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HomeMy WebLinkAbout05-27-09COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, ORPHANS COURT DIVISION t ~ ~~ ANNA MARIE SAUL, An Incapacitated Person Case No. ~~ ~ I ~ O~~ ~1 VERIFIED PETITION TO ESTABLISH EMERGENCY GUARDIANSHIP OF AN INCAPACITATED PERSON Petitioner, Joseph T. Sucec, an attorney admitted to practice law in the Commonwealth of Pennsylvania, hereby seeks appointment of himself to serve as emergency guardian of his natural mother, Anna. Marie Saul ("Respondent"), pursuant to Title 20, § 5513, PA C.S, upon a determination that she is an "incapacitated person" within the meaning of Title 20, § 5501, PA C.S.,' is that she has been comatose and unresponsive to all external stimulae since early on May 18, 2009, with an uncertain prognosis and an unknown etiology of her condition. (1) Particulars concerning the person alleged to be inca~citated Respondenrt, Anna Marie Saul, is a residetrt of 325 Peach Glen-Idaville Road, Gardners, Pennsylvania 17324, in Adams County, PA, which also is her mailing address. Respondent, ?4, has been domiciled in the Intensive Care Unit ("ICU") of the Carlisle Regional Medical Center ("CRMC") since the early hours of May 18, 2009, when she was admitted and placed in the ICU. Respondent has not regained consciousness since being admitted. (2) Relatives and presumptive heir of the person alleged to be incapacitated Respondent's spouse, Russel Saul, died in 2004, and her pazents also are deceased. Her only child and presumptive heir is the Petitioner, Joseph T. Sucec. (1) The institution providing residential services to Respondent: Cazlisle (PA) Regional Medical Center, Intensive Caze Unit 361 Alexander Spring Road ' Sectioa 5501 defines an "incapacitated person" as one whose "ability to receive and evaluate information effectively and communicate decisions in any way is impaired to such a significant extent that [she] is * * * totally unable to manage [her] * * * financial resources or to meet essential requirements for * * * [her] physical health and safety." Certainly as individual who is comatose and unresponsive to all external stimulae meets this definition. Carlisle, Pennsylvania 17013 (4) Other providers of services to Respondent. Medical Care: Dr. Timothy A. Clark 2250 Millenium Way Central Pennsylvania pulmonary, associates Enola, PA 17025 (717) 7242791 Women's Cancer Center of Central Pa, p, C, 3901 N. Front Street Harrisburg, PA 17110 (717-221-5940; fax - 717_233-1939) Lary L. Sollenberger, M.D. 3907 N Front St, Harrisburg, PA 17110 (717) 232-4567) Moffitt Cardiology & Vascular Group 360 Alexander Spring Rd, Carlisle, PA 17013 (717) 243-6557 (S) Name and address of person to be appointed as guardian Joseph T. Sucec, Esq. (Petitioner) 325 Peach Glen-Idaville Road Gardners, Pennsylvania 17324 717-315-2359 (6) Petitioner's relationship to Respondent. Petitioner is the natural son and sole heir of Respondent, and as such has no ' adverse to that of Respondent. interest (7) Gross estimated value ofResPondent's estate. The estimated gross value of Respondent's estate is as follows: Balance of a $10,000 in a checking /savings account at PNC Bank; equity of approximat PPro~mately in a manufactured home situated on the real ro elY $50,000 Road, Gardners, Pennsylvania 17324, in A p ~~ known ~ 325 Peach Glen-Idaville aforesaid real property; several items of perso r~ial prop rt'y Ava uedsa~t lpes o~~~p °f the the aggregate. s than $5,000 in (8) Description of the medical condition and circumstances of the incapacitated person; reasons for seeking appointment of emergency guardian; Respondent was admitted to the Emergency Deparhnent of Carlisle Regional Medical Center early on May 18, 2009, and then transferred to the Intensive Care Unit ("ICU"); where she remains as of this writing. From the time of her admission Respondent has been comatose and unresponsive, with an uncertain prognosis. The etiology of her condition is unknown It is manifest that in her preseirt state Respondent is incapable of any communicative activity, a~ her consistent unresponsiveness to any external stimulae indicates that she is unaware of such stimulae. An attending physician, Timothy A. Clark, M.D., has affirmed, in an unsworn affidavit submitted as Exhibit A hereto, and as an independent evaluation, that it is not medically possible to predict how long her present status will continue, particulazly in light of its unknown etiology. This comment is substantially in toto by the unsworn affidavit of Ih. Clazk. In view of the foregoing, no ahernative to the present treatment milieu is possible. In addition, attached as exhibit B, are the records retained by CRMC regarding Respondent's condition as May 21-22, 2009. The reason for seeking appointment of an emergency guazdianship is that Respondent has property and financial obligations that require immediate attention, including the obligation to pay a mortgage premium that is due. (9) Plenary guardianship of the person and estate of Respondent is sought. Because Respondent's incapacity is total, Petitioner seeks appointment as a plenary guardian of the persons and estate of Respondent. (10) Qualifrcations of Petitioner pertinent to his request to be appointed plenary guardian of the person and estate of Respondent: Petitioner, an attorney since 1994, has an unblemished record and broad experience in the law, particularly in criminal, transportation, and family law, so that it is likely that Petitioner can manage any aspect of Respondent's financial or business affairs. Furthermore, Petitioner, as the only son of Respondent, has a close and long-standing relationship with her, sharing a home with her for the last five years. Please note that 20 Pa. C.S.A. 5511(f), provides that a "family relationship to [az- incapacitated person] shall not, by itself, be considered as an interest adverse to the alleged incapacitated person." (I1) Additional relief sought. Petitioner requests that the unsworn but verified affidavit submitted herewith as Exhibit A, which was executed by Dr. Timothy A. Clazk on the basis of his role as a physician attending Respondent, be accepted by the Court as an independent evaluation to satisfy the requirements of 20 Pa C.S.A. 5511(d) and 5518. Please note that Dr. Clark does not have along-standing relationship with the Respondent or with Petitioner, and Respondent's estate is modest. (12) Further, petitioner respectfully submits that both his close familial relationship with the Respondent, as well as the modest cash value of the estate involved merits a waiver of any bond requirement indicated by the relevant statute. WHEREFORE, petitioner respectfully requests that he be guardian of both the person and estate of R aPpomted emergency Plenary espondent. S~~1lG~i Respectfully submitted, h . Sucec, Esq., pro se '~ +~ ~_ 25 Peach Glen-Idaville Road Gazdners, PA 17324 (717)677-9284 VERIFICATION I hereby AFFIRM under penalties prescribed by 18 PA C.S. Sec. 4904 and, except or unless otherwise indicated, on personal knowledge that the fore o COQ, and any matters herein that are be and m g ~ maters aze true and affirmed to be true and correct to the best of y ~~~ knowledge are hereby my lalowledge, information, and belief. Date: `~ 7 EXHIBIT A AFFIDAVIT t. Submitted herewith is the unswom affidavit of Timothy A. Clark, M.D., executed pursuant to his status as a physician attending Respondent, T. Clark, M.D., Respondent became comatose at approximately 3 a.m on May 18, 2009, and has remained in that state since then. Respondent's prognosis, according to Dr. Clatrk, is "uncertain". In her present state, Respondent is wholly unable to engage in normal intellectual or communicative activities, and thus is manifestly unable to manage her financial and other affairs. 2. Resporxlent underwent emergency surgery on or about Apri16, 2009 after cancerous growths were detected in her intestinal tract in the course of a colonoscopy that was conducted after discovery of a reappearance of cancer of the uterus. Following the emergency surgery, Respondent exhibited symptoms of serious dementia and was placed in an intermediate-care nursing facility operated by Manor Care at 940 Walnut Springs Road, Cazlisle, PA. In response to aggressive rehabilitative measures Respondent exhibited gradual, limited improvement, to the point that she was able to leave the nursing home on the evening of May 17, 2009, to have dinner with Petitioner. Respondent returned to the nursing home during the evening of May 1 ?. 4. Only a few hours after the above-described dinner outing, however, Respondent was discovered in an unconscious state, removed by ambulance on an emergency basis to the Intensive Care Unit of the Cazlisle Regional Medical Center, and remains there as of the filing hereof. 5. Respondent's present incapacity manifestly renders her unable to deal with her ongoing financial obligations and thus could that, if neglected, will result in seriously adverse consequences. For example, Respondent is obligated to pay a monthly mortgage premium of $770, the current installment of which is due as of June 1, 2009, Other monthly bills include (but are not necessarily limited ta) telephone service, propane delivery, and several outstanding credit cazd bills in the name of the Respondent. 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ND.. ~~ dM~ rr+~.r..•t Mr ~- e~...........r..ar..s n......~...