Medical Text: Admission Date:  [**2109-8-17**]              Discharge Date:   [**2109-10-16**]

Date of Birth:  [**2054-10-24**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
B/L ankle fractures, s/p fall

Major Surgical or Invasive Procedure:
[**8-18**]
.
1.  Closed reduction of left pilon fracture.
2.  Application of multi-planar external fixator left lower
    extremity.
3.  Closed treatment of calcaneus fracture with mild amount
    of manipulation.
4.  External fixation of Right Pilon fracture
.
[**8-30**]  Adjustment of external fixator of R pilon fracture
.
[**9-17**] ORIF right intra-articular distal tib-fib fracture R


History of Present Illness:
54 year old Spanish speaking male, in the US on vacation, with a
questionable PMH of liver disease presents after
jumping?falling? out a window.  Per his daughter he was drinking
alcohol with his son and reported feeling that someone was out
to kill him.  He locked himself in a second-story bedroom and
was later found by his daughter crawling outside.  He was
initially seen at [**Hospital3 **] and found to have opiates and
cocaine on UA in the emergency department there.  He was
transported to [**Hospital1 18**] with b/l ankle fractures.  Per family, the
pt has been confused at home.  In [**Name (NI) **], pt was aggitated and
received haldol and ativan.  He was later somnolent.  EKG
demonstrated atrial flutter with HRs in 110-140's, rate
controlled in the ED with IV diltiazem.

Patient is a poor historian, most information obtained from his
daughter

ROS: + b/l ankle pain, -CP, -SOB, -Abdominal pain

Past Medical History:
"Gets yellow"
High ammonia
HTN
questionable anginal history
depression, family states he see a psychiatrist

Social History:
EtOH abuse, polysubstance abuse, one ppd for mayn years
Urine positive for cocaine and opiates in ED
Not married
Daughter is involved in care


Family History:
Noncontributory

Physical Exam:
Vitals: 96.7 140/90 76 16 99% on 2L  NPO/1000
Physical Exam:
General: sleepy but arousable, oriented to place and person,
able to name the months of the year forwards, but not backwards,
not oriented to current month/year
HEENT: icteric sclerae, dry MM, + c-collar
CVS:  irregular rate, tachy, no murmurs/rubs/gallops appreciated
Pulm: CTA b/l, no wheezes, rales or rhonchi
Abd: soft, NT, mild hepatosplenomegaly, +BS
Ext: b/l ankle splints, mild bruising over b/l knees, - for
asterixis
GU: + foley

Pertinent Results:
CT C-Spine: negative for fracture
Left tib/fib: Comminuted fracture of the calcaneus. Dense sliver
of bone along the medial aspect of the proximal fibula, seen
only on a single view.  This could represent additional
calcification of the intraosseous ligament, a small cortical
fracture fragment, or a foreign body.
Right tib/fib: Comminuted, intraarticular, impacted, and
displaced fractures of the distal tibia as well as fracture of
the distal fibula as detailed above.
.
CT bilat LE
1. Comminuted intra-articular distal right tibial fracture.
2. Comminuted distal right fibular fracture with displacement.
3. Comminuted left calcaneal fracture.
.
RUQ U/S:
FINDINGS: The liver is coarse in echotexture without evidence of
focal lesion. The gallbladder is not distended due to nonfasting
stage. No evidence of gallstones. No evidence of intra- or
extra-hepatic biliary ductal dilatation and the common duct
measures 3 mm. The pancreas is not well visualized due to bowel
gas. There is no evidence of free fluid. The main portal vein is
patent with antegrade flow.
IMPRESSION: No evidence of cholecystitis.
.
Head CT ([**8-21**])
IMPRESSION: No evidence of acute intracranial pathology,
including no sign of intracranial hemorrhage.
.
CXR ([**8-21**])
No previous studies for comparison. Low lung volumes. Heart size
is difficult to evaluate in this semi-upright AP film. There
could be some LVH but no evidence for CHF and the lungs are
clear. Questionable slight impression on the right margin of the
tracheal air column which can be better evaluated by standard PA
and lateral chest films when condition permits.
.
Chest CT ([**8-23**]):
1. No juxtatracheal mass or left upper lobe lesion as questioned
on chest radiograph report.
2. Three foci of ground glass, right upper lobe, not detectable
on routine radiographs, a nonspecific finding. Six- month CT
follow up is recommended to look for change, because
bronchoalveolar cell carcinoma, though unlikely, cannot be
excluded.
3. Borderline size mediastinal and hilar lymph nodes should be
checked on followup CT.
4. Mild atherosclerotic coronary artery calcification.

