION : Humulin 70/30 with 30 units subq.q.a.m. and 20 units subq.q.p.m. Vasotec 20 mg. q. a.m. Prozac 40 mg. q.d. Lasix 40 mg. q.d. K-Dur approximately 28 ? mEq q.d. Atropine 1% 1 GTT OD b.i.d. Ocufen 0.03% 1 GTT OD t.i.d. Ventolin metered-dose inhaler . ALLERGIES : no known drug allergies . TOBACCO : Formerly smoked 3 packs per day x 25 years ; 2 cigars per day x approximately 6 months . He quit all tobacco approximately 27 years ago . ETOH : Rare . SOCIAL HISTORY : The patient is retired , lives with his wife and one son , who is 47 years old and had multiple myeloma and renal failure . PHYSICAL EXAMINATION : The patient is alert and oriented and has a sling for his left humeral fracture . Blood pressure 120/70 , temperature 97.8 F , pulse 68 , respirations 22 , Sa02 on 2 L 94% . HEENT : Right-sided ptosis , right eye not reactive to light , cataract present , patient blind in that eye , left eye reactive to light , cataract also present in that eye . Extraocular movements - conjugated eye movement intact . Oropharynx moist , without lesions . Mild right facial droop . Sensation intact . No slurred speech . Cardiac : regular rate and rhythm , no murmur appreciated , normal S1 and S2 . Chest / lungs : The patient is diffusely wheezy upon presentation . Abdomen distended , mild tenderness on the left , bowel sounds present , nohepatosplenomegaly . Extremities : 1+ edema of the ankles , pulses present bilaterally . No calf tenderness . Rectal : Guaiac negative . Neurological : Non-focal , except unable to assess left upper extremity secondary to the patient &apos;s broken humeral fracture . LABORATORY DATA : sodium 135 , potassium 4.1 , chloride 101 , C02 28.4 , BUN 17 , creatinine 1.0 , glucose 302 , calcium 8.6 , phosphorus 2.5 , magnesium 1.6 , total protein 6.7 , albumin 3.3 , globulin 3.4 , uric acid 6.3 , totalbilirubin .7 , alkaline phosphatase 93 , SGOT 20 , LDH 258 , CPK 95 , whiteblood count 15.3 , hematocrit 49.7 , platelet count 159 , MCV 98 . RADIOLOGIC STUDIES : Chest x-ray 10/10/97 : Elevated left hemidiaphragm of uncertain etiology or duration . Postoperative changes of the sternum and media stinum were seen and no acute pulmonary disease was visualized . The patient also had a shoulder film done on 10/10/97 that showed a severely comminuted fracture of the proximal left humerus with proximal distraction . A lucency and irregularity of the glenoid , possibly representing a fracture , was also seen , and a CT scan was therefore obtained in order to evaluate this area . This CT scan , done also on 10/10/97 , again showed the severely comminuted fracture of the proximal left humerus . Two major fracture fragments were seen at the humeral head , articulating with the glenoid fossa . The fracture fragments retained their proper site of articulation with the glenoid fossa . Innumerable smaller fracture fragments were interposed between the fracture fragment and the distal humeral shaft . The glenoid fossa was intact . No scapular fractures were present . EKG : normal sinus rhythm at 72 beats / minute , intraventricular conduction delay , Q - waves seen in II , III , and AVF with probable old inferior myocardial infarction . T - waves were also noted to be inverted in I and AVL . Ventricular bigeminy was also seen . HOSPITAL COURSE AND TREATMENT : 1. ORTHOPEDICS : The patient has a severely comminuted fracture of the proximal left humerus . He is status post a hemiarthroplasty on 10/17/97 . He received Ancef preoperatively . Physical Therapy has been seeing the patient and putting him through passive external rotation to the neutral position of the left shoulder and forward flexion with physical therapy assistance . Brittle bones were noted during the operation . A bone density scan would be recommended as an outpatient , in order to evaluate this . 2. NEUROLOGICAL : The patient has right facial droop , right ptosis , stable and present for greater than one year . 3. CARDIOVASCULAR : No chest pain , no shortness of breath , 1+ ankle edema . The patient was ruled out for a myocardial infarction , given his fall at the airport and bigeminy seen on electrocardiogram that he developed during conscious sedation during reduction of the fracture . Cardiology was consulted and aspirin and beta blocker added to his regimen , as well as chest wall nitroglycerin around the time of surgery , which was subsequently discontinued . An adenosine SESTAMIBI was performed on 10/12/97 , which showed a negative electrocardiogram for ischemia and cardiac perfusion scans , with a moderate-sized , dense , fixed inferior defect indicative of scar . A small / moderate-sized , mild-intensity , reversible posterior lateral defect was also seen , indicative of mild / moderate ischemia . An echocardiogram was performed on Columbus Day which showed an ejection fraction of 50% , left atrial enlargement , thickening of the aortic wall consistent with atherosclerotic changes , left ventricle size , and systolic function within normal limits . Cardiac monitor was placed on the patient , given the bigeminy , and he did rule out for myocardial infarction . Cardiology recommended that in addition to the medications already stated above , his hematocrit be kept greater than 30 . After his procedure on 10/17/97 , elevated CPKs were noted on 10/19/97 to 10/20/97 , and the first level was 744 , CPK # 2 635 , and CPK # 3 461 . MB fractionations of the CPKs were all negative and were thought to be secondary to the patient &apos;s beginning physical therapy on 10/19/97 , and all muscular in origin . 