tokens: Admission Date : 2017-08-14 Discharge Date : 2017-08-23 Date of Birth : 1943-08-23 Sex : M Service : MEDICINE Allergies : Sulfonamides Attending : Marcus W. Kelley , M.D. Chief Complaint : Transfer from Athol Memorial Hospital for acute on chronic respiratory distress . Major Surgical or Invasive Procedure : Lumbar puncture on 08-16 History of Present Illness : Mr. Lockley is a 73 yo male with a complicated past medical history , recently discharged from St. Margaret 's Center for Women & Infants on 08-02 following a prolonged admission for STEMI , respiratory failure felt secondary to pulmonary edema requiring intubation and subsequent tracheostomy 02-22 failure to wean , sepsis and C.difficile colitis treated with Vancomycin and Flagyl with a course of Levophed . He was discharged to Athol Memorial Hospital for continued weaning . Per Dr. John C. Corrigan Mental Health Center , patient remained ventilator dependent , intermittently on PS 20/5 and back on AC 15/5/500/0.35 on 08-08 . At OSH , sputum cultures grew Pseudomonas and MRSA , and he was restarted on Zosyn ( 08-08 ) and Vancomycin ( 08-09 ). He completed his course of Vancomycin on 2017-08-10 . However , today around 17:45 , while being moved by the nursing staff , Mr. Lockley Bosche started coughing . Suctioned X 1 , mucus not cleared . He then became dusky and cyanotic , and stopped breathing on his own . A code was called , + pulse . Patient placed on FiO2 100% . Vitals reportedly HR 88-98 , BP 150/80 . ABG done on FiO2 100% 7.36/66/417/98% . At Vencor Hospital , BP dropped to 90 , and patient was started on NS IVF , with improvement in BP . EKG without acute changes . He was transferred to St. Margaret 's Center for Women & Infants John for further management on AC , RR 15 , PEEP 5 , Vt 500 , Fi02 1.0 . In John , BP 80/60 , HR 80 . Continued on IVF ( received total 2300 cc ) , with improved BP to SBP 105-118 . Stool sent for C.diff and given Flagyl 500 mg PO X 1 dose . Past Medical History : 1. Non-small cell lung cancer s/p XRT and chemotherapy in French Guiana , s/p right pneumonectomy in 2016-09-21 for recurrence . Chronic left pleural effusion . 2. SSS status post PM/ICD placement 3. COPD/bronchiectasis 4. Hypertension 5. CAD , with known TO RCA . 6. CHF with EF 25% on last echo on 2017-07-19 7. BPH 8. Depression 9. Left femoral AV fistula 2017-04-19 10. Recent MRSA pneumonia and sepsis 2017-07-21 , treated with Vancomycin 11. C. difficile colitis treated with Flagyl ( completed 08-10 ) 12. Status post PEG tube placement 2017-07-21 13. Status post tracheostomy 2017-07-21 02-22 failure to wean 14. Status post partial colectomy 1972 Social History : Son is next of kin . See below for contact information . He has been living at The Cooley Dickinson Hospital House since 2017-08-02 . Per Dr. John C. Corrigan Mental Health Center , at baseline , patient not interactive . Opens eyes spontaneously , withdraws to painful stimulus . Family History : Non-contributory Physical Exam : PHYSICAL EXAM on admission : VITALS : BP 90s-118/47-59 , HR 80-90s . Vent : AC , RR 15 , PEEP 5 , Vt 500 cc , FiO2 1.0 . GEN : Intubated , opens eyes , responds to painful stimulus . HEENT : Pupils minimally reactive . Sclera anicteric . NECK : Unable to assess JVP . RESP : Bronchial breathing over right hemithorax . Ronchorous breath sounds left chest . Limited examination . CVS : RRR . Normal S1 , S2 . + S4 . No murmur appreciated . GI : PEG in place , site without drainage . BS present , hypoactive . Abdomen soft . No grimacing with palpation . CMED : Foley in place . EXT : 2+ edema both upper extremities , sacral edema . Cool extremities . Good pedal pulses peripherally . NEURO : Limited examination . Withdraws to painful stimulus . Moves all 4 extremities . Pertinent Results : LABS : WBC - 4.9 RBC - 2.92 * HGB - 8.8 * HCT - 26.2 * MCV - 90 MCH - 30.1 MCHC - 33.5 RDW - 18.5 * NEUTS - 86.5 * LYMPHS - 7.5 * MONOS - 4.7 EOS - 1.2 BASOS - 0.1 PLT COUNT - 145 * GLUCOSE - 91 UREA N - 21 * CREAT - 0.6 SODIUM - 143 POTASSIUM - 4.2 CHLORIDE - 106 TOTAL CO2 - 32 ANION GAP - 9 LACTATE - 1.4 K+ - 3.9 ABG : 2017-08-14 07:30 PM TYPE - ART PO2 - 468 * PCO2 - 44 PH - 7.50 * TOTAL CO2 - 36 * BASE XS - 10 INTUBATED - INTUBATED EKG ( at Athol Memorial Hospital , 17:11 ) : Atrial fibrillation , occasional V-paced , rate 74 . Normal axis . Old TWI V4-6 . EKG in John : Afib , occasional V-paced , rate 83 bpm . Normal axis . Long QT interval ( QTc 462 ms ). ST depressions V4 , 5 . Mild ST elevation in V3 . Old TWI V4-6 . **************** IMAGING : 2017-08-14 CXR : ETT in correct position . PM wires in good position . S/p right pneumonectomy . Blunting of left CPA likely effusion . New lower left lateral CW opacity , likely loculated pleural fluid . 2017-07-19 ECHO : Left-to-right shunt across the interatrial septum . LVEF 25% . Resting WMA include mid to distal septal akinesis , apical akinesis , inferior akinesis/hypokinesis , and mid to distal anterolateral hypokinesis / akinesis . No definite apical thrombus seen ( cannot exclude ). 01-22+ AR . Trivial MR . 1+ TR . 2017-08-16 CT head : New rounded low-density area measuring 2.5 cm in left basal ganglia , which partially extends to the left thalamus , probably representing subacute infarction . On this head CT without contrast , the evaluation is limited . 