~,r. ~ pracacr ss: prlnc~n'tlie pra~ireelorr! bir~ifiaas an~r lerae~n as Gerial Paruis~hpnia PRiiwrary AMOOirilea, wlMr ailioes at TZS0111'Ifss111e11111fi1r, Enols, PA 17'0?5 (let {7~T) 722791). 2 ! hw ta0c+allr frr+rMd I1nnw M~is Co.,~, an aidery Cas+caeirt tbwaM• wND 1 IM1091i1irw is tie sirbjaet aflMe irr~ar~t P*~~• sines 11Aa7r 20.20Q9~. Ttte paliati iena~ arelcsry~ ~ m aie tiro and nenreins g. F'ren~ fhe isiirre d trn ~dn/MIOfr ID S~ CI~iM(: 6ne bean COrrr~ae and tSMeSipOfilille, s~ an teio~tleti tailararrri. Mre. 8aisr 111as adrriiMed b lie ICU snd re belnp st sct#~ rink d aa~Y~p and in aaeid tit ellrasup 4_ ~ is r+rsriifed lraR in trar nnra~art stale I~ i9aur is aorMigenR iaireliporMMerraw b aril-e~rnal siirrriir awn urtrbre n preOirs ibw ~ her ps'lMit llt6Nt rril r ~~ ~ ~ P~~ Mre. slwl has Oe~. 711e e~DIDQY Oi her COrldl6on is ~a beOalree llIR1NOi and ~ awwwd as t1f arq commtuNtaletie eCrIYA~'. ana liar ~ She it raarnrrrr of track semalao. 1 pertloirlrrly In I~It dis adoriawn 'S. M aoaorderroe ttrh hsrwieFr. ss grporbed 1o are Drier riisrribwe dlfia niadfcal ~ by her srxt and lie Pieiwrer hsrein~, JasaOli T. 9aoee, her lritiraNtt pleb atoms Mrs. 9rr,l b rwrniN in r>. ICU so lorq as harcorrdtMon ntitainssfa6e~e~rllMy and stirs oatiarw b R~ ire lerai d toare prvriied I~t t'se iCt/ As hstrcotidtiort aA~sa,, wi Ite~rats b tafreterrirg her b err iaa>tlrig ~f-- 7ltane are no cagRilr~ble irrdcaiorts at ~ WneaR b Marrierarvrttett her oorrdFiort r~ rlrarsp~ t 1 hereby AFFIRM txrder pNte9ies preeeabaA MI 1s! PA ~ Sss~ ~9Q4 and. aeaoept or aiiees erter~afee nolle4 ~ Pmt ~ lrat rte foregoiy are Mtre and carat. Arty ntstllers herein 1f~t are 6syarrd ~ penicml I~slpe ane heralty Slrtrgred!iQIDeMae ~rrd e~ortectb ihs 6astat ny lararrle~}1~ intormiriTortti snd beef. alt Tirt A Clerk, M.D. Arerldirl~ PlinnnnrY sM r~tYc91 Caw M~diotno. ~~~ MEDICAL CENTER PATIENT CONTACT RECORD ~ 44C~ Emergency Contact Please list the person(s) you would like us to contact in the event of a medical emergency 1. Name Relationship to Patient: Home Phone: Work Phone: 2 Cell Phone: Permission to discuss details of your account: Yes No Name Relationship to Patient: Home Phone: Work Phone: Cell Phone: Permission to discuss details of your account: Yes No 3. Patient is a resident of a nursing home: Yes No / If yes, name the facility Patient's Rights and ResnansibLiities fin~atlents Onlvl I have received a statement of the Patient's Rights and Responsibilities. (Imhal~here) _~~~{2~1 Sigma of PatientlResponsible Party ~\ Date Dear Patient, . To protect patient confidentiality, the following personal identification number has been assigned to you. Medical information will not be disclosed or discussed with anyone who cannot furnish this number to our staff. You may give the mtmber to anyone you wish to have access to your medical information. rio isos ti~oel Carlisle Regional Medical Center Call (717 249-1212 and ask to speak to the patient's nurse. (Personal Identification Number) 'To protect patient confidentiality, the above personal identification number has been assigned to the patient. Uur stafl'wiii nut disclose or discuss medical information ~xith aripone who cannot furnish the -ti~mber written on this gird to our staff Carlisle Regional Medical Center Call (71 ~ 249-1212 and ask to speak to the patient's nurse. (Personal .Identification Number) 'I'o protect patient confidentiality, the above personal identification number has been assigned to the patient. Our staff will not disclose or discuss medical information with anyone who cannot ftirnish the number written on this card to ottr staff. 4' w~srtA ~' "Inaml.r spltw Rwd . c"'la., PA 1T016Nl~ ~ nt71 ~'~+' CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME SAUL, ANNA M ATTENDINfi PHYSICAN ROMSS, JEAN-PAUL ACCOUNT ~, 9 4 3 4 4 4 Q DATE i TIME OF ADMISBwN 0 5/ 18 / 2 0 0 9 0 3:24 CONSENT TO HOSPITAL CARE AND TREATMENT l AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND 1 VOLUNTARILY CONSENT TO THE RENDERING OF SUCH CARE, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY IT8 MEDICAL STAFF, OR THEIR DE5IGNEEB, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. 1 ACKNOWLEDGE AND UNDERSTANpp THAT MANY OF THE PHYSICIANS ON THE STAFF 011 THIS HOSPITAL, INCLUDING THE ATTENOINCi PHYSICIANIS) NAMED ABOVt, ANO RAOIOi.OGISTS. ANESTHESIOLOG{STS: PATHOLOGISTS ANO EMERGENCY PHYStC1AN8, ARE NQT EMPLOYtES OR AGENTS Of THE' HOSPITAL. eUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN OIUINTED THE PIIIVILEGE OF USINIE THE HOSPITAL FACIUTIEB FOR THE. CARE ANO TREATMENT OF THEIR PATIENTS. !AGREE TO ACCEPT 7HEU1 CARE EVEN. THOUGH THEY ARE. NOT EMPLOYED SY THE HOSPITAL. I UNDERSTAND THAT THE EXAMINATION ANO TREATMENT. THAT ! RECEWE ON AN EMERGENCY BASIS 18 NOT INTENDED AS. A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE.. CONSENT TO RELEASE INfORMAT101b I HEl1ESY AUTHORIZE THE HOSPItA~, TO DISCLOSE TtT INSUR~lNC1E COMPANIES, INCLUDINS, WORKE)1S ~b1~ENSA71pN1" CARRIER OR OTHER PAR'hES THAT MAY SE LIABLE FOR ALL 011 PART Of THE HO$MTAL CHARGES ALL 0!t PPART O1It (+AY H08PFTAL RECORDI~ AIE MAY BL NE~ IUgCkUDN~q Af~ll `. TREATMEMIT fat! ALCOF1~ OR DRUQ AWl1~: OR QEPENDENCEI. Tit. DETERMINE BENEFIT'S ENTCTLEMENT ANQ PIWCESS PA CLAIMS FOf1 HEALTH CAR# SERVICES PRGvIDEQ. , N~ICARE CERTMICATION II~.EA>IS TIME Xflf OIL, THE SQdAfi- SECURITY ACi'.IB SQdAt SECURITY AOIIIMNISTRI-TKk[ OII ITS REQUEST THAT PAYMENT OP AUTHORIZED- FlRSONAL 'AND VAWASLES I UNDERSTAND THAT 'ME HOSPITAL SHALL NOT BE LIABLE FdR THE LOSS OR DAMAGE QP ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY, GLASSES, DENTURES: DOCUMENTS, CLOTHING, ETC:1 UNLESS SUCH-ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSFITA{: WILL NOT 8E LIABLE IN EXCE88 OF t60 FOR THE L09S OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. ~. I UNDERSTAND THAt 1 WILL RECEIVE A BIl6 FROM TFIE HOSPITAL F0I1 PROVISION OF THE HOSPITAL SERVICES, INCLUDING StAFf AND EQUIPMENT, AND FOR- ANY SUPPLIES OR MEDICINEf UTILIZED. I WIL{. ALSO RECEIVE A BILL FAOM ANY- PHYSICIAN WHO- FROYIOES PROFE8810NAL CARE TO ME. FOR EXAMPLE. 1 MAY RECEIVE A SEPARATE BILL Ft~M ONE OR MORE OF THE FOLLOWING TYPES Oi PHYSICIAN= WHO RENDER SERVICES.: TC ME: MY ATT'ENDRiO PHYSICIAN ON PERSONAL. PMYStC1AN, EMERGENCY ROOM PHYSICIAN, RAOIOLOQIST, ANESTHESIOLCG18t, PATHOLOGIST, QR ANY OTHER SPECMLIST. INStNtANktE ASH' ` , t HERi1Bi't ASSKHi'-T0 ANO AUTHOlW 1'~ INSU~BENERTS OTHE~R~NIO E PBL! INSURANCE BENEf1T'S INCLUDES eUT IS NO HOSPITAL OR PHYSICIANS.. FILING PROOFS + MAY BE AMENDED FROM TIME TCt TIME W{TI THAT MAY BE REASONABLY NECESSARY TO STATEMENT OF FINANCIAL RESPONSIMLIT t UNDERSTAND THAI 1 THAT SHOULD l NOT P/ AGREE TO PAY COST! INTEREST WHICH SHAL1 FRAU ANY PERSON WHO KNOWINGLY AND WITH INTENT 70 INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM CONTAINING FALSE, INCOMPLETE OR MI$IEADiNG INFORMATION MAY eE SUBJECT TO PROSECUTION UNDER APlLICABLE LAW. ADVANCE DIRECTIVE IFOII ADMISSroN TO HosPITAt ONLYt IF 1 AM TO 0E ADMITTED TO THE HOSPITAL, I NAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. 1 HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT 1 AM NOT REQUIRED TO HAVE AN ADVANCE DIRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. 1 UNDERSTAND THAT THE NOSRTAL AND MY CAREGIVERS WILL FOLLOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. iRYIT1Al THE FOLIOWINO OPTION THAT APPLIES) • I HAVE EXECUTED AN ADVANCE DIRECTIYE AND WILL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. • 1 HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO. INIT. !FOLLOW-UP DONE BY . 1 WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. INIT. CERTIFY THAT {HAVE READ IOR HAVE BEEN READ) THE ABOVE CONSENTS AND CERTIFI T SATE: MONTH ~ ~--~ 'SIG T E F PI UNDERSTAND AND AGREE WITH THEM. WITNESS ~ PRINT NAME OF PERSON ABOVE HMA7110 INIT. DATE 843~4~W i~I~I~~M~~~~~ AND LEGALLY RESP'ONSIECE FOR CHARGES NQT COVEREa IN FULL SY ANY THIRD PARTi~. 1 FURTHER AGREt VIT)IIN THIRTY !30! GAYS AFTER THE DATE OF DISCHARGt, MY ACCOUNT WILL BE CONSIDERED DEtINOUENT, I , INCLUDING REASONABLE. ATTORNEY'S FEES ANi3 COSTS, COLLECTIQN AGENCY' FEES AND COSTS,. AND' 1 ` PATIENT. SAUL, ANNA r MED t#tt~;: 000064585 ADMIT DATE: 051,~r2009 CHIEF COMPLAINT: Hypoglycemia with altered mental status. HISTORY OF PRESENT ILLNESS: Mrs. Saul is a 74year-old lady with a past medical history of coronary arts. disease, chronic obstructive pulmonary disease, hypertension, diabetes mellitus type 2, and history of ovarian cancer. The patient is a nursing home resident. (the patient has significantly altered mental status and was not possible to obtain appropriate history from the patient. As such, we used the nursing hams records as wel! as the emergency room charts.) Apparently the patient was found unresponsive in the early hours of the rooming with fasting blood sugar of 44 and it seemed as if the patient also had another episode of hypoglycemia the day before. She was given 1 mg of glucagan and sugar orally. She remained unresponsive and was transferred by EMS to the Carlisle Regional Medical Center for further evaluation and treatment. Upon arrival in the ER, her blood sugar was 81. BRIEF EMERGENCY ROOM HOSPITAL COURSE: The patient's blood pressure was 184/66 with a respiration of 32, pulse 117, temperature 96.5, oxygen saturation 94°lo an room air. While in the ER, the patient's oxygen saturation dropped to about 84°~ on about 4 liters nasal canula. She was placed an non-rebreather mask with oxygen improving to 9896. it should be noted that the patient remained nonresponsive and appeared to be in severe respiratory distress. 