Chest CTA ([**8-24**]):
1. No pulmonary embolism.

2. Relatively unchanged appearance of multiple ill-defined
opacities and tiny nodules in the right upper lobe. Follow-up
stated on the examination from 1 day prior is again recommended.


3. New foci of opacification present at the lung bases compared
to examination from one day prior likely related to aspiration.
Layering debris present within the right main stem bronchus most
suggestive of aspiration as well. Clinical correlation is
recommended.

4. Recommend advancing NG tube at least 4-5 cm. The current
position elevates the risk of further aspiration.
.
CT RLE with contrast ([**8-24**]):
IMPRESSION: Comminuted distal tibial and fibular fractures with
intra- articular involvement of the tibial plafond and lateral
displacement of the talus with respect to the tibia. Posterior
displacement of the distal fibular fragment.
.
CT LLE without contrast ([**8-24**])
Comminuted left calcaneal fracture.
Lentiform area of fluid attenuation at the skin on the
posterolateral aspect of the left foot. The significance of the
latter finding is uncertain, but may be due to a skin blister or
possibly dressing material within the cast. Clinical correlation
requested.
.
CXR ([**8-26**])
1. NG tube could be advanced several centimeters for standard
positioning, as described in prior exams.
2. New perihilar opacities, likely due to acute aspiration in
the superior segments.
.
Head CT ([**9-3**])
IMPRESSION: There is no evidence of hemorrhage or CT evidence of
acute infarct.
.
CT abd/pelvis ([**9-22**]):
IMPRESSION: No CT evidence of pyelonephritis or abscess within
the abdomen/pelvis.
.
CT LLE without contrast ([**9-26**])
1. Markedly comminuted fracture of the calcaneus with wide
distraction and dispersal of the fracture fragments as above.
2. Non-displaced fractures of the sustentaculum tali and of the
middle facet of the talus.
3. No fracture identified of the medial malleolus.
4. Non-displaced fractures of the anterior aspect and of the
inferior aspect of the lateral malleolus.
5. Non-displaced fracture of the cuboid.
6. No fracture identified of the navicular.
7. No other fractures identified within the remainder of the mid
foot or the forefoot.
8. Lateral subluxation of the peroneal tendons with respect to
the fibula.
9. Probable tear of the anterior talofibular ligament.
.
Echo ([**9-26**]):
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) Transmitral
and tissue Doppler imaging suggests normal diastolic function,
and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral

regurgitation. There is no mitral valve prolapse. The estimated
pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.


Brief Hospital Course:
During course of hospitalization, pt was put on CIWA scale for
EtOH withdrawal and given thiamine, folate and a multivitamin,
his AFib with RVR was initially treated with metoprolol, then
diltiazem, his high ammonia levels were treated with lactulose.
His b/l ankle fractures were followed by orthopedics.

The patient was severely agitated on more than one occassion
during this hospitalization, requiring three codes puples to be
called as well as requiring restraints for protection of both
the patient and the staff.

The patient was originally sent from the floor to the MICU with
delirium of unknown cause and severe agititation.  He required
increased amounts of sedation and was returned to the floor
after a NG tube was placed. Once returned to the floor, the
patient required less sedation, was taken off of any
benzodiazipines and only intermittently needed restraints.

The patient remained somnolent and delerious.  He pulled out his
NG tube.  He was also febrile and rhoncorous on the floor.  He
was initially treated with vancomycin and flagyl, which was
changed to azithro/ceftriaxone/flagyl.  He was scheduled to
return to the OR for revision of his right external fixation.
In preop holding, he was found to be hypoxic and sent to the
MICU.

