Medical Text: Admission Date:  [**2115-2-22**]              Discharge Date:   [**2115-3-19**]

Date of Birth:  [**2078-8-9**]             Sex:   M

Service: MEDICINE

Allergies:
Vicodin

Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Post-cardiac arrest, asthma exacerbation

Major Surgical or Invasive Procedure:
Intubation
Removal of chest tubes placed at an outside hospital
R CVL placement


History of Present Illness:
Mr. [**Known lastname 3234**] is a 36 year old gentleman with a PMH signifciant
with dilated cardiomyopathy s/p AICD, asthma, and HTN admitted
to an OSH with dyspnea now admitted to the MICU after PEA arrest
x2. The patient initially presented to LGH ED with hypoxemic
respiratory distress. While at the OSH, he received CTX,
azithromycin, SC epinephrine, and solumedrol. While at the OSH,
he became confused and subsequently had an episode of PEA arrest
and was intubated. He received epinephrine, atropine, magnesium,
and bicarb. In addition, he had bilateral needle thoracostomies
with report of air return on the left, and he subsequently had
bilateral chest tubes placed.  After approximately 15-20 minutes
of rescucitation, he had ROSC. He received vecuronium and was
started on an epi gtt for asthma and a cooling protocol, and was
then transferred to [**Hospital1 18**] for further evaluation. Of note, the
patient was admitted to LGH in [**1-4**] for dyspnea, and was
subsequently diagnosed with a CAP and asthma treated with CTX
and azithromycin. Per his family, he has also had multiple
admissions this winter for asthma exacerbations.
.
In the [**Hospital1 18**] ED, 35.3 102 133/58 100%AC 500x20, 5, 1.0 with an
ABG 7.16/66/162. He had a CTH which was unremarkable. He then
had a CTA chest, afterwhich he went into PEA arrest.
Rescucitation last approximately 10-15 minutes with multiple
rounds of epi and bicarb, with ROSC. He was then admitted to the
MICU for further management.
.
Currently, the patient is intubated, sedated, and parlyzed.

Past Medical History:
Asthma
Dilated cardiomyopathy
Multiple admissions for dyspnea this winter ([**1-26**]).
Anxiety/depression
CKD
HLD
Obesity
HTN

Social History:
Unknown

Family History:
Unknown

Physical Exam:
ADMISSION:
VS: 35.9 124 129/67 99% AC 480x24, 5, 1.0
Gen: ETT in place, intubated, sedated.
HEENT: ETT in place.
CV: Tachy S1+S2
Pulm: Poor air movement bilaterally. Diffuse wheezes
bilaterally.
Abd: S/D hypoactive BS
Ext: 1+ edema bilaterally
Neuro: Unresponsive.
.
Discharge: 98.5 102/65 76 20 95-98% RA
In cage bed to prevent patient from falling out of bed.
Occasionally calling out. Lungs clear without wheezes.