2017-08-16 CTA chest : No evidence for pulmonary embolism . Findings consistent with failure or fluid overload . Development of small loculated pleural fluid collection along the periphery of the left major fissure or so-called pseudotumor , consistent with the recent chest x-ray . Unchanged appearance of right pneumonectomy . 2017-08-16 ECHO : The left atrium is normal in size . Overall LVEF is difficult to assess due to poor echo windows although the basal LV appeas hyperdynamic without regional contraction abnormality ( suspect significant improvement compared to prior study dated 2017-07-18 ). No masses or thrombi are seen in the left ventricle ( due to poor echo windows cannot fully exclude ). The ascending aorta is mildly dilated . There is no aortic valve stenosis . Mild ( 1+ ) aortic regurgitation is seen . Trivial mitral regurgitation is seen . The left ventricular inflow pattern suggests impaired relaxation . There is a small pericardial effusion . There are no echocardiographic signs of tamponade 2017-08-17 EEG : Markedly abnormal portable EEG due to the voltage suppression over the left hemisphere and due to the bursts of generalized slowing and right hemisphere slowing . The first abnormality raises the possibility of material ( such as subdural fluid ) interposed between the brain and recording electrodes or widespread cortical dysfunction on that side . Anatomic correlation would be of interest if clinically indicated . The generalized slowing indicates a non specific dysfunction in midline structures . There was also evidence of subcortical dysfunction on the right side . No epileptiform features were seen . MICRO DATA : 2017-08-17 STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY - PENDING 2017-08-16 CSF ; SPINAL FLUID GRAM STAIN - neg FLUID CULTURE - neg ; FUNGAL CULTURE - PENDING ; ACID FAST CULTURE - PENDING ; VIRAL CULTURE - PENDING 2017-08-15 SPUTUM CULTURE - PRELIMINARY { PSEUDOMONAS AERUGINOSA } 2017-08-15 BLOOD CULTURE NGTD 2017-08-15 URINE CULTURE - FINAL 2017-08-15 BLOOD CULTURE NGTD Brief Hospital Course : Mr. Lockley was admitted with respiratory failure , thought to be related to mucus plugging as well as a pseudomonal pneumonia . Both of these etiologies were treated , and he continued to oxygenate and ventilate well on his usual ventilator settings . However , the issue that dominated the admission was his recent acute decline in mental status . He was thoroughly evaluated by neurology and underwent head CT , MRI , LP , and EEG . This work-up demonstrated a small left basal ganglia infarct , likely cardioembolic . However , they felt this event could not account for his new , severe global deficit ; this was thought to be secondary to a more pervasive process , likely anoxic encephalopathy , for which the prognosis is extremely grim . This was discussed at length in several family meetings involving the patient 's wife , son , primary care doctor , ICU attending , and neurology consultant in the presence of a Asian interpreter . The end result of these discussion was that the patient 's wishes would not be consistent with this new level of functioning from which he had little hope of recovery ; the family decided to make him comfort measures only . He was disconnected from the ventilator and all medications beyond a morphine drip were stopped , and he expired shortly thereafter . The family was present . Medications on Admission : Jevity 1.2 65 mL / hour continuous with water 240 cc q 8 hours Lasix 40 mg IV QAM ( given 08-14 ) Vancomycin 1 gm IV q 36 hours ( last dose at 2000 on 08-13 ) . Started on 08-09 ) ASA 325 mg PO QD Lansoprazole 30 mg PO QAM Heparin 5000 units SC TID Zosyn 4.5 gm IV q 8 hours ( last dose on 08-14 at 1400 ) , started 08-08 . Metoprolol 37.5 mg q 12 hours ( last dose 07/25 in AM ) Protein / Soy supplement 2 scoops q 12 hours Ipratropium / Albuterol inhaler 4 puffs QID Completed course of Flagyl 07-25 --> 08-10 . Discharge Disposition : Expired Discharge Diagnosis : Anoxic encephalopathy Acute respiratory failure Chronic respiratory failure Pseudomonal pneumonia Volume overload Chronic obstructive pulmonary disease Bronchiectasis Hyponatremia Anemia of chronic disease Secondary : 1. Non-small cell lung cancer s/p XRT and chemotherapy in Western Sahara , s/p right pneumonectomy in 2016-09-21 for recurrence . Chronic left pleural effusion . 2. Sick Sinus Syndrome status post PM/ICD placement 3. COPD/bronchiectasis 4. Hypertension 5. CAD , with known TO RCA . 6. CHF with EF 25% on last echo on 2017-07-19 7. BPH 8. Depression 9. Left femoral AV fistula 2017-04-19 10. Recent MRSA pneumonia and sepsis 2017-07-21 , treated with Vancomycin 11. C. difficile colitis treated with Flagyl ( completed 08-10 ) 12. Status post PEG tube placement 2017-07-21 13. Status post tracheostomy 2017-07-21 02-22 failure to wean 14. Status post partial colectomy 1972 Discharge Condition : Expired Johnnie Callez MD 61-750 Completed by : Opal Anne MD 40-158 2017-08-23 @ 2054 Signed electronically by : DR. Teresa Loper on : FRI 2017-09-22 4:29 PM ( End of Report )