MICU COURSE:  Morning of [**8-28**], patient scheduled to return to OR
for revision of externally fixated RLE. Upon transport to PACU,
patient became more somnolent and had reported "agonal
breathing". O2 sats 83% on 2LNC and NRB applied with O2 sats to
100%. BP in 90s/60s, HR in 80s, RR 17-19. ABG drawn: 7.38/58/90.
 During stay in MICU, patient coughed up large amount of thick
sputum with improved respiratory status.  Surgery postponed and
patient transferred to MICU for further monitoring. In the MICU,
respiratory status has remained stable with Sp02 in the high 90s
on room air.  Pt is hemodynamically stable in chronic a-flutter.
 Called out to floor on [**8-29**]- no further intensive care needs
identified.

In the MICU, patient was started on Zosyn and restarted on
Vancomycin wiht marked improvement in his respiratory status.
Within a few days of returning to the floor, Vancomycin and
zosyn were stopped as CXR showed resolution of questionable
aspiration pneumonia - this was felt to be more likely
pneuomonitis which resolved.
.
After the MICU, patient's delirium started to improve, but then
worsened when he returned to the OR for removal of external
fixation.  He developed fevers to 102F post-operatively which
likely worsened delirium.  Source of fevers unclear - of note
patient had recently developed VRE in his urine but infectious
disease did not feel this was an active infection.  he received
three days of antibiotics (daptomycin and then linezolid).  When
these were stopped he became afebrile and delirium began to
lift.
.
#Aggitation was mostly controlled with haldol.  Zyprexa was
tried for two weeks but it did not seem to help acute
aggitation.  QTc was monitored while patient was on
antipsychotics and was stable at approximately 420-440msec.
Overall etiology of delirium has remained unclear but was
thought to be multifactorial due in part to chronic alcohol use,
hepatic encephalopathy, benzodiazepine use, and post-operative
delririum.  Although spanish-speaking 1:1 sitters and
interpreters were employed as much as possible, language also
likely contributed to persistance of delirium. Delirium has
completely resolved patient is now restraint and sitter free.
All haldol has been stopped. He has past the period of etoh
withdrawal.  It is recommended that patient follow up with
alcohol abuse counseling.
.
#Afib/flutter
While febrile, his afib/flutter was complicated by more frequent
episodes of rapid ventricular rate.  This was controlled with IV
metoprolol when needed but also by increasing PO metoprolol and
diltiazem.  Treating fever with tylenol also seemed to help.  He
was briefly put on therapeutic lovenox for atrial fibrillation,
but this was stopped as he was not felt to be eligible by CHADS
criteria and also because of high fall risk.  Patient was
transitioned off of beta blockers and placed on Diltiazem 120mg
daily.
.
#Urinary retention
patient failed several voiding trials.  He also pulled out his
foley on several occasions, causing hematuria.  Intermittent
straight catheterization was tried to reduce infection risk of
long-term indwelling foley.  However given delirium and
aggitation this was untenable.  This resolved with reductions in
haldol. Patient now able to void freely on his own. History of
VRE on urine culture, but no signs of infection, dyruria,
increased urinary frequency. There is no evidence based
literature or other clinical indications to treat this
asymptomatic bacteuria at this time.
.
#Fractures
patient followed by orthopedics during admission.  L ankle
fractures treated with casting, however repeat plain films and
CT scan 4-6 weeks post-op showed fractures which were not
initially visualized. Orthopedics felt casting was still
appropriate and that there was no indication for surgery. R
pilon fracture managed initially with external fixation system
because of skin breakdown making internal fixation difficult.
One month into hospitalization ex-fix removed and tibial and
fibular plates were placed.  He is to remain Non-weight bearing
for a total of one month after his hospital discharge. Patient
has completed the necessary course of lovenox.He has a follow up
appointment scheduled with his orthopaedic surgeon Dr. [**Last Name (STitle) **]
for [**11-28**] at 1030am, at [**Hospital3 **] [**Hospital Ward Name **], [**Location (un) 1385**] of the [**Hospital Ward Name 23**] building.
.
Transfer to [**Hospital **] Rehab Hospital.

