tokens: Admission Date : 2013-05-18 Discharge Date : 2013-05-24 Date of Birth : 1811-08-19 Sex : F Service : MEDICINE Allergies : Patient recorded as having No Known Allergies to Drugs Attending : Sarah Q. George , M.D. Chief Complaint : Hip fracture Major Surgical or Invasive Procedure : OPERATIVE PROCEDURE : 1. Closed reduction of right hip with open placement of dynamic hip screw , right hip . 2. Examination under anesthesia with placement of splint , right elbow . PROCEDURE #2 : 1. Exploratory laparotomy with drainage of intra-abdominal abscess and peritonitis with gross soilage with bile and gastric contents . 2. Exposure and wide drainage of perforated posterior duodenal ulcer with internal and external drainage . 3. Feeding jejunostomy . 4. Tube gastrostomy . 5. Placement of a right femoral arterial line . History of Present Illness : 90 yo F with MMP ( see below ) who sustained a mechanical fall down stairs resulting in a hip and arm fracture . Fall was witnessed by daughter . Nicholas seizures , no LOC , no head or neck trauma . Patient denies CP , SOB , light headedness , or dizziness prior to of after the fall . She fell on her R side and had a great deal of pain in her R arm and hip . Presented to Taunton and found to have R humerus and R hip fx . Ct of head and neck neg for fx , bleed , and dislocation . Past Medical History : 1. Coronary artery disease status post non-ST-elevation myocardial infarction in 2009-05-05 , status post cardiac catheterization with left anterior descending artery stent placement in 05/2001 . 2. CHF with an ejection fraction of 40-45% 02-09 3. Diabetes type 2 . 4. Anemia , transfusion dependent every three months . Hct 28 b/l 5. Polymyalgia rheumatica . 6. Hypertension . 7. Hypothyroidism . 8. Chronic renal insufficiency with a b/l creatinine of 1.4 . 9. History of syncope and first degree A-V heart block with beta blocker therapy . 10. History of lower gastrointestinal bleed in 2009-06-05 . 11. spinal stenosis 12. Pacemaker - DDD dual chamber rate response pacemaker 2011-08-22 for symptomatic bradycardia Social History : Lives alone in elderly housing , a daughter in the area , two children and exercises two times a week by walking and stretching . no , tob , no etoh , no drugs Family History : Noncontributory Physical Exam : at admission T 96.0 BP 177/61 P 70 R 18 O2 97 on RA Gen - somnolent , confused HEENT - PERRL , OP clear , EOMI Cor - rrr , no m/r/g Chest - CTAB anteriorly Abd - s/nt/nd +BS Ext - 2 + edema to knees , warm 2 + pulses , pain in R arm and R hip Pertinent Results : 2013-05-18 06:00 PM GLUCOSE - 188 * UREA N - 48 * CREAT - 1.3 * SODIUM - 138 POTASSIUM - 4.0 CHLORIDE - 106 TOTAL CO2 - 21 * ANION GAP - 15 2013-05-18 06:00 PM CK(CPK) - 32 2013-05-18 06:00 PM CK-MB - NotDone 2013-05-18 06:00 PM WBC - 14.9 *# RBC - 2.91 * HGB - 8.5 * HCT - 24.7 * MCV - 85 MCH - 29.3 MCHC - 34.5 RDW - 14.6 2013-05-18 06:00 PM NEUTS - 87.9 * BANDS - 0 LYMPHS - 6.3 * MONOS - 5.7 EOS - 0.1 BASOS - 0 2013-05-18 06:00 PM HYPOCHROM - 1 + ANISOCYT - NORMAL POIKILOCY - NORMAL MACROCYT - NORMAL MICROCYT - NORMAL POLYCHROM - NORMAL 2013-05-18 06:00 PM PLT SMR - NORMAL PLT COUNT - 216 2013-05-18 06:00 PM PT - 13.3 PTT - 26.4 INR(PT) - 1.2 EKG - NSR 64 , 1st deg block , LAD , new TWI inf/lat leads , new ST depressions V4-6 Echo 02-09 1. The left atrium is moderately dilated . The left atrium is elongated . 2. The left ventricular wall thicknesses are normal . The left ventricular cavity size is normal . There is mild regional left ventricular systolic dysfunction . Overall left ventricular systolic function is mildly depressed . Resting regional wall motion abnormalities include inferolateral , inferior and mid septal hypokinesis . 3. Right ventricular chamber size is normal . Right ventricular systolic function is normal . 4. The aortic valve leaflets ( 3 ) are mildly thickened . No aortic regurgitation present . 5. The mitral valve leaflets are mildly thickened . Moderate ( 2 +) mitral regurgitation is seen . 6. There is moderate pulmonary artery systolic hypertension . 