Pertinent Results:
Labs on Admission:
[**2115-2-22**] 08:50AM BLOOD WBC-19.5* RBC-4.76 Hgb-14.9 Hct-44.3
MCV-93 MCH-31.4 MCHC-33.7 RDW-12.9 Plt Ct-201
[**2115-2-22**] 08:50AM BLOOD PT-14.1* PTT-25.9 INR(PT)-1.2*
[**2115-2-22**] 08:50AM BLOOD Glucose-306* UreaN-21* Creat-1.2 Na-144
K-4.1 Cl-111* HCO3-28 AnGap-9
[**2115-2-22**] 08:50AM BLOOD Albumin-3.4* Calcium-6.2* Phos-5.5*
Mg-2.2
[**2115-2-22**] 09:32AM BLOOD calTIBC-320 Ferritn-1129* TRF-246
[**2115-2-22**] 07:17AM BLOOD Type-ART pO2-162* pCO2-66* pH-7.16*
calTCO2-25 Base XS--6 Intubat-INTUBATED
.
Labs on Discharge
[**2115-3-18**] 11:34AM BLOOD Type-ART pO2-95 pCO2-33* pH-7.54*
calTCO2-29 Base XS-5 Intubat-NOT INTUBA
[**2115-3-5**] 05:35AM BLOOD ALT-49* AST-23 AlkPhos-53 TotBili-0.9
[**2115-3-19**] 04:45AM BLOOD Glucose-73 UreaN-25* Creat-1.4* Na-133
K-4.1 Cl-95* HCO3-21* AnGap-21*
[**2115-3-19**] 04:45AM BLOOD WBC-12.4* RBC-4.47* Hgb-14.3 Hct-41.3
MCV-93 MCH-32.0 MCHC-34.6 RDW-13.3 Plt Ct-352
[**2115-3-19**] 04:45AM BLOOD Neuts-56 Bands-0 Lymphs-38 Monos-3 Eos-3
Baso-0 Atyps-0 Metas-0 Myelos-0
.
CXR (in MICU): Mr read - cardiomegaly, RIJ in SVC, ETT 4.5 cm
above carina. Blunting of costophrenic angles bilaterally with
low lung volumes. Loss of retrocardiac diagphragm and bilateral
opacities (L>R)
.
CXR:
1. NG tube at 7.2 cm above the carina. [**Month (only) 116**] consider advancing
for optimal placement.
2. Severe cardiomegaly with globular shape. In the absence of
prior
comparison, the differential is broad, including moderate
pericardial
effusion, mediastinal hemorrhage, or acute cardiac failure.
Recommend
clinical correlation.
.
CTH: My read, no acute bleed
.
CTA Chest:
1. No evidence of pulmonary embolism, although evaluation of
subsegmental branches is limited.
2. Moderate cardiomegaly without pericardial effusion.
3. Bilateral dependent atelectasis.
4. Multiple nondisplaced rib fractures on the right, some of
which are subacute. Also possible subtle nondisplaced fractures
of the left ribs.
5. Nondisplaced acute sternal fracture in addition to a subacute
nondisplaced sternal fracture.
.
TTE: The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated. LV
systolic function appears depressed (ejection fraction ? 30
percent) with regional variation. There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
.
ECG (post-arrest):  Sinus with 1:1 conduction. LAA. LAD, RBBB,
LAFB. STD in V4-V6.
.
ECG (pre-arrest): Sinus with 1:1 conduction. LAD, bifascicular
block. No lateral STD.
.
ECG (OSH, unclear pre/post arrest): Sinus with 1:1 conduction.
Bifascicular (RBBB, LAFB) block. STD in V5-6.
.
EEG [**2-27**]
IMPRESSION: This is an abnormal video EEG telemetry due to the
slow and
disorganized background of 6.5 Hz with bursts of generalized
slowing
that showed no clear reactivity. These findings indicate a
severe
encephalopathy. This may be consistent with the patient's
history of
anoxia; however, toxic/metabolic disturbances, infection, and
medication
effects are also among the most frequent causes of
encephalopathy. No
clear epileptiform discharges or seizures were seen.

LUMBAR SPINE [**2115-3-11**]

CLINICAL INFORMATION: Evidence of fracture, seizure, fall, low
back pain.

FINDINGS:

Three views of the lumbar spine demonstrate mild narrowing of
the left
femoroacetabular joint. There is mild scoliosis of the
thoracolumbar spine.  The ventricular lead of a pacemaker is
identified. No fracture of L2 through L5 is identified. However,
there is a compression fracture of L1, with compression of the
superior endplate, and a sclerotic fracture line. Given the
mechanism of fall, if there is acute pain referable to L1, then
this would be considered an acute finding. There is no apparent
retropulsion of the posterior margin of L1 into the spinal
canal. No other fractures are identified at this time. Facet
joints are aligned. There is early calcification of the aorta.
IMPRESSION: Compression fracture of L1 with anterior wedge
deformity, likely an acute finding. No other fractures
identified.
EKG: Normal sinus rhythm. Complete right bundle-branch block
with left anterior fascicular block. Diffuse ST-T wave changes
laterally.
CT Head:
COMPARISON: [**2115-2-22**].
TECHNIQUE: Non-contrast axial images were obtained through the
brain.
FINDINGS: There is no intracranial hemorrhage, edema, or loss of
[**Doctor Last Name 352**]/white matter differentiation. Ventricles and sulci are
normal in size and configuration. The basilar cisterns are not
compressed. Paranasal sinuses demonstrate fluid in the sphenoid
air cells and right posterior ethmoid air cell, likely related
to prolonged hospitalization.  Mastoid air cells are well
aerated.
IMPRESSION: No evidence of acute intracranial abnormalities.