Medications on Admission:
Diltiazem 180 mg one daily

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*1*
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*15 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 2222**] - [**Location (un) 538**]

Discharge Diagnosis:
Primary:
1)	Bilateral Lower Extremity fractures
a.	Closed left tibial plafond fracture/pilon fracture.
b.	Dislocation left tibiotalar joint.
c.	Right calcaneus fracture, intra-articular
2)	Persistent agitated delirium ?????? resolved
3)	Aspiration Pneumonitis - resolved
4)	Alcoholism ?????? continuous
5)	Delirium Tremens
6)	Polysubstance Abuse (cocaine, opiates, alcohol)
7)	Atrial Fibrillation/Atrial Flutter
8)	Abnormal CT chest ?????? follow-up ([**2111-1-5**]) recommended
9)	Liver Failure ?????? presumed secondary to alcoholism (No evidence
for HBV or HCV infection)
a.	Thrombocytopenia presumed secondary to thrombopoitin
deficiency.  No evidence for splenomegaly on imaging.
10)	Elevated AFP level ?????? etiology as yet undetermined

Secondary:
1)	Hypertension
2)	Urinary retention ?????? resolved
3)	Bactiuria ?????? asymptomatic, colonized with Vancomycin resistant
enterococcus

Contact information:
[**First Name8 (NamePattern2) **] [**Known lastname 1794**] (daughter): [**Telephone/Fax (1) 74301**]
[**Female First Name (un) 74302**] & [**First Name9 (NamePattern2) 74303**] [**Known lastname 1794**](son) cell [**Telephone/Fax (1) 74304**]

For Follow-up:
1) Repeat CT scan of chest in [**2111-1-5**] to f/u 3 foci of
ground glass in the RUL as well as borderline mediastinal and
hilar lymphadenopathy
2) Assess etiology of elevated alpha-fetoprotein
3) Further evaluate etiology of pancyctopenia ?????? consider bone
marrow aspirate as well as HIV testing


Discharge Condition:
Stable, Non-weight bearing in both legs for one month starting
[**10-15**]


Discharge Instructions:
You were transferred to [**Hospital1 18**] emergency room after a large fall.
You were found to have bilateral ankle fractures. You had a CT
scan of your head which did not show any acute bleed. When you
came into the emergency room your heart rate was fast, and you
were given medications to help slow it down.
.
On [**8-18**] you had an operation on your left leg for a heel
and ankle fracture, you had several pins placed in your left
leg. Your left leg was then casted.
.
On [**8-30**] you had an operation on your R tibula fibula fracture
that stabilized the leg externally.
.
On [**9-17**] you had an operation on your right tibula and
fibula and screws were placed to help your leg heal.
.
During your hospital stay. You were very confused and placed on
many psychiatric medications, you became very agitated at
times,and had to be restrained at times.  This has resolved you
are no longer on any psychiatric medications.
.
While in the hospital you developed some breathing problems. [**Name (NI) **]
spent time in the intensive care unit, because there was some
worry that you might have a pneumonia, you were started on
antibiotics, but your breathing problems improves, and your
chest xray improved. It was thought that you did not have a
pneumonia and the antibiotics were normal.
.
You were also found to have some bacteria in your urine called
VRE, because you were not having, any burning with urination.
The infectious disease doctors thought that the bacteria should
not be treated.
.
You are being transferred to a rehab facility. It is important
that while at that rehab facility you, follow up and get
counseling for your problems with alcohol abuse.
.
You have follow up appointments schedule with both orthopaedics
and a new primary care physician. [**Name10 (NameIs) **] is important that you
follow up with both of these appointments.
.
It is also important that you do not put any weight on your legs
for next month.  Please return to the hospital or the emergency
room if your condition worsens in any way.

You had an abnormal chest x-ray/CT scan and should have this
repeated in [**2111-1-5**] to make sure you don't have lung
cancer.