7. There is no pericardial effusion . Compared with the findings of the prior study ( tape reviewed ) of 2009-06-05 , the LV function has improved with an improvementt in function of the apex , septal and anterior walls . New inferior and inferolateral wall motion abnormalities with more severe mitral regurgitation present . Cath 2001 1. Coronary angiography demonstrated single vessel disease in a right dominant system . The left main was normal . The LAD had serial 90% lesions proximally , involving the origin of the first diagonal , which was occluded and filled via left to left collaterals . The mid-distal LAD was underfilled initially but was without obstructive disease . The non-dominant circumflex system had no hemodynamically significant stenoses . The dominant RCA was a large vessel with no significant disease . 2. Resting hemodynamics revealed elevated right and left sided filling pressures with a mean RA pressure of 12 mm Hg and a mean wedge pressure 24 mm Hg . Moderate pulmonary hypertension was present with a PA of 52/28 . The cardiac index was preserved at 3.0 L / min / m2 . 3. Left ventriculography was not performed due to the presence of moderate renal insufficiency ( creatinine 1.6 ). 4. Successful PTCA and stenting of the proximal LAD with overlapping 2.25 x 13 mm and 2.25 x 18 mm Hepacoat stents with no residual stenosis or dissection and normal flow ( see PTCA comments ). FINAL DIAGNOSIS : 1. One vessel coronary artery disease . 2. Moderately elevated right and left sided filling pressures . 3. Successful stenting of the proximal LAD . Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 2013-05-24 09:40 AM 19.3 * 4.46 13.1 39.2 88 29.4 33.5 14.4 159 2013-05-24 12:52 AM 19.8 *# 4.73 13.8 42.1 # 89 29.3 32.9 14.3 147 * DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas 2013-05-22 06:15 AM 90.0 * 0 5.6 * 4.2 0.1 0.2 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr 2013-05-22 06:15 AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL BASIC COAGULATION ( PT , PTT , PLT , INR ) PT PTT Plt Smr Plt Ct INR(PT) LPlt 2013-05-24 09:40 AM 159 1 + 2013-05-24 09:40 AM 14.9 * 1 31.9 1.5 1 NOTE NEW NORMAL RANGE AS OF 12 AM 2013-05-04 2013-05-24 12:52 AM 147 * 2013-05-24 12:52 AM 14.6 * 1 33.8 1.4 1 NOTE NEW NORMAL RANGE AS OF 12 AM 2013-05-04 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap 2013-05-24 09:40 AM 192 * 87 * 2.4 * 146 * 5.1 114 * 16 * 21 * 2013-05-24 12:52 AM 160 * 86 * 2.6 * 148 * 4.4 115 * 14 * 1 23 * 1 VERIFIED BY DILUTION NOTIFIED Y. Welch - TSICU 140 AM 2013-05-24 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili 2013-05-24 07:40 AM 628 * 2013-05-24 12:52 AM 22 65 * 739 * 52 81 1.0 OTHER ENZYMES & BILIRUBINS Lipase 2013-05-24 12:52 AM 17 CPK ISOENZYMES CK-MB MB Indx cTropnT 2013-05-24 07:40 AM 15 * 2.4 2013-05-24 12:52 AM 14 * 1.9 0.12 * 1 1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron Cholest 2013-05-24 09:40 AM 8.3 * 5.4 * 2.1 2013-05-24 12:52 AM 2.1 * 7.7 * 5.1 *# 1.6 LIPID / CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc 2013-05-19 09:20 AM 1603 - 5419 LDL(CALC) INVALID IF TRIG > 400 OR NON-FASTING SAMPLE LAB USE ONLY GreenHd 2013-05-18 06:00 PM HOLD1 1 HOLD DISCARD GREATER THAN 4 HOURS OLD Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calHCO3 Base XS AADO2 REQ O2 Intubat Vent 2013-05-24 07:58 AM ART 102 36 7.26 * 17 * -9 2013-05-24 04:31 AM ART 36.4 16 / 662-15484 * 7.26 * 16 * -10 ASSIST / CON1 INTUBATED 1 ASSIST / CONTROL 2013-05-24 12:58 AM ART 147 * 39 7.22 * 1 17 * -11 1 VERIFIED PROVIDER NOTIFIED PER CURRENT LAB POLICY WHOLE BLOOD , MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl calHCO3 2013-05-24 07:58 AM 4.5 * 1 1 VERIFIED 2013-05-24 04:31 AM 5.1 * 1 1 VERIFIED 2013-05-24 12:58 AM 6.2 * 1 1 VERIFIED HEMOGLOBLIN FRACTIONS ( COOXIMETRY ) Hgb calcHCT O2 Sat COHgb MetHgb 2013-05-23 09:36 PM 11.4 * 34 73 1 1 2013-05-23 01:08 PM 10.9 * 33 96 CALCIUM freeCa 2013-05-23 09:36 PM 1.00 * 2013-05-23 01:08 PM 1.22 RADIOLOGY Final Report CT ABDOMEN W/O CONTRAST 2013-05-23 5:46 PM CT ABDOMEN W/O CONTRAST ; CT PELVIS W/O CONTRAST Reason : Please eval for perf / ischemic bowel UNDERLYING MEDICAL CONDITION : 92 year old woman with MS changes , abd pain hypotension and bloody lavage on Lovenox+ASA REASON FOR THIS EXAMINATION : Please eval for perf / ischemic bowel CONTRAINDICATIONS for IV CONTRAST : renal failure INDICATION : 94-year-old woman with mental status changes , now with abdominal pain and hypertension . TECHNIQUE : A multidetector scanner was used to obtain contiguous axial images from the lung bases to the pubic symphysis . Neither IV nor oral contrast were used . CT OF THE