4. GASTROENTEROLOGY : GI was consulted on 10/15/97 for melena , decreased hematocrit prior to his humeral fixation surgery . Upper endoscopy x 2 were done . The first was on 10/15/97 , which showed clotted blood in the esophagus . The stomach had evidence of prior surgery and old blood in the stomach . It was thought that the blood in the esophagus was secondary to a possible Mallory-Weiss tear . A second endoscopy was also performed several days later , in order to rule out a gastric ulcer , and also because the patient had had another episode of melena . A gastric ulcer was found and this was biopsied and pathology is pending at this time . This report needs to be followed up , and will be available at Bri Health in the Pathology Department some time within the next three to seven days . The patient also needs a repeat endoscopy and a GI follow-up appointment inapproximately two months . I have spoken with the patient in detail , and he will be getting in touch with his primary-care physician , Dr. Fordwoodall Stick , in Ranegei Pkwy , Verertliet , South Carolina 62156 . The patient is to arrange follow up with a GI doctor in Jotar Boulevard , Cunahtampfordama , South Dakota 62848 through his primary-care physician . The patient was initially on Cimetidine and Carafate here at Bri Health , and then switched to Prilosec 20 mg bid . 5. PULMONARY : The patient &apos;s admitting chest x-ray showed an elevated left hemidiaphragm consistent with atelectasis versus splinting on that side . Incentive spirometry was started . Albuterol and Atrovent nebulizers were done . The patient received chest physical therapy bid . 6. ENDOCRINE : The patient needs still better diabetes control . He has been somewhat noncompliant with his diet ( eating Pringle &apos;s in the room ) . His NPH was recently increased today ( 10/23/97 ) to 24 units in the a.m. and 14 units in the p.m. with CZI sliding-scale coverage . 7. INFECTIOUS DISEASE : The patient urinalysis on 10/19/97 showed moderate occult blood , pH 5 , albumin 1+ , white blood cells present , 2-50 red blood cell , 10-20 white blood cells , few bacteria , and moderate bladder epithelial cells . Floxin 200 mg po bid was begun . However , his urine culture from the same day remained negative , and this was discontinued two days later . A repeat urinalysis on 10/22/97 was negative . 8. RENAL : After the patient &apos;s procedure , he was felt to be volume overloaded . He was given Lasix 40 mg IV x 1 and also had Nitro paste around the time of his surgery and beta blocker . The patient became slightly hypotensive on the night of 10/18/97 with systolic blood pressures in the 80s to 90s. His BUN/ creatinine rose from 16/1.2 on 10/18/97 to 25/1.9 on 10/18/97 to 22/9.1 to today &apos;s labs , which are 15/0.7 on 10/23/97 . 9. HEMATOLOGY : The patient transfused 2 units on 10/15/97 for a hematocrit of 27.6 . The patient transfused 2 units of 10/16/97 for a hematocrit of 30.03 . The patient transfused 1 unit on 10/18/97 for a hematocrit of 29.4 . The patient transfused 1 unit on 10/19/97 for a hematocrit of 27.9 . The patient transfused 2 units on 10/20/97 for a hematocrit of 28.2.10 . FEN : Repleting potassium , magnesium , phosphorus as needed . The patient was noted to be slightly hyponatremic over the past few days , with sodiums in the 128-132 range , but this was secondary to elevated glucose fingerstick blood sugars . CONDITION ON DISCHARGE : Stable , good . MEDICATIONS ON DISCHARGE : NPH insulin 24 units subq. q. a.m. NPH insulin 14 units subq. q. p.m. CZI sliding scale on a q. a.c. and q. h.s. fingerstick basis with the following scale : FBS less than 200 = 0 units of CZI FBS 201-250 = 2 units of CZI FBS 251-300 = 4 units of CZI FBS 301-350 = 6 units of CZI FBS 351-400 = 8 units of CZI FBS greater than 400 = 10 units of CZI . Atropine sulfate 1 GTT 1% OD b.i.d. Ocufen 0.03% 1 GTT OD t.i.d. Vasotec 20 mg. p.o.q. a.m. Prozac 40 mg.p.o.q. a.m. Oxygen 2-4 L to keep Sa02 greater than or equal to 94-95% and wean as tolerated . Colace 100 mg. p.o. t.i.d. Senokot 1 p.o. q. h.s. Nystatin powder to affected area t.i.d. Lopressor 25 mg. p.o. b.i.d. Atrovent 0.8/2.5 c.c. normal saline nebulizers q. 8 h. Albuterol 2.5/5 c.c. normal saline nebulizers q. 4 h. with q. 2 h. p.r.n. Percocet 1-2 p.o. q. 4 h. p.r.n. pain . Prilosec 20 mg. p.o. b.i.d. Vexol 1% 1 GTT OD b.i.d. Lasix 40 mg. p.o. q.d. KCl 20 mEq p.o. q.d. Tylenol 650 mg. p.o. q. 12 h. p.r.n. Ativan 1 mg. p.o. q. h.s. p.r.n. SAY REKE , M.D. TR : vr DD : TD : 10/23/97 3:05 Pcc : NABETH NA GLYNCRED , M.D. MI T THULRO , M.D. / Fordwoodall Stick , M.D. 7922 Fordknoxtall Illinois