8 type natriuretic peptide done in the ER was 618 and the patient was given Lasix IV with diuresis of more than 8500 mL of urine. Upon review of the nursing home records and emergency room record, the patient was seen previously in the ER with hypoglycemia, which was treated and the patient discharged back to the nursing home. REVIEW OF SYSTEMS: Unable to obtain. PAST MEDICAL HISTORY: As per HBP, otherwise unable to obtain. ALLERGIES: PENICILLIN AND SURGICAL TAPE CURRENT MEDICATIONS: Nystatin, Aliegra, Robitussin, Qcean spray to the nose, Travatan, Combivent, Advair, Maalox, l3enadryf, Synthroid, Megace, risperidone, prednisone, Fiorastor, Klonopin, iron supplement, Zetia, Lantus, Imdur, aspirin, Coreg, Cipro and Tylenol. FAMILY HISTORY: Unable to obtain. SOCIAL HISTORY: The patient is a nursing home resident. As per nursing home records, the patient has alcohol or current tobacco usage. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 121/40 with heart rate of 70, respirations 25 with a temperature of 37.4. The patient is saturating at 97% on non-rebreather. GENERAL: The patient is lying supine in bed and appears to be in moderate respiratory distress. She is able to move ai) extremities but is completely but is unresponsive to painful stimuli. HEENT: Normocephalic. Head is atraumatic. Oropharynx is clear but there are some oral lesions, suspicious of bite marks. Pupils equal, round and reactive to light. Extraocular eye movements not tested. PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05!18/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01!26/1935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING: Amusa Ntatin, MD CARLISLE REGIONAL MEDICAL CENTER HISTORY AND PHYSICAL EXAMIN}1TION Page 1 of 3 PATIENT . 3AUL, ANNA MED Rte: 000064585 ADMIT DATE: 05! ~ „r2009 NECK: Supple. No jugular venous distention. CHEST: Normal chest wall excursion. LUNGS: Bilateral rhonchi, no crackles heard. HEART: S1 and S2 heard, no murmur, rub or gallop. Rhythm is regular. Peripheral pulses palpated. ABDOMEN: Soft, nontender and nondistended. Bowel sounds heard. No organomegaly. EXTREMITIES: Mild pedal edema. No calf tenderness. NEUROLOGIC: The patient is unarousable but most all extremities inappropriate in response to painful stimuli. Deep tendon reflexes present bilaterally in both lower extremities. Babinski is downgoing bilaterally. Otherwise unable to complete a full neurologic exam. SKIN: Warm, dry, normal coloration, no skin rash. LABORATORY AND X-RAY REVIEW: ABG done in the ER shows a pH of 7.5, pC02 of 30, P02 440, bicarbonate of 23. This is after the patient was intubated with Fi02 of 100%. A V/Q scan done in the ER is unremarkable with no evidence for PE. Ahead CT scan done in the ER shows chronic vascular changes associated with aging. No acute intracranial abnormality. A chest x-ray done is consistent with CHF with possible pulmonary edema. Hemoglobin was 8 and hematocrit 23 with white blood cells of 13.4, platelets 218. INR was 1.5, creatinine 1.7, BUN 37, sodium 139, potassium 4.8, C02 25.2. First set of cardiac enzymes done showed a troponin I of 3.15. ASSESSMENT: 1. Change in mental status, rule out seizure. 2. Congestive heart failure with pulmonary edema. 3. Non ST elevation MI with ischemia secondary to sepsis. 4. Sepsis (secondary to possible pulmonary source). 5. Acute anemia, rule out GI bleed. 6. Uncontrolled diabetes mellitus. PLAN: The patient has been intubated in the ER to protect the airway and is currently sedated with Diprivan and on mechanical ventilation. She will be transferred to the intensive care unit. A neurology consult and EEG to rule out seizure has been requested. Serial cardiac biomarkers and EKGs have also been requested and a cardiology consult with the Moffitt Heart and Vascular Group requested. The patient will get a 2 dimensional echocardiogram to evaluate left ventricular function as well as to assess for any segmental wall motion defects suggestive of ischemia. Given that the patient is anemic and that the NG tube that was just placed is suctioning bloody material, we are not going to start any anticoagulation in the patient. We are going to hold the previously ordered heparin subcutaneously as well as PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05118/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01 /26!1935 ACCOUNT: 9434440 DISCHARGE DATE: DICTATING: Amusa Ntatin, MD CARLISLE REGIONAL MEDICAL CENTER HISTORY AND PHYSICAL EXAMINATION Page 2 of 3 PATIENT: SAUL, ANNA MED REc:: 000064585 ADMIT DATE: 0511 c., ~t709 aspirin. We will modify the patient's insulin regimen and place her on sliding scale for now until her blood sugar is consistently well controNed. Given that she has been hypoglycemic, she has been noted to be hypoglycemic several times. Will type and cross match 2 units of packed red blood cells and will closely fol{ow hemoglobin and hematocrit and any significant drop will be corrected. In addition, we will obtain a GI consult for possible GI bleed. We have started the patient on Protonix IV. I have discussed with the patient's sister as well as the patient's son who is her power of attorney and have updated both of them on the critical nature of the patient's illness. DD: Mon May 18 18:35:37 2009 DT: Tue May 19 05:22:28 2009 15484738/1209 CC: PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05!18/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D Signed: Amusa Ntatin, MD DOB: 01 /26/1935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING: Amusa Ntatin, MD CARLISLE REGIONAL MEDICAL. CENTER HISTORY AND PHYSICAL EXAMINATION Page 3 of 3 1 PATIENT : CAUL, ANNA DATE OF CONSULTATION: 05/20/2009 REFERRING PHYSICIAN: { r MED RE4: 000064585 ADMIT DATE: 05/1 ~i2009 CONSULTING PHYSICIAN: Timothy Clark, MD HISTORY OF PRESENT ILLNESS: This is a 74-year-old, white female, who was admitted to the Carlisle Regional Medical Center on 05/18/2009. The patient was admitted from Manorcare. The patient was admitted with episode of unresponsiveness in the early morning hours and was found to have a low blood sugar at that time. The patient reportedly had an episode of hyperglycemia prior to that as well. The patient was given glucagon and sugar at that time. The patient was transfer-ed by EMS to the Carlisle Regional Medical Center for evaluation in the emergency department. I have been asked to see this patient for a critical care evaluation in consultation. The patient's son was interviewed at the bedside in regard to the patient's condition. The son is currently planning on petitioning the court for guardianship. The son does state that his mother was alert and oriented last Friday. The past medical history, social history, family history, allergies and review of systems are all noted in the admission HBP. PHYSICAL EXAMINATION: VITAL SIGNS: Noted in the bedside record. HEAD AND NECK: Pupils are unresponsive but not significantly dilated. The left eye is gazing to the left somewhat. The right eye is midline. Neck is supple. Endotracheal tube is secure. There is a gag reflex. CHEST: No extra sounds or murmurs. LUNGS: Decreased breath sounds at the bases. Scattered rFtonchi. ABDOMEN: Soft, nontender. Bowel sounds are heard. EXTREMITIES: No clubbing or cyanosis. There is 1+ bilateral pitting edema. NEUROLOGIC: The patient does have a gag reflux. She has unresponsive pupils; however, they are not dilated. Other neurologic exam is deferred to neurology. DIAGNOSTIC STUDIES: Laboratory data as well as radiographic data are noted in the computer database. IMPRESSIONS: 1. Critically ill. 2. Respiratory failure. 3. Unresponsiveness; etiology of such is uncertain at this time. This may be secondary to seizures as noted by neurology. In addition, underlying encephalopathy due to metabolic etiology such as azotemia/elevated BUN may be a possibility as well. 4. Urosepsis. 5. History of ovarian cancer with metastatic disease. RECOMMENDATIONS: 1. Maintain vent until the patient is able to protect her ai-way. 2. Continue with respiratory treatments. 3. Continue with neurologic evaluation and treatment. 4. Consult nephrology regarding renal failure. If we can decrease the BUN, the patient's mental status may improve. 5. Check laboratory data. 6. DVT prophylaxis with SCDs. 7. Ventilator protocol/bundle. PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05118!2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01!26/1935 ACCOUNT#~: 9434440 DISCHARGE DATE: DICTATING: Timothy Clark, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 1 of 2 i PATIENT: CAUL, ANNA MED REL: 000064585 ADMIT DATE: 05/1b<<~09 8. Sedation as needed. 9. See orders. Total critical care time was 120 minutes. Thank you. DD: Wed May 20 10:25:25 2009 DT: Wed May 20 10:48:30 2009 15505678/10412 CC: Signed: Timothy Clark, MD PATIENT: SAUL, ANNA MED REC: 000064585 DOB: 01/26/1935 ADMIT DATE: 05/18/2009 ACCOUNT#: 9434440 ATTENDING: Amusa Ntatin, MD DISCHARGE DATE: ROOM: 0003 D DICTATING: Timothy Clark, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 2 of 2 { PATIENT: oAUt, ANNA MED REL: 000064585 HDM1T DATE: 0511o,~t)09 DATE OF CONSULTATION: 05/18/2009 REFERRING PHYSICIAN: Amusa Ntatin MD CONSULTING PHYSICIAN: Gregory L Lewis, MD REASON FOR CONSULTATION: I was asked to see Mrs. Saul by Dr. Ntatin because of an anemia of uncertain etiology. HISTORY OF PRESENT ILLNESS: This widowed female who is a resident of Manor Care apparently became unresponsive there and was brought to our emergency room today and admitted to the hospital. Initially her glucose was thought to be 44. She was treated with glucagon. She arrived in the ER however remained unresponsive and her sugars have fluctuated to as high as 600. She was noted to have an absent gag reflex as well as bite marks on her tongue; it is uncertain whether she had a seizure or not but she was intubated and then transferred to the intensive care unit. She was noted to have a hemoglobin of 8.8 and hematocrit 26.4 with normal red cell indices. 