DATE OF EXAM: 10/07/2011 at 08:20.  SUBJECTIVE: The patient is an 80-year-old lady who was brought in to the Emergency Room last night unconscious.  I reviewed the reviewed the history in the system as well as reviewed the history from the patient's family at bedside.  The patient's daughter saw the patient during lunchtime and had lunch with her. She was in her usual state of health.  She has not had any fever or chills. No productive cough, no chest pain, no abdominal pain and no diarrhea.  She was in her usual state of health without any evidence of an infectious process.  After lunch time, the patient was supposed to get her flu shot and was on her way to get her flu shot.  The patient's family believes that she has gotten her flu shot.  They were not told otherwise.  It is presumed that the patient has received her flu shot.  We are at this time unsure of the route it was given if indeed she received it.  At around 6:00 after work, the same daughter came to visit the patient to cook her dinner.  She was noted to be unconscious, sitting up in her electrical wheelchair.  The patient does have episodes of syncope and has had multiple episodes in the past.  Normally this is associated with "bowel movement" vasovagal syncope).  At this time, the patient was not on the toilet bowl.  The patient's daughter did not smell or see any evidence of bowel or bladder incontinence or any sign that she had tried to move her bowels.  The patient's daughter tried to pick her up, thinking that this was one of her usual episodes of syncope.  She asked the nursing staff to help her wake the patient up, but when they could not wake up the patient, EMS was called.  When EMS arrived, the patient was noted to have low blood pressure.  The patient's daughter believes that she had taken all of her morning medications since her medication dispenser for that day was empty.  The only thing that they are not sure of is whether or not the patient took her "fibromyalgia pill".  The patient was then brought to the emergency room.  The patient remained unconscious and had to be intubated to protect her airway.  She was given IV fluid boluses without good response and started on vasopressor initially with dopamine and subsequently changed to Levophed.  While the patient was in the emergency room, the patient was noted to have a pulseless electrical activity.  They were not sure how long the patient had pulseless electrical activity and so CPR was performed.  The patient sustained some broken ribs as well as mild pneumothorax.  I have counseled the patient's family regarding this and they are aware.  The patient remains unresponsive on the vent.  Occasionally, she tried to move her upper extremities.  She is noted to have some movements of the lower extremity, but is not necessarily consistent with stimulation and not necessary purposeful.  Occasionally, she will bite down on her ET tube. She is also noted occasionally to be "ruminating".  The patient has guaiac positive stools, but there is no evidence of active bleeding or GI bleed. Blood count remains stable despite aggressive IV fluid hydration.  There is some decrease in blood count, but mainly secondary to hemodilution.  OBJECTIVE: GENERAL:  The patient is mainly unresponsive, intubated, on vent support and vasopressor support.  VITAL SIGNS:  Most recent vital signs showed blood pressure 114/90, heart rate of 98, respirations of 15-22, temperature 35.4 degrees centigrade.  Temperature minimum was 34.7 degrees early this morning. HEENT:  Normocephalic and atraumatic.  ET and OGT noted.  Pupils were 4-5 mm bilaterally and minimally reactive to 3-4 mm bilaterally.  Doll's eyes were equivocal.  There is some eye movements, but not entirely consistent with doll's eye movement.  Pink conjunctivae, no icterus.  I was unable to fully evaluate the patient's oral mucosa. NECK:  Supple.  CHEST: Lungs are symmetrical with good chest expansion.  Diminished breath sounds at the bases with occasional scattered rhonchi noted, otherwise no significant wheezing. CARDIOVASCULAR:  Normal rate, regular rhythm, S1, S2 noted.  I do not appreciate any rubs or gallops.  PMI is difficult to palpate secondary to the patient's low blood pressure.  No significant JVD noted.  GASTROINTESTINAL: The abdomen is globular very hypoactive bowel sounds, soft, no grimace to palpation, no rebound tenderness.  MUSCULOSKELETAL:  There is no significant edema of bilateral lower extremities.  Pedis pulses are significantly diminished.  