Brief Hospital Course:
Mr. [**Known lastname 3234**] is a 36 year old gentleman with a PMH signifciant
with dilated cardiomyopathy s/p AICD, PE not on anticoagulation,
asthma, and HTN admitted to an OSH with dyspnea now the
transferred to [**Hospital1 18**] MICU after PEA arrest x2.

# PEA arrest and subsequent anoxic brain injury.: Suspect that
original OSH PEA arrest due to hypoxemia or acidosis, with [**Hospital1 18**]
ED PEA arrest due to acidosis with admission pH 7.16 on arrival.
 TTE with evidence of RV failure to suggest PE. LVEF 30% with
known dilated cardiomyopathy. He was cooled per protocol.
Initially, his EEG was concerning without evident brain
activity. On hospital day 3, there was only comatose activity
and his prognosis was guarded. However, the patient was able to
be weaned off the vent and over the course of the next three
days his mental status improved.  He was alert, oriented to
place and day of the week and moving all 4 extremities.  He
became more interactive on transfer to the floor, was initially
speaking in spanish and English and not always making sense but
then started responding more appropiately and following
commands.  On hospital day 11 he had a witnessed grand mal
seizure and was given ativan and started on Keppra with
neurology consult.  His mental status was worse for 24 hours
after the seizure but then he slowly returned to his recent
baseline.  He was somewhat aggitated so his Keppra was switched
to Topiramate. He had a subsequent seizure on [**3-18**] with LUE
tonic clonic activity and impaired consciousness but this
resolved spontaneously after 1-2 minutes. He was contineud on
topamax per neuro recommendations. OT and PT were consulted and
worked with the patient as he will likely require a long
rehabilitation course.  At the time of discharge the patient was
alert, oriented (though not always to date), following commands
but impulsive with poor motor planning leading to several falls.
 Neurology notes indicate the patient has the potential
toimprove from a neurologic standpoint. He also may have
recurrent seizures which should be treated with ativan IV or IM
and do not neccessarily indicate patient needs to return to
hospital unless they continue for greater than 5 minutes or he
has multiple recurrent seizures or complications such as
aspiration.
-patient will be on Topiramate 25mg PO BID until [**3-22**] PM then
increase to 50mg po BID for seven days then increase to 75mg [**Hospital1 **]
ongoing.
-patient will follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) **] in his s/p
arrest neurology clinic
-patient will require intensive PT and OT in an anoxic brain
injury unit.
.
# Respiratory failure: Believed to be due to status asthmaticus,
although inciting event unclear. [**Name2 (NI) 227**] multiple cardiac arrests,
also a concern for development of ARDS.  The patient was
initially treated broadly with vancomycin, cefepime, flagyl,
cipro, and oseltamavir. He was treated with IV soludemedrol and
albuterol MDI. He was ventialted according to ARDS-Net protocol.
On admission, he had two chest tubes placed for pneumothoraces.
They were removed on hospital day 1. In his first several days,
his respiratory status was comprimised by lobar collapse, first
of the RUL and then of the RML. His extubation was initially
limited both by agitation requiring sedation and by requirements
for high PEEP to maintain oxygenation. His oxygenation was
improved with diuresis and agitation was better controlled with
seroquel. He was extubated on [**3-1**] and respiratory status was
stable.  His Asthma was treated with standing and PRN albuterol
and ipratriopium and a slow prednisone taper which he l
completed on [**2115-3-18**] and he was restarted on Advair
-patient may require additional nebs on top of his standing
advair though his respiratory status has been very stable,
without wheezing for the last week.
- would like benefit from outpatient PFTs and is scheduled to
see a pulmonologist in follow up.
.
# Ventilator associated pneumonia:  Patient developed a fever on
[**2-27**] with new infiltrates on chest xray while intubated. He was
initially covered with vanc/cefepime and cipro. Cipro was
eventually discontinued. He did not grow any organisms other
than yeast in his sputum. He completed an 8 day course of
Vanco/Cefepime.
.
# Myoclonus: when mental status improved, was noted to have
myoclonic jerks. per neurology, likely [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Syndrome
which is anoxic injury to the purkinje cells.  These jerks
continued for about one week and then became rare.
.
# dilated [**Last Name (LF) 89982**], [**First Name3 (LF) **] 30%. s/p ICD.  Patient was
diuresed with IV lasix in the ED and then transitioned to PO
lasix, home dose, on the floor.  His respiratory status remained
stable. Also continued on home dose of carvedilol and Lisinopril
but ACE downtitrated from 40 to 20 when had elevated Cr 1.9 on
[**3-18**] and slightly low BPs high 90s/60s. BP improved to 100s/60s.