ABDOMEN WITHOUT IV CONTRAST : There are bilateral pleural effusions , right greater the left ; there is compressive atelectasis at the left lung base . There are coronary vascular calcifications . A nasogastric tube is seen coiling in the stomach . A dual chamber pacemaker is seen with leads terminating in the right atrium and right ventricle . Nasogastric tube is seen coiling in the stomach , with its tip at the pylorus . Allowing for the limitations of this noncontrast study , the liver , pancreas , adrenals , stomach are unremarkable . A 1.8 cm exophytic renal cyst is seen on the left . A similar lesion is seen on the right , measuring 2.2 cm . The aorta is normal in caliber , with vascular calcifications . A small amount of free fluid is seen tracking around the liver , right pericolic gutter , along the mesentery and surrounding the right colon , which is collapsed . A small amount of nondependent free air is seen in the anterior aspect of the abdomen . The remainder of the bowel loops are fluid filled , and nondilated . CT OF THE PELVIS WITHOUT IV CONTRAST : As previously noted , there is a small amount of free fluid surrounding the right colon , tracking along the mesentery and into the pelvis . A small amount of free air is seen in the nondependent portion of the pelvis . Vascular calcifications are seen in the abdominal aorta and iliac arteries . Subcutaneous edema is noted in the lower abdomen and pelvis . A catheter is seen entering the left inguinal region and coursing along the iliac vessels , terminating in the left pelvis . Osseous structures are remarkable for degenerative changes of the spine , and a fracture of the proximal right humerus , with orthopedic hardware causing beam hardening artifact . IMPRESSION : 1. A small amount of free air and free fluid in the pelvis and abdomen , mostly along the right pericolic gutter and surrounding the ascending colon , concerning for perforation . Other bowel loops are unremarkable on this limited study . This was discussed with Dr. Jason Long at approximately 6:30 p.m. , 2013-05-23 . 2. Bilateral pleural effusions , right greater than left , with left-sided compressive atelectasis . 3. Right proximal humeral fracture status post fixation . The study and the report were reviewed by the staff radiologist . DR. Billy L. Boender DR. Pat K. Walton Approved : FRI 2013-05-24 4:01 PM Brief Hospital Course : 95 yo F with MMP who sustained a mechanical fall down stairs resulting in a hip and arm fracture . 1) s/p Fall - unlikely to be mechanical in nature . Patient has injuries to her shoulder and hip . 2) CV - Patient has CAD and CHF with a low hct and major trauma . She also has new changes on EKG . On pressor to hold mean 60 . 3) Anemia - patient transfusion dependant with a baseline of 28 . - transfuse 2 units today , with lasix 4) GERD - PPI 5) DM - glipizide , ISS 6) PMR - cont prednisone 7) GI : Ms. Pimental is an unfortunate 95 year old woman , status post a recent fall necessitating right ORIF of the hip and right wrist fracture ORIF , who was in the hospital for this event , when it was noted that she had abdominal pain , distention and coffee ground emesis with worsening mental status and renal failure . CT scan was obtained and this revealed free air and massive ascites . Pt underwent surgery on 05-23 1. Exploratory laparotomy with drainage of intra-abdominal abscess and peritonitis with gross soilage with bile and gastric contents . 2. Exposure and wide drainage of perforated posterior duodenal ulcer with internal and external drainage . 3. Feeding jejunostomy . 4. Tube gastrostomy . Continue to deteriorate spiking fevers with ventilatory support on pressors to hold the bp. with no improvement in mental staus was made CMO 5/20/5 . Expired at 5 pm Medications on Admission : lasix alt 40 mg and 20 mg qday levothyrox 50 mcg qday lisinopril 5 mg qday famotidine 20 mg qday fe so4 325 mg qday asa 325 mg qday toprol xl 25 mg qday glipizide 5 mg qday imdur 60 mg qdau prednisone 5 mg qday tylenol Discharge Disposition : Expired Discharge Diagnosis : MULTIORGAN FAILURE DUODENAL PERFORATION MULTIPLE TRAUMA Discharge Condition : deceased Followup Instructions : none Frank Linda MD 44-897 Completed by : Deanna Patague MD 48-130 2013-05-24 @ 1820 Signed electronically by : DR. Marta Keever on : FRI 2013-06-21 9:40 PM ( End of Report )