1 do see evidence that this patient has had an iron deficiency, dating back to at least 2001 and she takes iron as well as omeprazole on a daily basis. She has been seen and evaluated by Dr. Burke in the past. She had a colonoscopy with ileoscopy on 07/2001 that was done for abdominal pain and diarfiea at that time. She had several small hyperplastic rectosigmoid polyps removed. Biopsies were otherwise normal. She also had an EGD by Dr. Burke on 03/31/1997 and had chronic gastritis that was H. pylori positive and was treated with Helidac. She also has a history of gastroesophageai reflux. For other most significant is ovarian cancer and she presented with ascites and 2001. Laparoscopy showed omental caking and poorly differentiated carcinoma on peritoneal biopsy. She was treated by Dr. Barnes with Taxotere and carboplatin. Other past medical history includes at the anterior abdominal wall incisional hernia, diabetes diagnosed in the 1970s, coronary stent placed in 2002. She has chronic renal insufficiency, sleep apnea, asthma, hypertension, obesity, depression and arthritis. SURGICAL HISTORY: 1. Laparoscopic chotecystectomy in 2001 for chronic cholecystitis with cholesterolosis and cholelithiasis. 2. She had a bile leak requiring endobiliary stent. 3. She has had an appendectomy. 4. C-sections. 5. Glaucoma surgery. 6. Cataract surgery. 7. Bilateral rotator cuff repair. 8. Bilateral carpal tunnel release. 9. Left knee replacement. 10. Drainage of right pleura! effusion. FAMILY HISTORY: Two sisters who had ulcers. There is no family history of colorectal cancer. PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05/18/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01/26/1935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING: Gregory L Lewis, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 1 of 3 PATIENT: oAUL, ANNA MED REL: 000064585 t+DMIT DATE: 05/1r~~J09 SOCIAL HISTORY: She was widowed in 2004. She has one son and she is a resident of Manor Care. She does not smoke or abuse alcohol. ALLERGIES: PENICILLIN AND SURGICAL TAPE CURRENT MEDICATIONS: Nystatin, Allegra, Robitussin, Ocean spray to the nose, Travatan, Combivent, Advair, Maalox, Benadryl, Synthroid, Megace, risperidone, prednisone, Florastor, Klonopin, iron supplement, Zetia, Lantus, Imdur, aspirin, Coreg, Cipro and Tylenol. REVIEW OF SYSTEMS: Cannot be obtained because she is sedated with propofol and on a ventilator. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 130/50, temperature is 37 degrees centigrade, respiratory rate 12 psr minute, pulse is 74 per minute. She does have bite marks on the tongue. CHEST: Clear. HEART: Regular without a murmur. ABDOMEN: Slightly distended, soft and nontender without organomegaly. EXTREMITIES: Shows no pedal edema, but she has some venous insufficiency. DIAGNOSTIC STUDIES: Database includes a hemoglobin of 8.8, hematocrit 28.4. White cell count 13,400, normal red cell indices. She had an MRI of her brain recently that shows no acute disease. This patient is anemic but I note that she has a chronic iron deficiency anemia from old charts. Hemoglobin was 10.1 on 10/04/2001. ASSESSMENT: This patient is anemic and based on the chronic use of iron and anemia dating back at least 8 years, I suspect her current anemia is a chronic one. She did have an EGD in 2001, which a biliary stent was removed. No other abnomnalities were noted. An EGD in 1997 revealed chronic H. pylori positive gastritis and colonoscopy to the ileum in 07/2001 did reveal small hyperplastic rectosigmoid polyps. This patient is seriously ill with an absent gag reflex and is unresponsive. I do not know the status on her ovarian cancer and thus there are a lot of unanswered questions. She is not ready to have a GI work-up for iron- deficiency anemia at this time. However, we would be glad to re-evaluate her should she respond to her current PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05/18!2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01!26/1935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING: Gregory L Lewis, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 2 of 3 PATIENT: aAUL, ANNA ` MED REL: 000064585 r+DMIT DATE: 05/1c„~J09 medical treatment. If it can be demonstrated that she was Hemoccult-positive stools or does have potential site of GI bleeding, then she would need a repeat endoscopic evaluation from above or below or both. DD: Mon May 18 20:55:22 2009 DT: Mon May 18 23:54:47 2009 15486276/20739 CC: Amusa Ntatin MD Signed: Gregory L Lewis, MD PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05/18/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01 /26/1935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING: Gregory L Lewis, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 3 of 3 j ~ i ° { ~< PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05/1b~rc009 DATE OF CONSULTATION: 05/19/2009 REFERRING PHYSICIAN: CONSULTING PHYSICIAN: David G Pawlush, MD REASON FOR CONSULTATION: Abnormal cardiac enzymes. HISTORY OF PRESENT ILLNESS: Mrs. Saul is an unfortunate 74year-old woman with a known history of coronary disease who was brought to the Carlisle Regional Medical Center last night from her nursing home with altered mental status. The patient has a history of coronary disease having undergone percutaneous intervention for LAD and circumflex. She is also known to have an occluded right coronary artery. Revascularization from 2003 and cardiac catheterization in 2004 demonstrated that her stents were patent. The patient recently presented to Holy Spirit Hospital with lower GI bleed and anemia as well as chest pain and shortness of breath. During that hospitalization, astress nuclear study demonstrated apical ischemia and an old inferior wall myocardial infarction. The nuclear study suggested that an EF was approximately 27%. However, echocardiogram suggested a higher EF in the range of 40°~. The patient underwent colon surgery and was found to have recurrent ovarian cancer in the proximity of her colon. She did fairly well from a cardiac standpoint postoperatively and was sent to the nursing home for continued rehabilitation. Unfortunately, the patient was brought to the emergency care unit last evening with altered mental status. When she was attended to, her blood sugar was found to be 44. She was brought to the ER where respiratory distress was documented. That coupled with a brain atretic peptide level of 618 suggested that she also had congestive heart failure. She was subsequently intubated. I discussed Mrs. Saul's recent condition with her son. The patient herself is intubated at the time of my consultation. She has not been having chest pains or shortness of breath recently. MEDICATIONS: The medications that she was sent home from the hospital on include the following. Nexium, Advair, Vytorin 10/40 mg at bedtime, Lantus insulin, Synthroid 50 mcg daily, Combivent, iron, Travatan eye drops, Elestat eye drops, multivitamin, spironolactone 25 mg daily, Lasix 40 mg daily, potassium 20 once daily, trazodone 50 mg daily, sertraline 50 mg daily, Kionopln, lisinopril 5 mg daily, Coreg 12.5 mg twice daily, aspirin 81 mg daily. ALLERGIES: SHE IS ALLERGIC TO LATEX AND PENICILLIN. PAST MEDICAL HISTORY: Remarkable for ovarian cancer and coronary disease. She also has a history of diabetes as well as gastroesophageal reflux disease, spinal stenosis, asthma, dyslipidemia, hypothyroidism, glaucoma and depression. SURGICAL HISTORY: Unobtainable as the patient is currently intubated and sedated. SOCIAL HISTORY: The patient does not smoke cigarettes or drink alcohol according to her son. PHYSICAL EXAMINATION: GENERAL: The patient is awell-developed, elderly woman who is intubated and sedated. VITAL SIGNS: Her heart rate is 50 to 60 beats per minute, blood pressure 125/40. PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05/18/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01!26/1935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING: David G Pawlush, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 1 of 2 x i ~ ~ RATIENT: sAUL, ANNA MED REC: 000064585 NDMIT DATE: 05/10,009 HEENT: Her sclerae are nonicteric, She does not move purposefully to voice. Her pharynx has an endotracheal tube emanating from it. NECK: Veins are difficult to assess given the strap of the endotracheal tube and I cannot hear carotid bruits. CHEST: Has bilateral crackles and rhonchi. HEART: Has a regular rate and rhythm with a soft crescendo decrescendo murmur consistent with aortic sclerosis. I cannot hear an S3 or S4. ABDOMEN: Soft, nontender, distended. Bowel sounds are hypoactive. There is trace degree of peripheral edema. LABORATORY AND X-RAY: Electrocardiogram demonstrates sinus fiythm with an old inferior wall myocardial infarction and nondiagnostic lateral ST-T changes. Serial CPKs demonstrated CK of 62, 72 and 83. MB 2.6, 1.7 and 1.6. Troponin 0.23, 3.15 and 0.69. Additional laboratory data includes an admission hemoglobin of 8.8, platelet count 218,000. INR 1.5, BUN 34, creatinine 1.7. Brain natriuretic peptide level 627. Chest radiograph demonstrates congestive heart failure and potential left upper lobe infiltrate. Aventilation-perfusion scan was without evidence for pulmonary embolism. IMPRESSION: It is my impression that Mrs. Saul has a known history of coronary disease and presents with altered mental status as well as respiratory failure. Her respiratory failure is likely on the basis of congestive heart failure due to her known LV systolic dysfunction. Her biomarker analysis is confusing and is not diagnostic for an acute myocardial infarction given the normal CK and normal MB. Her troponin did become elevated, but then decreased suddenly suggesting that this may in fact be a matter of poor renal clearance rather than true myocardial necrosis. She clearly is at risk for myocardial infarction/ischemia, however, given her recent positive stress nuclear study and severe physiologic stress she is facing with her heart failure and altered mental status. RECOMMENDATION: 1. Follow EKGs. 2. Continue nitrates and beta-blocker. 