.
#Hypertension: Patient's home regimen was continued on the
floor, but his SBP dipped into the high 80s and low 90s so
lisinopril was decreased to 20mg po daily and his SBP remained
100-130.
.
# L1 compression fracture: After the patient fell, he was
complaining of low back pain so a L-spine Xray was performed and
showed L1 compressin fracture with No cord impingement on
imaging.  The patient had no localizing deficits on serial neuro
exam.  He was treated with pain medication including low dose
ultram, standing tylenol and a lidocaine patch.  Calcitonin was
tried for pain with compression fracture but this did not seem
to help with symptoms so was discontinued.
.
# Leukocytosis: WBC >20  persistently in the MICU even after
being treated for infection.  Since no new infection was found
this was presumed [**12-26**] steroids and the leukocytosis improved
with prednisone taper.  WBC 12 on day of discharge
.
# Hyperglycemia: Patient is not known to be a diabetic and was
felt [**12-26**] steroids,  his sugars were controlled on sliding scale
insulin in the hospital but he no longer had insulin
requirements as his prednisone was tapered.
.
#. [**Last Name (un) **]: Cr 1.9 on [**3-18**] from 1.2 which improved to 1.4 on [**3-19**]
with decreasing ACE and 500cc bolus. He should have repeat
creatinine and labs on [**3-22**] to ensure stability.

# Guardianship: Guardianship paperwork was started in the
hospital.

Medications on Admission:
Carvedilol 25 [**Hospital1 **]
Lasix 80 mg po bid
Xanax 0.25 mg 1-2 tabs prn
albuterol MDI
Ibuprofen prn
Benadryl prn
Advair diskus
Lsinopril 40 daily

Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**11-25**] Tablet, Rapid
Dissolves PO QHS (once a day (at bedtime)) as needed for sleep.

9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain/fever.
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on and 12 hours off every 24 hour period.
13. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
16. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 3 days: 1 [**Hospital1 **] until [**3-22**] PM then increase to 2
tablets [**Hospital1 **] for 7 days then 3 tablets [**Hospital1 **] ongoing.
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
18. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
19. lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection twice a day
as needed for seizure that last longer than 5 minutes.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Anoxic Brain Injury s/p PEA arrest x2
Status Asthmaticus
Ventilator Associated Pneumonia
Chronic Systolic Heart Failure
L1 compression fracture
Seizures after hypoxic brain injury


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) because he has poor motor planning


Discharge Instructions:
You came to the hospital after having a cardiac arrest and an
asthma exacerbation.  You had another cardiac arrest in our
hospital and were admitted to the MICU.  You required intubation
but were able to wean off the machine and breathe on your own.
We treated you for pneumonia and asthma.  Your mental status
slowly improved, though you did have 2 seizures, last on [**3-18**].
You were started ons eizure medications for this.
.
Please take your medications as prescribed and follow up with
your doctors [**Name5 (PTitle) 7928**].

Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2115-4-3**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2115-4-3**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2115-4-11**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage




ICD9 Codes: 4275, 4254, 5849, 2762, 2760, 5180, 5859, 4280