Your blood counts were low but stable during your
hospitalization.  You should see a Hematologist (Blood Doctor)
about this and consider testing for HIV.

You had an elevation of a marker in your blood called AFP (alpha
fetoprotein).  The significance of this is not know.  It may be
related to your underlying liver disease but should be further
evaluated by a specialist.

You should absolutely refrain from further use of alcohol,
cocaine or any illicit drugs not explicitly prescribed to you by
a physician.

Ten??????as una exploraci??????n anormal [**Doctor First Name **] pecho x-ray/CT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 7214**]
esto
repetido en diciembre de [**2110**] para cerciorarse de t?????? no [**Last Name (un) 7214**]
pulm??????n
c??????ncer.

Tus cuentas de sangre [**Doctor First Name **] [**First Name9 (NamePattern2) 74305**] [**Last Name (un) **] [**First Name9 (NamePattern2) 74306**] [**Last Name (un) 33761**] tu
hospitalizaci??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7213**] [**Last Name (un) **] a un hemat??????logo (el doctor [**Last Name (Titles) **]
[**Last Name (Prefixes) 74307**])
sobre esto y considerar el probar para el VIH.

Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP
(alfa
fetoprotein). [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 74308**]??????n de esto no es saber. Puede ser
relacionado con tu enfermedad [**Doctor First Name **] higado [**First Name9 (NamePattern2) 74309**] [**Last Name (un) **] debe
ser m??????s futuro
evaluado por un especialista.

[**Last Name (un) 7213**] refrenarse absolutamente [**Doctor First Name **] uso adicional [**Doctor First Name **] alcohol, de
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????na o de cualquier droga il??????cita prescritos no
expl??????citamente a ti por un m??????dico.

Followup Instructions:
Ten??????as una exploraci??????n anormal [**Doctor First Name **] pecho x-ray/CT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 7214**]
esto
repetido en diciembre de [**2110**] para cerciorarse de t?????? no [**Last Name (un) 7214**]
pulm??????n
c??????ncer.

Tus cuentas de sangre [**Doctor First Name **] [**First Name9 (NamePattern2) 74305**] [**Last Name (un) **] [**First Name9 (NamePattern2) 74306**] [**Last Name (un) 33761**] tu
hospitalizaci??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7213**] [**Last Name (un) **] a un hemat??????logo (el doctor [**Last Name (Titles) **]
[**Last Name (Prefixes) 74307**])
sobre esto y considerar el probar para el VIH.

Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP
(alfa
fetoprotein). [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 74308**]??????n de esto no es saber. Puede ser
relacionado con tu enfermedad [**Doctor First Name **] higado [**First Name9 (NamePattern2) 74309**] [**Last Name (un) **] debe
ser m??????s futuro
evaluado por un especialista.

[**Last Name (un) 7213**] refrenarse absolutamente [**Doctor First Name **] uso adicional [**Doctor First Name **] alcohol, de
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????na o de cualquier droga il??????cita prescritos no
expl??????citamente a ti por un m??????dico.

Please follow up with Dr. [**Last Name (STitle) **] from orthopedic surgery you
have an appointment scheduled for [**2112-11-28**]:30 am, [**Location (un) 1385**] of the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name **] of [**Hospital1 771**]. Please call [**Telephone/Fax (1) 9769**] if would like
to change this appointment.

Please follow up with your new primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 15259**] on  [**2109-11-19**] at 3pm in the [**Hospital Ward Name 23**] Center on
the [**Location (un) **] of the [**Hospital Ward Name 516**] [**Hospital1 1170**].

You had an abnormal chest x-ray/CT scan and should have this
repeated in [**2111-1-5**] to make sure you don't have lung
cancer.

Your blood counts were low but stable during your
hospitalization.  You should see a Hematologist (Blood Doctor)
about this and consider testing for HIV.

You had an elevation of a marker in your blood called AFP (alpha
fetoprotein).  The significance of this is not know.  It may be
related to your underlying liver disease but should be further
evaluated by a specialist.




ICD9 Codes: 4019, 2875, 5990, 5070, 5180