3. Hold aspirin given her bloody NG drainage. 4. Will check her echo report. 5. Will follow with you. DD: Tue May 19 11:42:59 2009 DT: Tue May 19 13:39:14 2009 15492407!1209 CC: Signed: David G Pawlush, MD PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05!18!2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01!26/1935 ACCOUNT;I<: 9434440 DISCHARGE DATE: DICTATING: David G Pawlush, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 2 of 2 i S PATIENT: aAUI, ANNA MED REV: 000084585 ADMIT DATE: 05lto~[009 DATE OF CONSULTATION: 05/18/2009 REFERRING PHYSICIAN: CONSULTING PHYSICIAN: Mohammad K Ismail, MD REASON FOR CONSULTATION: Decreased mental status and possible seizure. HISTORY OF PRESENT ILLNESS: Ms. Saul is a 74-year-old woman who has multiple medical issues including history of metastatic ovarian cancer, hypertension, chronic renal failure and diabetes mellitus who has been in a nursing home. She is unable to give me a history and since she has been sedated. Apparently she presented to the hospital from the nursing home with decreased mental status. Her son is present at the time of this evaluation who reports that the patient was talking last night, but she was confused. She was able to engage in a conversation with her son but he noted that she was not making whole lot of sense. In the emergency room, she was noted to be unresponsive and she has some that she had tongue bite. She presented to the emergency room and she was hypoglycemic and anemic. She was given glucagon and her blood sugar peaked around 600 mgldl. The patient, however, was not very responsive and she was intubated and transferred to the intensive care unit. The patient is a full code. She was suspected of having a seizure although she was not witnessed by any member of the nursing staff at the nursing home to have seizures. The patient has no previous history of seizures as well. My consultation is initiated for further evaluation. PAST MEDICAL HISTORY: 1. History of hypertension. 2. History of coronary artery disease status post stent placement in the past. 3. History of diabetes mellitus since 1977, type 2 since 1970. 4. History of chronic renal insufficiency. 5. History of sleep apnea history. 6. History of asthma. 7. History of depression. 8. History of hyperthyroidism. 9. History of morbid obesity. 10. History of ovarian cancer diagnosed in 2001. PAST SURGICAL HISTORY: Significant for cholecystectomy, appendectomy, C-section, glaucoma, cataract surgery, carpal tunnel release bilaterally, left knee replacement, rotator cuff repairs. ALLERGIES: TO PENICILLIN AND SOME SURGICAL TAPES. CURRENT MEDICATIONS: Her nursing home medications include Combivent inhaler q.4 hours, Protonix 40 mg a day, and she was started on Solu-Medrol as well. She is also on insulin, Travatan eye drops, Risperdal 1 mg b.i.d., Synthroid 50 mcg a day, lmdur 30 mg a day, Coreg 3.125 mg b.i.d., Zocor 40 mg at bedtime. She is also on Klonopin but the dose is not known. The patient was started on Diprivan drip. She is also getting Solu-Medrol 125 mg every 6 hours. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is not married. PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05/18/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01/2611935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING: Mohammad K Ismail, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 1 of 3 ~ ~ ~ ~ ~. PATIENT:- CAUL, ANNA MED RE(:: 000064585 ADMIT DATE: 05/1oi2009 SOCIAL HISTORY: The patient is a widow. She has been in a nursing home for the past few years. HABITS: She does not smoke, drink or use illicit drugs. REVIEW OF SYSTEMS: Not obtainable. PHYSICAL EXAMINATION: General: The patient is a 74-year-old woman who was lying in bed and does not appear to be in any acute distress. She was sedated and was intubated. Vitals: Blood pressure was 135/51, pulse was 76 and regular, and she was afebrile. EYES: Pupils are round, 2.5 to 3 mm and were minimally reactive to light. Extraocular movements could not be tested since the patient was not awake. However, no forced gaze deviation was noted. Examination of the fundi showed no acute hemorrhage or bleed. Cardiovascular: Heartbeat is regular in rate and rhythm. Auscultation reveals no murmurs, gallops, or abnormal sounds. Pedal pulses were barely palpable. Carotid artery exam reveals no bruits and full and equal pulse. The patient has 1+ edema at both ankles. Respiratory: The patient was intubated and was breathing on a ventilator. Breath sounds were present bilaterally. Musculoskefetai: Inspection, palpation: of spine and both upper and lower extremities, unless stated otherwise, showed no misalignment, deformity, asymmetry, tenderness, mass, or sweNing. ROMs were assessed in spine and upper body and lower extremities and found to be normal. Tone was normal in all 4 extremities and in fact were somewhat decreased. Muscle strength examination could not be accomplished since the patient was unable to move both arms and legs. He was sedated. Gait and station was evaluated and found to be normal. Neurological: Mental Status: The patient was sedated. She was unable to follow any commands. She was showing no response on even deep sleep stimulus. Language: Speech appears to be fluent with good comprehension and expression, no dysarthria or dysphasia noted. Cranial Nerves: Cranial examination was limited. There was no apparent facial droop. Pupils were not very reactive. Extraocular movements could not be tested. Corneal reflex was also depressed. She was still having gag reflexes in the emergency room as well. Sensory Examination: The patient is not showing any response to deep stimulation of the upper and lower extremities and detailed examination was obviously not possible. Reflexes: The patient has absent ankle jerks bilaterally, otherwise reflexes were also diminished in the both upper and {ower extremities. Babinski was showing an unequivocal response. Coordination was not done. LABORATORY AND X-RAY: The patient had an initial CT scan in the emergency room and showed chronic vascular changes. No acute abnormality. The patient's UA examination showed that she has positive nitrites and positive protein and blood. She also had positive leukocyte esterase. Urine microscopic examination showed she has 4-8 white cells and large amount of bacteria. The patient's total protein was 65, AST was 38, albumin was 2.6, ALT 28. Sodium 139, potassium 4.8, BUN 34, creatinine 1.7, calcium 8.4, blood sugar 144. White count was 13.4, hemoglobin was 8.8, platelet count 218,000. ASSESSMENT: This is a 74-year-old woman who has multiple medical issues including metastatic ovarian cancer, coronary artery disease, hypertension and diabetes who presented to the hospital with decreased mental status. The patient had a tongue bite noted by the nursing staff. There is strong suspicion that she had convulsive seizures and she became hypoxic. Her neurologic examination was minimally helpful considering the fact that she is sedated in the emergency room. Her pupils are nat very reactive at the moment. This may be due to the fact that she is on Diprivan drip. Nonetheless the differential diagnosis at this point is. PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05/18/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01 /26/1935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING; Mohammad K Ismail, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 2 of 3 PATIENT: CAUL, ANNA i. t. MED REL: 000064585 ADMIT DATE: 05J1oi2009 1. Cerebrovascular ischemic event causing diffuse ischemia of the cerebral hemisphere. 2. Status epilepticus. 3. Infection of CNS meningitis especially considering elevated white count. 4. Carcinomatous meningitis is also of concern considering the history of patient's ovarian cancer. 5. Metabolic encephalopathy is also a consideration since the patient has urinary tract infections. RECOMMENDATION; At this time I recommend a thorough work up. The patient's CT scan of the head was negative, but that doss not exclude the possibility of ischemia. 