The patient's extremities are cold to touch and the left upper extremity appears to be somewhat cyanotic. SKIN:  Cool to touch as noted above.  No other rash or skin breakdown noted.  I am not able to detect any injection site on both of the patient's deltoid areas. NEUROLOGIC AND PSYCHIATRIC:  Examination severely limited secondary to the patient's mental status.  Babinski are equivocal.  There are some occasional movements of both upper extremities and left lower extremity as noted above.  DIAGNOSTIC RESULTS: Laboratories obtained this morning showed WBC 12.2, hemoglobin 12.5, hematocrit 36.5, MCV of 93, and platelet count 243.  PT 11.6, INR 1.1. Sodium 151, potassium 3.6, chloride 113, CO2 18, BUN 47, creatinine 2.2, calcium 7.3, magnesium 3.8, phosphorus 4.4.  Lactic acid 4.6, alk phos is 614, total bilirubin 1.6, AST 213, ALT of 84, total protein 5.3, albumin 2.8, glucose of 166.  PH is 7.20, pCO2 42, pO2 of 109, CO2 17, oxygen saturation 95% at 60% FIO2.  Stools for guaiac came back positive.  Stools for Clostridium difficile back negative x2.  CT of the abdomen and pelvis obtained, preliminary reading, showed multiple findings without definite evidence of bowel obstruction, left-sided pneumothorax with left-sided rib refracture of the left transverse process at L1-L2.  Compression fracture of T12 of indeterminate age with marked compression deformities in retropulsion noted.  ASSESSMENT AND PLAN: * Hypotension with mental status change presumed to be secondary to severe sepsis with septic shock.  Unclear source at this time.  Urinalysis obtained did show some evidence of possible infection; however, this was a contaminated urine with a lot of squamous epithelial cells.  So far there is really no other definitive infectious source.  We will continue vasopressor support.  We will continue IV antibiotics with vancomycin and Zosyn.  We will need to ascertain whether the patient did receive a flu vaccine and what route it was given.  We might need to know the lot number.  I personally spoke with Dr. from Infectious Disease.  I recommend continuing IV antibiotics and this might need to be reported, especially once we are certain that the patient did receive a flu vaccine.  I will also order a rapid flu test.  We will follow the results of blood cultures and urine cultures. * Status post cardiac arrest with pulseless electrical activity requiring chest compression.  Initial troponin did come back negative.  I will not order further troponins since it is likely this will be elevated secondary to the CPR that was performed at the Emergency Room.  We will check digoxin level.  The patient was intubated for protection of her airway and from my understanding she did not have any respiratory arrest. * Acute renal failure.  I believe this is secondary to acute tubular necrosis (ATN) from the patient's hypotension.  I will repeat urinalysis.  We will monitor the patient's I's and O's closely.  At this time, it appears that the patient is starting to be oliguric.  We will continue IV fluid hydration and will obtain ultrasound of the abdomen. * Probable shocked liver secondary to hypotension with mental status change and hypertension.  Continue supportive care.  We will continue to monitor the patient's kidney function including PT and INR. * Osteoarthritis. * Neuropathy. * Hypertension.  The patient's blood pressure is low and needs vasopressor support, so we will hold the patient's amlodipine and benazepril.   Given the patient's acute renal failure, benazepril is not a good medication for this patient at this time.  We will try to obtain old records from the patient's primary care doctor. * Positive guaiac stools.  No evidence of acute bleeding.  Hemoglobin and hematocrit remain stable. * GI and DVT prophylaxis.  We will continue IV Protonix, but I will increase the dose to q.12 hours given the guaiac positive stools.  I will discontinue Lovenox, but I will give low-dose heparin subcutaneous injections instead given the patient's kidney function and guaiac positive stools.  It is easier to reverse the heparin than Lovenox if you do end up needing to reverse it. * Condition is very guarded.  Prognosis is poor. * Pending patient's clinical course and at this time, I will obtain EEG for altered mentation will hold off any sedation until after the EEG done.  The patient already has p.r.n.  Ativan ordered as well as fentanyl. DISPOSITION: Pending the patient's clinical course.  At this time, I will obtain EEG for the altered mentation.  We will hold off any sedation until after the EEG is done.  