CPC 8/19/16

Patient 56 year old man CAD nonischemic cardiomyopathy s/p LVAD prior R MCA stroke 2005 HTN HLD AFIB COPD Tobacco use

Meds Home Medications (from 'Document Medication by Hx') acetaminophen (Tylenol 325 mg oral tablet) 650 mg Every 6 Hours PRN By Mouth albuterol (albuterol 0.083% inhalation soln) 2.5 mg Every 6 Hours PRN Aerosolized amiodarone (amiodarone 200 mg oral tablet) 200 mg ONCE A DAY By Mouth amLODIPine (Norvasc 2.5 mg oral tablet) 2.5 mg EVERY MORNING By Mouth amLODIPine (Norvasc 5 mg oral tablet) 5 mg EVERY EVENING By Mouth aspirin (aspirin 325 mg oral tablet) 162.5 mg ONCE A DAY By Mouth [Order Comment: Dose reduced this admission.] calcium carbonate-magnesium chloride (calcium carbonate-magnesium chloride 112 mg-64 mg oral delayed release tablet) 2 tab(s) ONCE A DAY By Mouth carvedilol (carvedilol 25 mg oral tablet) 75 mg 2 TIMES A DAY By Mouth cefuroxime (cefuroxime 500 mg oral tablet) 500 mg 2 TIMES A DAY By Mouth clonidine (cloNIDine 0.2 mg oral tablet) 0.2 mg 2 TIMES A DAY By Mouth ferrous sulfate (ferrous sulfate 325 mg (65 mg elemental iron) oral delayed release tablet) 325 mg 2 TIMES A DAY By Mouth fludrocortisone (Florinef Acetate)(fludrocortisone 0.1 mg oral tablet) 0.1 mg 2 TIMES A DAY By Mouth folic acid (folic acid 1 mg oral tablet) 1 mg ONCE A DAY By Mouth levothyroxine (levothyroxine 25 mcg (0.025 mg) oral tablet) 25 mcg EVERY MORNING By Mouth lisinopril (lisinopril 20 mg oral tablet) 20 mg ONCE A DAY By Mouth pantoprazole (Protonix 40 mg oral delayed release tablet) 40 mg Before Breakfast By Mouth potassium chloride (potassium chloride 20 mEq oral tablet, extended release) 80 mEq 2 TIMES A DAY By Mouth senna (Senna 8.6 mg oral tablet) 17.2 mg AT BEDTIME PRN By Mouth simvastatin (Zocor)(simvastatin 20 mg oral tablet) 40 mg AT BEDTIME By Mouth thiamine (thiamine 50 mg oral tablet) 50 mg ONCE A DAY By Mouth tiotropium (Spiriva 18 mcg inhalation capsule) 18 mcg ONCE A DAY PRN Inhalation topiramate (Topamax 25 mg oral tablet) 25 mg ONCE A DAY By Mouth warfarin (Coumadin 2 mg oral tablet) See Instructions warfarin (Coumadin 4 mg oral tablet) 4 mg EVERY WEDNESDAY AND FRIDAY By Mouth

2009 CTH

What deficits would you expect based on his imaging??

Neuro exam 12/2009 (admission for confusion) MS - alert and oriented times three. Language is intact to commands, reading. Atypical memory deficits ie specifically in recalling his wife and wrist watch, he is able to spell "world" backwards without difficulty, Two of three delayed recall at 10 minutes, 2/3 delayed recall at five minutes. Fund of knowledge is good. Vocabulary is normal. CN - PERRL, EOMI, VFFTC, face symm, P/T/U ML, SCM/Trap 5/5. Motor - 5/5 x 4 normal tone Sens - intact to LT/temp/pain x 4, no ext to DSS Coord - normal FTN, HTS, RAM, no drift Gait - def DTR - 1+ UE/LE toes downgoing on babinski testing.

HPI 1 day prior to death Found down (1pm, unclear LKW), PEA arrest LVAD alarm – low flow state since 10:30 am Taken to OSH where started CPR, intubated and started on pressors, transferred to PUH 2:30 pm where CPR continued (~2 hours total)

Exam General: Laying in bed HEENT: Normocephalic TempC 34.8 (32.7-34.8) SBP 68 (30-81) DBP 64 (27-72) Pulse 70 (70-70) RR 33 (15-33) SaO2 73 (73-73). General: Laying in bed HEENT: Normocephalic CV: Regular rate on monitor, no pulse Pulmonary: Intubated NEURO MS: Unresponsive, Does not attempt to speak, Does not follow commands CN: No BTT, Gaze midline, L pupil ~2mm and R pupil ~1.5mm both not reactive to light, No obvious facial asymmetry around ETT MOTOR: Flaccid in all 4 extremities REFLEXES: Mute plantar responses SENSORY: No response to touch/nox stim in all 4 extremities COORDINATION: Unable to assess GAIT: Unable to assess NIH Stroke Scale 1A. Level of Consciousness (0-3) = 3 1B. LOC Questions (0-2) = 2 1C. LOC Commands (0-2) = 2 2. Best Horizontal Gaze (0-2) = 0 3. Visual Fields (0-3) = 3 4. Facial Palsy (0-3) = 0 5. Motor Arm Right (0-4) = 4 Left (0-4) = 4 6. Motor Leg 7. Limb Ataxia (0-2) = 0 8. Sensory (0-2) = 2 9. Best Language (0-3) = 3 10. Dysarthria (0-2) = UN 11. Extinction and Inattention (0-2) = 0 Total: 31UN

Other complications included ARDS, ischemic bowel Made CMO after discussion with family Passed away shortly after removing life-sustaining care