1 will recommend close neurochecks. If the patient is not improved on neurochecks, I also recommend EEG. If the patient is not improved, I would recommend getting a spinal tap done, and having an MRI of the brain. In time the patient should be evaluated for systemic infections or metabolic abnormalities. Thank you very much for your consult. I will follow this patient with you. DD: Mon May 18 23;43:05 2009 DT: Tue May 19 08:20:21 2009 15487176 !1209 CC: Signed: Mohammad K Ismail, MD PATIENT: SAUL, ANNA MED REC: 000064585 ADMIT DATE: 05/18/2009 ATTENDING: Amusa Ntatin, MD ROOM: 0003 D DOB: 01126!1935 ACCOUNT#: 9434440 DISCHARGE DATE: DICTATING: Mohammad K Ismail, MD CARLISLE REGIONAL MEDICAL CENTER CONSULTATION Page 3 of 3 • LxAr'T Carli~'a ReOiop dical Center DRt1 i 361 Alexander Spring ~ ,Carlisle, PA 17013 ~ !. (717)249-1212 Patient: SAUL, ANNA M DOB: 1/28!1933 Patient t~: 9434440 MRN: 0000064583 Dato In: 5/18/2009 CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: JPR OS/ 18/2009 04:01 SAUL, ANNA M is a ?4 year old F that presented to the Emergency Department at 03:24 by ALS. The patient was triaged at 03:24 with the following vital signs: T: 96.5 PO, P: 117 Regular, R: 32 Unlabored, BP: 184/066, SP02: 94 Amt:RA, Pain: d Pt Unable to Describe. The patient's primary care physician is GUISTWITE, DARRYL K. Chief Complaint -- HYPOGLYCEMIA--DIABETES Exam Tirne: 04:01. History obtained from: nursing home. History limited by: Altered mental status. Pt from NH- at 2100, fsbg was 600. At 0245 pt was found unresponsive with fsbg 44. She was given glucagon 1 mg X2 and EMS gave pt sugar orally. She remained unresponsive. 02 cats at NH 84% in notes. On arrival- BG was 81. Pt moaning in ER- not verbally responsive, appears to be in respiratory distress (sats on NRB Mask 98%). Pt was seen here yesterday for acute AMS, CHF exacerbation (BNP 613) and hypoglycemia- treated in ER and returned to NH. Time of onset of symptoms is indeterminate. Symptoms are present now. Symptoms are severe. At time of history patient is found to be agitated, unresponsive. REVIEW OF SYSTEMS: JPR 05/1812009 04:23 Unobtainable due to mental status. PAST MEDICAL AND SURGICAL HISTORY: JPR 05118!2009 04:23 Past Medical History: positive CAD, positive COPD, positive HTN, positive DM, positive OVARIAN CA. Past Medical and Surgical histories reviewed. FAMILY AND SOCIAL HISTORIES, ALLERGIES AND MEDS: JPR 05/18!2009 04:23 Allergies: PCN, SURGICAL TAPE Medications: NYSTATIN POWDER, ALLEGRA, ROBITUSSIN, OCEAN SPRAY TO NOSE, TRAVATAN, COMBIVENT, ADVAIR, MAALOX, BENADRYL, SYNTHROID, MEGACE, MVI, RISPERDAL, PEMIRLAST EYE DROPS, PREDNISONE, FLORASTOR, KLONOPIN, SENNA S, ZETIA, IRON SUPPLEMENT, LANTUS, IMDUR, EC ASA, COREG, CIPRO, TYLENOL, MOM, DULCOLAX Family History has been reviewed and is not pertinent. Social history is negative for alcohol and tobacco use. Physician Documentation (Pro-MED Clinical Systems, L.L.C.) Printed on: 05/18/2009 06:34 Page 1 of 4 IRAFT DRAFT ', DRA) Carlisle Re;icuit ~ical Center 361 Alexander Spring 0. ,Carlisle, PA 17013 I S (717}249-1212 Patient: SAUL, ANNA M DOB: 1126/1935 Patient ~: 9434440 MRN: 0000084583 Dab In: 5/1812009 PHYSICAL EXAMINATION: JPR 05/18/2009 04:23 General: Nursing documentation reviewed. Vital signs noted. Pulse Oximetry results noted. Patient in moderate distress. HEENT: HEENT WNL. Na evidence trauma. Oral Cavity: Mucous membranes: dry, lips crusted with blood- bit tongue/lip at nursing home ?seizure- bite lass to sides of tongue- bleeding stopped. Chest: No visible external evidence trauma. Non-tender to palpation. Respiratory: Respiratory effort is moderately labored. Lung Sounds: Rhonchi entire posterior chest. Decreased breath sounds entire posterior chest. Crackles noted bilateral bases. Wheezes upper right chest, upper left chest. Patient shows evidence of mild respiratory fatigue (will order BIPAP) Cardiovascular: PMI normal. RRR. Sl, S2 normal with no murmurs, clicks, gallops or rubs. All distal pulses 2+ and symmetric. Abdomen: There is no guarding. Rebound tenderness is absent. Unable to determine tenderness due to mental status Abdomen is soft. Bowel sounds are hypoactive. Musculoskeletal/Extremity: Normal joint range of motion; no swelling or deformities. Negative cyanosis, clubbing or edema. Neurologic: Mental Status: lethargic, unresponsive. DIAGNOSTIC TEST RESULTS: JPR 05/18/2009 04:30 . Radiology: X-Ray: Interpretation by Emergency Department Physician. Chest X-Ray AP Portable View -- Bilateral infiltrates, vascular congestion and enlarged cardiac silhouette consistent with acute congestive heart failure and pulmonary edema. Computerized Tomography Scan: Brain -- No acute disease. LABORATORY.• Orders/Procedures JPR BUN = 34 reviewed as Abnormal JPR Creat =1.7 reviewed as Abnormal JPR F102 = 100 reviewed as Normal JPR HC03 = 23.5 reviewed as Normal JPR HGB = $.8 reviewed as Abnormal JPR pC02 = 422 reviewed as Normal JPR pH = 7.363 reviewed as Normal JPR p02 = 225.8 reviewed as Normal JPR WBC =13.4 reviewed as Abnormal EKG: EKG interpretation by Emergency Department Physician. Normal sinus rhythm; rate normal. Clinical Impression: Unremarkable EKG. Non-diagnostic EKG. EKG: Non-specit3c ST-segment changes. ST segment depression noted in leads V5, V6, 2, 3. Physician Documentation (Pro-MED Clinical Systems, L.L.C.} Printed on: 05/18/2009 08:34 Page 2 of 4 )RAFT DRAFT Carlisle Regi~nf ~ical Center DRAF 361 Alexander Spring G. ,Carlisle, PA 17013 (717)249-1212 Patient: SAUL, ANNA M DOf3:112811935 Patient #: 9434440 MRN: 0000084585 Date In: 9!18/2009 CLINYCAL IMPRESSION: JPR 05/18/2009 05:06 1. Altered Mental Status 2. Congestive Heart Failure 3. Acute Pulmonary Edema 4. Acute Respiratory Failure 5. Acute Hypoglycemia DISPOSITION: JPR OS/ 18!2009 04:22 Disposition: Dispositioned to (admission) Intensive Care Unit at 45/18/2009 06:31. Admitting Physician: HOSPITALIST, DOCTOR. Disposition date/time: 05/18!2009 06:31. Condition: Critical. PHYSICIAN ORDERS (1) CT Scan Head w/o Contrast [JPR] sent at 5/ 18!2009 4:30 (1) PTT [JPR] sent at 5/ 18/2009 4:16 (1) PT [JPR] sent at 5/ 18/2009 4:16 (1) Basic Met Profile [JPR] sent at 5/18/2009 4:16 (1 } ABG [JPR] sent at 5118/2009 4:16 (1) CBC [JPR] sent at 5/18/2009 4:16 (1) Culture Blood [JPR] sent at 5/18/2009 4:16 (1) Chest Portable [JPR] sent at 5/ 1812009 4:16 (1) EKG [JPR] sent at 5J 1812009 4:16 (1) CPK MB [JPR] sent at 5/ 18/2009 4:16 (1) Troponin Quant [JPR] sent at 5/ 18!2009 4:16 (1 }CPK TOTAL [JPR] sent at 5/18!2009 4:16 (1) BNP [JPR] sent at 5/ 1812009 4:16 (1) CT Scan Chest w/ contrast [JPR] sent at 5!18/2009 5:04 (1) Pulse Ox-Continuous [JPR] ordered at 5/ 1812009 3:25 [by: SEN, Verbal order read back] (1) Cardiac Monitor/Telemetry [JPR] ordered at 5/18/2009 3:25 [by: SEN, Verbal order read back] (1) **IV Insertion [JPR] ordered at 5118/2009 3:30 [by: SEN, Verbal order read back] (1) Accu Check /FSB5 [JPR] ordered at S/ 1812009 3:30 [by: 5EN, Verbal order read back] (1 } IV Dextrose 50% 1 amp [JPR] ordered at 5/ 18!2009 3:40 [by: WAC, Verbal order read back] (1) Accu Check /FSB5 [JPR] ordered at 5/18/2009 4:10 [by: 5EN, Verbal order read back] (1) Duoneb Treatment [JPR) ordered at 5/ 1 812009 4:16 (1) 100% NRB [JPR] ordered at S/ 18/2009 4:17 (1) Message: BIPAP [JPR] ordered at 5118/2009 4:17 { 1) SL NTG 0.4 mg [JPR] ordered at 5/ 18/2009 4:33 (1) SL NTG 0.4 mg [JPR] ordered at 5/ 18/2009 4:33 (1) SL NTG 0.4 mg [JPR] ordered at 5/18/2009 4:33 (1) IV Lasix 80 mg [JPR) ordered at 5/1812009 4:34 Physician Documentation (Pro-MED Clinical Systems, L.L.C.) Printed on: 05/18/2009 06:34 Page 3 of 4 )RAFT DRAFT Carlisle Rpgian ' dical Center DRAFT 381 Alexander Sprang ~. ,Carlisle, PA 17013'' (717)249-1212 Patient: 3AUL, ANNA M DOB: 1/28H93S Patient ~: 9434440 MRN: 0000084585 Dats in: 5/18/2009 Physician Documentation (Pro-MED Clinical Systems, L.L.C.) Printed on: 05/18/2009 06:34 Page 4 of 4 nRAFT rap ~ ~..~, AUM1011=~1 ~ hNrblt ~YMJ b t]iIO~IMI MIS aiMf~ric ~drrlrr u~Y~~ e~rrwr:.....+~r..~..r w., r....~~,.,r DaN TMn~ Camplaa !op porlloR wIM noh L~v~l d Can dwpa IndkaN otdar wNh s Ch~ok Mael~. ^ ro+oaa4ry bt rm.aMeM ~ararf, ^ Plaa M Outpatlant Obaarvaiia+ S~vicaa fca __ mNd~eM ~...aN, Q AdnMt ar Inpatient fo- rnNa~rr Phyeidan Slgndun: ,- f-- & Ssnsitivirie~ Q Nw4 ii~~ ~I ~a ~q ~q ~I ~I ~I ~ SAUL, ANNA M ACCT 9434440 MRk00000645g5 0511812009 NTATIN, AMUSA D06:0112611935 074 F CARLISLE REGIONAL MEDICAL CTR 0003 D Aur-orts~IOA 4 Mid p-~n Io tl~ priwie ~qu~vMMK urM~ olfwwal mdlCal~O Oy tf N pAy~eNn. IoM THIN COIII~t~N b' pOt11011 Y11N~1 NOA tilf~t d C~ Ctloll~. In~aM Otdw wMh ~ CINC1t M~1'k { I I ~ talc. in a,tp~ai.r~t obrw.+bn s.wic« ror ~""°k'i I ' ' Q Admit M Inp~tl~nt tot im«xea~ ~wonl. ' Physician stgr~in: ~i~/ d (' ~ C} ~~ o ~ VIS+ C }~ hone ~t tv . -r2h~o>1Y1 d s ttuin- t•2 ~o4r r~or ~v Ne, a~lq~ - rrt~,uro ~d~N~ 5 c., c.MP, nna ~r- /~1-/1 d ~ win rrs _, ;,_ ; ~,~. ~a~,1 ~- br, S~,~-i .~ ~. ,,..~ e , ,~ - ,~ - -r ~,~ r--~ ~ ' -.~~ -- Allergies & Sensi~critler-_.. p Ntut___ _. ___ --? ._`~~ ~ ~ ~~o`~ ~ ~, `~{ - • PA 1 ~ III~~~~~~~q~~~N~~~l SAUL, ANNA M ACCT 9434440 MR~-0000064585 0511812009 NTATIN, AMUSA OOB:01126I1935 074 F UWig1~t f~l+t Qlpnow CARLISLE REGIONAL MEDICAL CTR 0003 D ~. ~1 ! -~ ~- » DATE ORDERED ORDERS NOTED f311 RESTRAINT ORDERS Raison for Rastrsints: ^ Medical -Reorder every 24 hours. C Behavioral -Reorder every 4 hours C PediaMc -Ages 9 to 1 T-reorder every 2 hours Under 9 years of age -reorder every hour. Apply / Inttlab rutrafnb st (tlm~) Rutrain wMh: (cMck all that apply) Soft restraints: p L wrist p R wrist ^ L ankle p R ankle O chest ^ mitb ^ elt>ovv p 4 skis rails ^ Geri chair ^ Sitter Leather restrainb: ^ L wrist ^ R wrist ^ L ankle I-1 R ankf~ RESTRAINT ORDERS N ~ N ~ ~ ~ 1 ~~ ~ N SAUl, ANNA M ACCT 9434440 MRA'0000p64585 05!1812009 CARLISLE REG ONA LMEOICAL CTAS 003 0 r~ i ~uNOataroff ~ -~+~ pMn b i1hp~-eN eh~ ~rwel~ ~quMMrnf urrw oMwwrsr a-aNC~l~d DY d11 pIM~eNn. pw TNn~ Cpnpl~ toy partloe wllh Ndl liv~l of Cah olwp~. I~dk~ otdw wNA ~ CMNt Mrit. ^ Oulp~ti~nt Pnoadu~ ~aoc~a~wN (ot (-rwdital rwon~. ~ Paa ~ outer c>r~-.tdon s«vlc.. ~a ~~r ~•aonr. Q ~ r Inpdhflt for nfuaa~ nMOffl. Phveici~n 31~n: 5 9 AAStti ~6 - uC~ 10- itW,Q ~t~ m S~l-t~ti OA OA , Q ~ ~. ~ I ~ - ~ ,, ~ ~ ,- , .,- Aliargier• 8~ Sensitivvitie~ O NKA • P" • ~~~~~~~~~~~~~~~h~~~ SAUL, ANNA M ACCT 9434440 MR~0000064585 0511812009 iW~i~ht Hight Olapnwr NTATIN, AMUSA D08:01126f1935 074 F CARLISLE REGIONAL MEDICAL CTR 0003 D ti t7`...