The patient already has p.r.n. Ativan ordered as well as fentanyl. Total critical time spent was 60 minutes including discussion with the patient.  The patient's family has been made aware of the critical nature of their mother's condition.  All of their questions were answered to their satisfaction.  DATE OF EXAM: 10/07/2011 at 11:15.  SUBJECTIVE: I was called to the bedside because of a rhythm change. I looked at the tele monitor and I was unable to see P-waves.  EKG has been ordered.  I was unable to find radial pulses right away.  Femoral pulses were very faint and were not necessarily correlating with electrode activity on telemetry monitor. Doppler ultrasound was used to monitor the patient's pulse.  The patient's pulse was noted to be 35 beats per minute, but heart rate on the telemetry monitor showed 70 beats per minute.  EKG obtained showed a junctional rhythm. Because of this 1 amp of atropine was given.  Prior to this, blood pressure was also in the 70s systolic.  The patient's blood pressure, telemetry heart rate and palpable pulse improved.  Repeat blood pressure obtained showed systolic in the 110s.  Repeat EKG done after atropine still showed accelerated junctional rhythm with a rate of 75.  OBJECTIVE: The patient remains intubated with altered mentation and unresponsive.  DIAGNOSTIC RESULTS: New laboratories obtained since the earlier visit with the new ABG obtained showed a pH of 7.27, pCO2 31, pO2 80, and CO2 15.  Oxygen saturation 93% at 60% FIO2.  Digoxin level 0.7.  Repeat chest x-ray, 1 view, obtained today showed bibasilar subsegmental atelectasis.  There is a left-sided central venous catheter seen with its tip apparently having been retracted now with appearance in the region opposing the medial clavicle head on the left.  No obvious pneumothorax was detected.  Reactive CRP was 1.8.  ASSESSMENT AND PLAN: * Electrical impulse dissociation presently with a junctional rhythm.  The dissociation improved with atropine. At this time, blood pressures are acceptable and heart rate is acceptable.  Because of the low pH and electrical rhythm and pulse disassociation, 1 amp of bicarb was given even though pH was only 7.27. Cardiology consultation would be obtained. Echocardiogram has been ordered. * Hypotension.  The patient's Levophed drip was titrated to 27 mcg per minute. * Presumed severe sepsis with septic shock.  Again, no focus can be found aside from questionable urinary tract infection, which was contaminated/colonized.  Inflammatory CRP is only 1.8, which does not really correlate with a person in septic shock.  Continue IV antibiotics for now. * Acute renal failure with acute tubular necrosis.  The patient is becoming more and more oliguric.  The patient was given 500 mL of normal saline bolus. The patient remains on fluid resuscitation. Kidney ultrasound has been ordered. * Please refer to the previously dictated progress note as well as diagnoses for further details. * Prognosis remains poor. Condition is very critical. * Total critical time spent was another 40 minutes.  DATE OF EXAM: 10/07/2011 at 1355 hours.  SUBJECTIVE: The case was discussed with cardiologist who recommended the patient will need to be transferred since she might need a pacemaker to be placed. Transfer was arranged.  The case was discussed with the intensivist at another Medical Center who accepted the patient in transfer.  Medevac was informed, but arrived at approximately 1356 hours, the patient was noted to have a rhythm change and became bradycardic and suddenly asystole.  Code blue was called, aside from me 2 other doctors responded.  Dr. ran the code according to ACLS protocol.  The patient was given 3 rounds of epinephrine and atropine.  Rhythms checks were made intermittently.  Despite aggressive progressive attempt, the patient remained in asystole.  The patient was coded for approximately 15 minutes and the code was called off at 1411 hours.  The patient's family was informed.  They were aware when the code blue was called.  I spoke to them during the middle of the code, informed them that we will continue to try cardiac resuscitation, will continue on for 15 minutes.  They agreed with the plan.  They were also notified after the code was called.  Patient's family was informed about the outcome of the code.  Because the patient has not been in the hospital for less than 24 hours, the cause of death cannot be ascertain at this time. The case will be forwarded to the medical examiner. Noncritical time spent was 15 minutes.