~~rJ~~f~ ArJ~r~ Awna+rauan w n«br P~ a ~t~pa~ ~ pMr~rla k urwr or-~ ,naic.~s qr ens p1~w~ DAY TM~N CanpNN toN porflo~ wiM NoA L~vM d Cw ohMpa IndleaN adK wIM a CMok Meek ^ Ou~nt Proadta~: rwaya+~ is an.d~ear r...on~ ^ PMc~ In OuipatlNit Ob~viNon 3wvbN for ~n~dleal rNp~ Q AdnMt at I~p~tNnt for un~awer ~ronJ. Pltivdcian Siprtrl~ur~: • r { ~ ~'. Allergies ~ Sensidvitie~ O N~u- P''' • II{N~I~NI~N{IN~~~N~{~I I~ SAUL, ANNA M ACCT 9434440 MR~0000064585 05118!2009 ~~ H~ht a~~ NTATIN, AMUSA DOB:0112611935 074 F CARLISLE REGIONAL MEDICAL CTR 0003 D Phv~tleisn't Ani~r~ 'w; l~ ~ ORDERED vnvana NOTED 0Y RESTRAINT ORDER8 S R d y Reason for Restraints: p ~ p ~ k:al -Reorder every 24 hours. p Behavioral -Reorder every 4 hours p Pediatric -Ages 8 to 17 -reorder every 2 hours Under S years of aye - reorder every hour. _, `Apply / IniWte reetrafrtts at f3 ~y CJ (time) Reeiaraln with: (check aY they! apph-~ Soft rite: writ! wrist p t. ankle p R ankle p chest p mitt p elbow ^ 4 side rails O Geri chair ^ Sitter Leather rsstrairtts: p L wrist p R wrist ^ L ankle p R ankle ^ Ssduskxt p Other clktk;r lrtdigdlat fa Reetratnts / Sed~aon rertcs watt IMe support (W, Di, (3U tunes, etc.) O Safely risk (felts risk, unable to remember instructions) ^ Danger of injury to seH or others / flight risk -- i 10' ~t ~ ~ i a~ l~ a .'71; _ .~ .-, /L~.t i-. , .:_ G u t_.r~,~~ ~. i~Clat~j. 1NBDICAL CBNTBR RESTRAINT OADEAS 1.r/ ~.r ` ,.1 PATIENT IDENTIFlCA710N i IIO ~ ~ ~ ~ ~ ~ ~ ~I N ~N ~i p ~ I l~ SAUL, ANNA M ACCT 9434440 MR,y0000064585 05!18!2009 CAR ISLE REGS NA LMED CAl CTR 0003 D NO 1607 (M07} AuMloe~ if hN~b-~ QNNi to Qflp~-~N MN pM~MIC puA~NfM wNNe a~wwrs mdr~.d ev ~Ir eA.M•u~. Oala TNna Complala to* Fallon wltA aaoh Laval d Can dlan~a,, indkata ordw wNh a Chaolt Mark 0 Outpatient Procaduro• raoeal~- fa- r~+.aiw nno,-~. ^ Plea in Outpatient Obaarva~on 3avicee tar ,,,,~~,~. Q Admit at Inpatient for ~~~ ~. Physician 3fn: s ~ v ~• ~ ,~, X ~!U T~/ ~ ~~ _• _......~._._.~ , l ~l ~.- ~ _- p v _._.._.._ j. J 1K~ ~ s ~r ~f S ~ ~, 6 'l ~ i ~~ Fs 4S ~ ~/s ~~'" a G~• ~v .~ l .,Q~ ~. "l; try ,r. ~ v. ` 1 ~ ''~' / J ~ ~G G /L/~ r /y --.w_.___._ -.._. . _. 1 ~ Gn~onn n ~ v -~ iv ~oan~. . ~ kll~1 ~ t0.~¢AV11Y\ ~~ ~ ~' ~~it GBG~ tMp. t~1nQ ~~ A'A/l >~ ~ vac , .--- ~ , , ya r / Y. ~ p Allsroitl» 8 Senai tivi~tisa n tulu- • w- f II~II SIN INII ~N ~N SIN f~N INI ~ SAUL, ANNA M ACCT 9434440 MR~0000064585 0511812009 NTATIN, AMUSA D08:0112611935 074 F CARLISLE REGIONAL MEDICAL CTR 0003 D ~. :" OrN'Elf1W ORDERS ~ ~ ~, OIIDlR~p p= ~ ELECTROLYTE REPLACEMENT FOR CRRICAL CARE p Ong Tuna Orclw p lJ>ta with aac~ lab draw (InducWq daily labs) ^ Cornrow Schadulsd doNS of el~ctrdytM at ordarad in addltlon to ord~ra below MaOnaalun~ K mapnaNwn Is laaa than 1 J piva 2 Oramta mapnsatum auUata N x 1 M Zti to a Diva 20 mEq IOCI In 100m! N q 1 hour x 21br a toW d 40 mE;q IaCL M ~.1 to S.6 Olva SO mE:q IaCL In t OOrM N for a tool of 20 mEq l~l. K swum potaMN,m Is lea than ~ or praat~r that 6, oaN phyaidan - - FoNow pharmacy polloy ibr K~CL adrrtir>igratlon M~drr~um 10 mE:q potaahxn In 100ttM o~var 1 hour for peripheral Iinea alw owr 4 bows each. Ca1011M1k N 4~{Rp ~ wa man ~ QaYV an /1~Ymin NrwN. C brlTlld~ RlCtad caldum•sarwn caldum + 0.S ~4 - sanxn albunNn). M ilta corrected Calolum nmakw leas that 7, piw 10rfll of Cak*un phkonata N In 100mi N8 over 2 boon. ~CARI~SLE CXVAL NtDICAL CLNTtR r~ f PATIENT IDENTIFICATICiIM II~II~N~IN~IflII~I~INiNI PHY8ICIAM'8 ORDERS ELECTROLYTE REPLACEMENT F011 CRITICAL CALM SAUL, ANNA M ACCT 9434440 MRIt0000064585 0511812009 NTATIN, AMUSA D08:011261193'S 014 F CARLISLE REGIONAL MEDICAL CTR 0003 D +c os~o ill i t f AUfhOr(zaNon 1s HQ/ObY ANen to dl1DNIQe fns on1~C eauaal~nf unl~se eMwerrie~ inAirs~oA hu N,..,ti,,.;,.;. Deb Tbna Complete top portion with oath LwN of Can chan~a, tndk.ata orda~ wNh a Chock Mark Outpatient Procedure: fprocsdlar) fa rmedrer re~son-. ^ Place in Outpatlant Observation Services for r~rcr rosoq. Admit as Inpatient fa ~med~cr sa.onl Physician Signature: c. r t~ ~~ ~~ O t1 ~- N iZhA ; '~ ir-~1- cue e sa urned~l w sc~ ~~e. ~w ~pl ctlr~t lrrt`~IK" ~ SBP L 9 ~~( `L` ,-% l t~GT « b. tJ zzy c~c gs ~ ° - n o ~' ~ ~' 4r1 2 CID 4 r ~ ~~~ Ue~ to-.J-- ~ p C e f,.,1 -~ n ~ , 8t S@1181t~V~t~@8 C NKA S Heigh 'i ~ i IIBn ~N ~I~ ~q ~I ~fl III ICI I~ SAUL, ANNA M ACCT 9434440 MRk0000064585 05118!2009 NTATIN, AMUSA D06:011261'1935 074 F CARLISLE REGIONAL MEDICAL CTR 0003 D .1i O 1613 10/04 f~ AutliaJZatlon a hereby even 10 dJSpanaa dra gana~JC squMNrM unJasa otheewisa inaaNcalsd by the phyaicJan. IDate Tlma Complete top portion with pch t~nrei of can changs. Indk:Ne o-da- wMh .Check Nark. Outpatisnt Procedure: ~p,~1/feJ for (medreaJ roeaon). ^ Place in Outpatient Observation Services for ,,,,,dry,,,,,~~. Admit as Inpatient for imedical n~aaon). Physician Signature: eta Time Additional Orders: Oaten/77J~nss ulred Q~ 18 -~ s. G n -fir can s e ~~- b ~ J s u10 -I-- - V(} . ~ r i h L I t ,./ i .,t, ~ ~ (. , Q ~ ~Y ~ i'1 Q~~J a ~. -~ art, ~ I o I ~ ~ n OtiJ Allergies ~ Sensi tivities G NICA • PArienrr io s' ....- ~ 1 t y ~, ,~ ~,; ~, J \ L II~N ICU ~~ ~V ~BI~a ~I ICI I~ SAUL, ANNA M ACCT 9434440 MRa0000064585 0511812009 NTATIN, AMUSA DOB:0112811935 074 F CARLISLE REG10NAl MEDICAL CTR 0003 D s Orders ~~{` ~~~~ ~ i'I~rh :vo t6t3 toioa OATS ORDE ED ORDERS NOTED BY 1. Vernllator settings: 2. ABC3 30 minutes following ventilator set-up and every morning until extubated discontinued by physician, and when indicated during an acute crisis. 3. Notify physician of all ABt3 results. 4. Portable chest x-ray STAT, then every morning until extubated or discontinued by physidan. 5. Titrate Fl02 by oximetry to maintain Sp02 greater than 92%. 6. HOB elevated g fgater than 30 degrees. 7. OD tube to low intermittent suction. 8. Tracheal Aspinsb for gram stain, culture and sensitivity. 9. CBC, Basic Metabolic, liver, unless dons previously. 10. Daly weight. 11. Vital signs every 1 hour for 24 hours, then every 2 hours if stable. 12. Nutritional consult. - , 13. NPO oral care D4 hours and pm 14. Physical therapy consult after 48 hours to evaluate and treat as indicated; continue treatment after extubation. 15. DVT prophylaxis 18. PUD prophylaxis 17. initladte therapeutic bed orders. ~' Swditle~n [)rd~r~ ^ Midazolant mg bolus, then mg per hour IV infusion. Titrate to sedation level: 3 4 (circle) ^ Ferrtanyl mog bolus, then mcg/hour N infusion. Titrate to sedation level: 3 4 (circle) ^ Dfprivan initial dose of 5 mcg/kg/min IV infusion. Tltrate to sedation level: 3 4 (circle) Sedation Agitation Scale: Score Description 1 dangerously agitated 2 agitated 3 calm and coopenstive 4 sedated ~ 5 very over-sedated 8 unarousable J ^x Adjust sedation daily to waken patient, unless on paralytic therapy. D Assess for readiness to extubate. Initiate weaning protocol. ' ~~~ Physician's Signature S~Qn~tU t p ~d>.t I _--___._ ''~ ,, ~r1 / --, /Cl ~ ~~ r T ~ IF1C/~01V f~", REGICJNAL IIpINI~I~IN~N~IN~I~I~{~ MEDICAL CENTER $pUL, ANNA M PHYSICIAN'S ORDERS ACCT 9434440 MR~0000064585 0511812009 STANDING VENTILATOR CARE ORDERS NTATIN, AMUSA 008:0112611935 074 F Nu ~~ ~~~ ~ CARLISLE REGIONAL MEDICAL CTR 0003 D ! ~ ~ ~ ~ 1 i ~F t . ~,~ OIIDEIIEO Y7 ~I,~I AduR Insulin Cowra9~ Orden ~ 1. Finq•rstick Bkaod SuOar (FS83) AC and HS or 0 6 hours at NPO 2. For FSBS la• than 40, plus 2S ml Dextrose SO% 1V (or Gtucagon 0.5 rrro SO if patient does not haw N sit•-. tasp•at FS83 in 30 minutes and ca11 MO/DO with results. ( For FS83 70 - 160 ... No Insulin ~ Fa F388 40.70, ~lw 1 tube Olucoa GN oraly d repeat F383 in 30 minutes. n FBft~ nmMns lea than 70, caH MD/DO with results 3. NOV'0~~00 (h~sulln •aps~ In•u1M Standsrd Sear: Give 3D only FSttIS 161 - 160 ..... 3 units 1 tit - 240 ..... S unite 241 - 300 ..... 8 units 301 •360. . 12 units 361 -400 ..... 16 units Orsater than 400 ..... CaM MD/DO ^ 4. Apply iit''ort device to a SQ injection site; change q 72 hours / ~ D S. Use iPort site foc all SQ Novolag SSI injections ~ ...~_ _.__ ... .~. w.r. Physlclan's Si9natur• Date e `~ PHII ,_ ADULT IN. ir:r!~ar ~o9~nf11 TRL~L /~ RFC~ONAL M[DICAI C~NT[R S IAN'S OADEps .~'~. %=,'v" IU NCO OAOERi PATIENT IOENTIFlCATION III~~~NN{~~~~~~I~ SAUL, ANNA M ACCT 9434440 MR>v0000084585 0511812009 NTATIN, AMUSA DOB:0112611935 074 F CARLISLE REGIONAL MEDICAL CTR 0003 0 Autlron7atlon tr herby ~ ro disp~ns~ tM g~-tc equlwNnt unwa othNwis~ InoYc~led by oM phyaiGiMr. Dab I Tun. l Complt~ top portion rrtth ••oh Lw•t of can cha~q•. Indkat• order wMh . CMek 1-Aark ^ Outpatient Procedure: (proceobre) for (medical rsson-. ~ ~ ~ Q Place in Outpatient Observation Services for imsdkal mason). ~ ~ ~ ~ ~] Admit es Inpatient for ~medlcal ieaon-. ~ Physician Signaturo: Dab TNn• AdditbnalOrders: DMee/Tlr--es rod o ~ ~pn+t 4.04 CQ '~' ~`~r Z,ocor ~0 ~a dq~ arc ttn ca 6• z5 ~•0 R ~b 1*lSA• $l P 0 dG~i tn~c~r '~ ~'• 0 I bus ~lSt~ s S - tb11~ ~la~tSlrlr X156 ~•a St S ~ sOrn,cro rxrr ~•p ol~i, ,~o ~o d-u rrAva~tn .a ova/ ~ ~h bakh ~ ~vr^ d6~5 r b, (~lo R+S o• P-0 'gt ~otDnnc. Rp ola- acs. M~ - ~~~ ~ u s~ ,, sol t N ~ SCQ ~~ ~+c , tsH- c,~o~6 ~ ~- 8 x ~ o s~-eal ic. 2 -1~Q~ der' SGT q ~' - ~¢. ~~a r varn I~ - le a c!. a+ -pas -~nht ~cnn Plcce, 3Orhin ~ 12 x'00 S l ~ Wo,+~ &t~'t~ ~ z 1~~~'~ , Allergies s'~~ _ NiCA li~AI~~~~~~~~~~Nl~ ~ D SAUL, ANNA M ' (~ ~ ACCT 9434440 MRIf0000064585 0511812009 _ - ~ ~ ~ ~ ~ CARLISLE REG ONAI MEDIAL CTR30000 F Weigh ( HsigM _~ ~_ f ^ ^^~v^v^~a^^ v v^w^v .,~ l~/• /r~/:~V lO,IJ 1V/V'~ DATE ORDERED ORDERS tvoTED t3Y OS' ~ ~ q 1. Petieaf Staff C One D Outpatlent Procedure: (list procedure) far is reason . D Place in Outpatient observation Services far (med~~ ro the service of fist f~Adnoit as Inpatient for CMS - r a SGzW4 ~ 6 : medical reason) to a of R¢d - ist sic 2. S Mtd Sd wi13 Tel t Women's 2. ua-rd > sa ~ ~ a. xN ~ } v-r -- ~ ~ 7. - PD 4 0~ ' 8. t 1~OIArt11 t' 10. : Consid an Ord i N Y{ 8 MP C8 U Urine u` C Profl K KMB T ! crrrd,rtFiC 4 GU ~ 11. R Considered an rder N is a Sty 12. I con P lob 13 N-4WA ct! 'cZ,t~i~ 14. P~ Merikellee Ong Considered an order ONLY when boot is checked) Would you INte ro provide the foti0wi ? e vnee c 4 4 fever Pale: Zdran ondaneeaon 4 N B boon H~rtbrrm: Maalox 3 ml 6 hours heartburn ~ . Mkt d M 30 ml 6 hours ~~ Olher: 4 p~ w nredkaNon Orden oa next page, M ne' ::~ P hysician Signature: h -_-'-~_- '~BDICAL CBNT / ~'- -- - - PHYSIeIAN'S I At ©RDERS SAUL, ANNA M ACCt 9434440 MR~OQ00064585 0511'6(2009 ROMES, JEAN•PAUL D06:0112611935 p74 F CARLISLE REGIONAL MEDICAL CTR 0000 /~~~~ ~` , , i~ y~,~ ~~ DATE ORDERED ORDERS ,~ THERAPEUTIC BED ORDERS ~ Ptease choose ~ of the following: 1. ^ "Flexicair" for pressure relief ^ FuN bed frame and scale (MC3) ^ Replacement mattress (Flexicare Eclipse) OR 2. ^ "Size Wise" for bariatric pal3ent care OR 3. ^ "Sport" bed for rotational therapy (ICU only) CPT via bed a. ^ yes frequency b.0 no Physician Signature I _.. 1 ~ .. ~~ _.1 /~S~ MEDICAL CEN;TER PHYSICIAN'S ORDERS THERAPEUTIC 8E0 OIiQERS > > e~ srs ~oaas- 1 ~ ~ 3 , ~; ,~ PATIENT IDENTIFICATION Is~A~~~N~~~N~~~~I~II~ ~'1 l., AN,tNNNNA M ACCT 9434440 MR,~0000084585 05118/2009 CARLISLE REG ONA MEDICAL C=50003 D Nc ~~ d ` Pb/~~ROIp!! Or Pt~OCl~l~! NOa PICC Lin+ 0 SF dual lu Date of Inset Internal Lenl External Len Total Length Arm Circum Arm Circum Peat Opecadw D-is~isz ~- ~ ~i~(~ ~~ Sp~iasMO~i) Comrplicatioa~c ~"'- Pl!)rdc6Nt'li sipv4m~ _ ._ REF aaaasss `-'-- -'-'"~ PICC ~w ~" ~ ~ ~ RETBO175 ~ men ~F Power lion - ;th d~~'- ~ '~'~ - :erence 3 inches above site 'erence 3 inches below site ~~ Ph sician's Pm sa Notes N016T! ILM II~~NN~N~~~N~N~I~ SAUL, ANNA M kCCT 9434440 MR~0000064585 0511812009 NTATIN, AMUSA DOB:Ot(2611935 074 F CARLISLE REGIONAL MEDICAL CTR 0003 D PROGRESS NOTE: DatDe /Time . oDA ~Z~~ S S- ~, a Q~s~y - wry- ~~, ~ ~-~.11.~ J~ V° SJ - C ~~-- ~~ ' ~~ ~ ~~ >~-z. , .~._,_~ .sue , ~~ I {~~~~~~~ I P~nENT i~ i il~~ lU~ aIN Ian IIi~ ~N IIIO ~! ~~ SAUL, ANNA M u~eTiN4e~ta RxoOB U0626151935 O8~ 009 Nuo~a CARLISLE REGIONAL MEDICAL CTR 0003 u Progress Notes '33NA NU018 10108 PROGRESS NOTE oats ~ Time s ~ ~' ~ . ~ `'r • l ~J./ z ~~-~ _ . t - ~ ,. . ,,~ ,- ~ .. . ., ... t • , X-RAY COMPLETED ~ ' ~ ~ • ' TYPE PUC.~ ~ :.; ~ . DATE 5 ,-° '~, BY ~5 ,, „. ~ , ~., ., ' '' .,. .. r. . ,, ~ , . ~„ .. Ii .. i ~~~~~~ PATIEM IQ,t. .. , , . SAVE. AN~~~//~, NTAr, 943ggqo ~ A _MI ~ Huo~s Progress Notes EIIrIA NUOIa 1Ql'08 05/18 ~ARI/S(F RED OVA[ M ~~~~ s/Ig35 pZQZOpg l CTR 0003 p PROGRESS NOTE, Dats /Time J s- ~~-~~ s ~,,,,, ..r,. ~ ~ ~, /l 1 r ~Zy ~ ) r 7 t"Y'~'liti- ~'~ ~--- b ~1-- i~ }-~~-~-~ f 4 ~ ~„ ,~ , 77 ~/,~s ,~. ~ ..~ ~j . iu~ ~' `~a ~ ~~ U' I .~, ~-~ ~w ~'~~~~~ P~no~rr to ;~ 1sl~A I ~I ~ N III ~ II ~ I Id -I ~ I IIp ACCT 9434440 R,gr0000064 NTATIN, AMUCe ,,.,,, ...._ 5$5 05/1812nna rams Progress Notes fDriA NUO1810i108 caKUSLE AEGIONAI MEDICAL CTR5 003 D PROGRESS NOTI Date !Time X-RAY C~MPLETED TYPE ~f x DATE S-I `~ -09 BYD+-~3/ --____ oSl~~~a ~ s . ~ r even}' oue~ n, ht o. I~oJp. ~- s ~ iaa'~ w16oo 5 j~o ~~~ 31•oz.~~4bS jm- a8.3 9z~~• (r~-ech• vev~t • rn~ova3 ~ ¢~~eH-~he*S ~up~ls -ne~Ll+ve h l~yh~ • ~-34Z.! 36.6 X21 Z,1 lung-• 1b~1 r`r~ortihi ~ ~.~. I•a~ 4$ -1- ~ ~ar~-SSrz. 4-z. ~w ~• 1 Alod-so~'~NTINb~B~ S"`~~' ~~~ 6s~ k' DMS ~?c~h~q~; r~ 3a12~.1hC ~ Th1- ~•~.•6CC 3•t ~ . ~P~IYcI¢rVtiq ~,~_ 8~L ~ ~{~~eS G~ ~tlM~are c~czocl~aed pneurrron~ ~~S ~• ~=~cr.,L~ NSTtM1 ,v5 . ~amA~d -.c~rr¢vNIG+ ~~, S2pS1 S +4rerh~c~ Caen a12~+C+ehCY -a ? d~pp ~n ti(t~~, 51P 2uh~~' P~L~C qar- - ad wSt' ar~hb~o~cs hv¢loX; c~ vanCo yt~c~,~nrc c~nhrd, c~~ yfs , ac~kS'1• i~l~~ . ~l'v ~rd~ct ~ '~~ovr~aVt~rr! ~ ~ Echo ~ cRr~ co-ns~l~ . Nlc~hr0 e~~,114 ; V~¢w~n seC~~1 M1 ~ uSSeSS K10~~1 .!'~ i^u~~n -~ ~ ~~ PATIENT ID ~~~ IIIIIIIINN~INII811111111niIIIII~IIIN SAUL, ANNA M ACCT 9434440 MR~0000064~j85 0511812009 CARLISLE REGIONA LMEDICAL CTR50003 D Progress Notes >En~- rrvois >i~. ~ ( { PROGRESS NOTE: Die /Time a~loSb ~ ~t~ ~f ~ dlc4~ ~. rl Q IlT ~~ ~ ~- ~iSSQS S • 4,~S - ~~0 5et2~Ye ^ f A MRS t1 N-Q,u~p • Res . ~~ (u~~e D P-(a PE IIv~ • ~~ D ~v tas,~ ~1 Z ~ ~chb Q c~ c bt ~' ~ ~ ~ ~ s-lq-o9' o~3d~~. ~ ~G air. ~-c..4 2b ~I G ~ '• i^i~~m Progress Notes iMA NU018 10108 II~a~I~VN~I~N~N~lll~ SAUL, ANNA M ACCT 9434440 MR~6'0000064585 05!1812009 ROME$ JEAN-PAUL 008:0112611935 074 F CARLISLE REGIONAL MEDICAL CTR 0000 r .~~TERDISCIPLINAF~ rROGRESS NOTE Date: Discipline: Time: Visit Duration: Treatment 3 ~ L~ ~ is v Code S: 0: A: P: Date: Discipline: Time: Visit Duration: Treatment 3 Code S: 0: A: P: Therapist: Date: Discipline: Time: Visit Duration: Treatment ~ Code S: 0: A: P: Therapist: ~._._ xanj c~'~ci~ii INTERDISCIPLINARY PROGRESS NOTES I IIN~ ~~ DIY ~~ W~ ~N ~~ ~ SAUL, ANNA NTATIN4AMU3A R D06:011~2s8935i074 F09 CARt1SLE REGIDNAI MEDICAL CTR 0003 D PT 0901 (08101) ~ ~ .,~TERDISCIPLINAR~ PROGRESS NOTE Date: Discipline: Time: Visit Duration: Treatment 8 S /9/09 v ~ T ~r~ --'---'- Code S: 0: A: P: Date: Discfpline: Time: Visit Duration: Treatment 3 Code S: 0: A: P: Therapst: Date: Discipline: Time: Visit Duration: Treatment ~ Code S: 0: A: P' ___ R~c~. MiD1CA1 CiNTII INTERDISCIPLINARY PROGRESS NOTES INU~I~faiaiffuff~~IN~Ii~ SAUL, ANNA M ACCT 9434440 MRA'0000064585 0511812009 NTATIN, AMUSA DOB:01126t1935 074 f CARLISLE REGIONAL MEDICAL CTR 0003 D PT 0901 (OSI01) NAME L 1!~] TREATMENT- DIAGNOSIS- PRECAUTIONS Pi1YSICIAN ~-~ DATE ._ AGE ~ DATE OF ONSET ~~ .~.. xv u.~l u: ~/'-/ ~ ~~-p rr•o~,.~ G ~(~'~, G9 ~~ 1~-H711' - ~ . d yBiL~;.th f~/I?lI'jc ~ v / ~5~~.,Sf~pr~~ • GJ~Q {w,r,Q,~ fiOME ENVIRONMENT: N v~~ ~p~~ fz-4~nitb-~ ~'Y1.~i,,a~c..4.(fL~ ~"_'~ ds~t,4 ~. Sd n Z~6ii ~ ...o ~ ZS~'Q~f° s ~.-. '(-+'~e._ C f~-A+R~ -.`n ~ sic D/C PLANS: _~ ~~~ ^ _ ~ ~~ `~~~~ EQUIPMENT NEEDS: G S: Pain: (alo scale> MENTAL STATUS: COMMUNICATION: A+ O x 3 Y N Speech: WNL WFL A + O x time, lace Comprehension: WNL WFL unresponsive U cLh ~.(I' ~ Other. llvsrECTioN: THiN/AV WEI HEP LOCK UR OXYGEN SKIN CATHETER RES ? IMMOBILIZER or BRACE PLEXIPULSE O~~ rOSTURI~ TRANSFERS SITTING- WNL WFL ROLLING- L IN=OUT OF BED R STANDIIYG- WNL WFL LIE=SIT ON~FF COMMODE COMMENTS- ~~ ~~~ ~ SIT=STAND OTHER '~ ROM STRI~NGTN G ERAL- WNL GENERAL- S 4 3 2 1 0 UE'S- WNL UE'S- 3 4 3 2 1 0 LE'S- WNL WF LE'S- S 4 3 2 1 0 COMMENTS- ~r,_ "' /y COMMENTS- ~~.tl ftia cc~~,~~,o ~tJ - -fir. AYe ~ WI° l..~~~~ r s_~ .•~. ,~. ~ ..~...... wti,ww wr r~wrnwr PAt J III~Ct, Ilttt~ Impaynp, tAN~ AbNflt, (D) O~pOnd~nt PdNnt do~a 0.2dli, moc (/l) = petl~nt doM 2e-60%. mod (A) ~ p~tl~nt doN 51-76%r min W . Pxtl~nt doM 76100%, (s) Sup~rvi~ion: vKbd a~a onyr, (n Ind~pOnd~ no vKbal cuN a physical at+aNt n~~dOd, NA =not appNcablO at elwlu~tlon, NO -not ot~rvOd ~t ~vd. •,T•~•~ ~ T~nnt ~-G~ IsIIIAIII~IIIIIIIIiIIIIl011NIIIIIIIiIIIIUI F-6G'~VAL L, ANNA IVI Y t D l C A L C t N T t R ACCT 9434440 MR/t0000064585 05! 1812009 PHYSICAL THERAPY DEPARTMENT CART siE REGSONA LMEDICALC7R50003 D EVALUATION PT 0311 A I O6i03) coos ~ r (~ ~,.1~-t~o/~ t t ~ ~'~~/-~' ~~ G~Q'`,`'4- -~ It~l~ ~-, 1. Pedant wiN transfer supine <--~--> da assist to allow for functional acdvitles in sitting in sessions. 2. Patient will transfer sit <----> stand wMh assist to allow for inltlation of gait and tolletk-g ectlvities in sessions. 3. Patient wIN transfer bed <-----> chak with assist to allow for hmcdonal activitlss in siWng in sessions. 4. Patient wIN transfer floor <---->st~d with assist to albw Ibr knorMsdge d safe tectlmigw ~ sessions. 1. Pedant will ambulate dstsnce wifh with assht in ' sessions, . 2. Padsnt wiN achieve indent ambulation with appropriate assisdve.davlce on level stsfaces and slats as necessary flue days plus. 1. Patient w~ ascend/descend slaps wph with assbt In sessions. 2. Pedant wilt ascendidescend or» stapler curb with MrNft assist in sessions. ~. 1. Pedant wiM demortetrate bder>ce witit >p ensure satiety with trarnhts and ambulation to sesabns. 2. Paderrt wiM be abk to st vrxh support in sessions. 1. Patient vriM be independent wNh a home eaoerclse program ht sessions. 1. Pedant wtN tolerate repetltlons of eocen~es >Do. lradeese endurance necessary far ADL's h sessions. 1. Pf>ysk:d Therapy DepartrnarK.wiN assistwNh.dlsdlange Planning. 2. Patient andlar famNy >n agreen>ferit rrttit above goals yes no THERAPIST: DATE: _~I~-% , w-rsrr ioemncnroN INIDICAL CYN7Bl GENERAL PATIENT OOiA1.8 111111 NIN IIIII IIIII IIIN IIIII IIIN III NN SAUL, ANNA M ACCT 9434440 MR~0000064585 0511812009 NTATIN, AMUSA DOB:0112611935 074 F CARLISLE REGIONAL MEDICAL CTR 0003 D PT 0511C (31t>~