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Home My WebLink About11-17-06 . Lk ( ,( r:. tj~~i LI_ __0' LL I. e> (~5 0'-""- U-l C-i Of-: CC (J'J c) c.) U L....i Lt.J 0,'- a: v-. ... >- o :z \,G c:::::I c:::::I "" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY NINTH JUDICIAL DISTRICT OF PENNSYLVANIA ORPHANS'S COURT DIVISION In Re: James Huncharik An alleged incapacitated person No.: 21-06-0953 ORDER OF COURT AND NOW, this 17th day of November, 2006, after hearing, the Court finds by clear and convincing evidence that James Huncharik is a totally incapacitated person; IT IS FURTHER ORDERED AND DIRECTED that Sherial Huncharik, is hereby appointed plenary guardian, of the person and estate of James Huncharik. The posting of bond in this matter is waived. The guardian is directed to file reports in accordance with the provisions of the Probate, Estates and Fiduciary Code applicable to such guardianships. By the Court, ,t~\ M. L. Ebert, Jr., J. Debra K. Wallet, Esquire Attorney for Petitioner bas N ..:r M z: Q.. r- tf r- ex: ~ u...~x 00....' (...) -, ::::c:: L_-" ex: v:>.~ ~.~.._'i ,. ... 0:: '-' L.:.J 0) :ii: OB . ... ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF In Re: JAMES HUNCHARIK AN ALLEGED INCAPACITATED PERSON CUMBERLAND COUNTY PENNSYLVANIA NO. 21-06-0953 CERTIFICATE OF SERVICE OF ORDER ORDER DATE: 11-17-06 JUDGE'S INITIALS: MLE TIME STAMP DATE: 11-17-06 IN RE: ORDER OF COURT """,.............................,..,',...,',.....,'""""""""""",,,,,,,,,,,,,,',..,""""',.,..,"""""""" SERVICE TO: DEBRA K WALLET ESO METHOD OF MAILING: ENVELOPES PROVIDED BY: D USPS DRRR j:gI HAND DELIVERED D OTHER_ D PETITIONER D JUDGE D CLERK OF ORPHANS COURT MAILED: 11/17/06 ,.........,...",.".."...""""...,"""""""',."""""""".."""""..""",,"""""""'"""""""",. SERVICE TO: METHOD OF MAILING: ENVELOPES PROVIDED BY: D USPS DRRR D HAND DELIVERED D OTHER_ D PETITIONER D JUDGE D CLERK OF ORPHANS COURT MAILED: ~~ puty C crk ofOq>hon,' Court PULMONARY AND CRITICAL CARE MEDICINE ASSOCIATES, RC. RICHARD G. EVANS, 0.0, FC.CP FRANKLIN J. MYERS, III, M.D., FC.C.P SAFA P FARZIN, M.D. ROBERT C. GILROY, M.D., FC.C.P WilLIAM M. ANDERSON, III, M.D., FC.C.P 1631 N. FRONT STREET HARRISBURG, PENNSYLVANIA 17102 TELEPHONE: (717) 234-2561 FAX: (717) 236-1121 2808 OLD POST ROAD HARRISBURG, PA 17110 TELEPHONE: (717) 920-4549 November 15,2006 The Honorable M. L. Ebert Cumberland County Court of Common Pleas One Courthouse Square Carlisle, PA 17013-3387 RE: Estate of James Huncharik, an Alleged Incapacitated Person; No. 21-06-953 Dear Judge Ebert: I have been asked to provide this information about my patient, James Huncharik, age 59, who has been under my direct medical care since August 2006. My professional qualifications are contained in the curriculum vitae attached to this letter. I am licensed to practice medicine in Pennsylvania. The patient was admitted to the Harrisburg Hospital on August 23,2006, with a diagnosis of pneumonia and a staph infection. He remained at Harrisburg Hospital from August 23 until approximately Oct. 6, at which time he was moved to Select Specialty Hospital (which is a separate entity but physically located on the 5th floor of Holy Spirit Hospital). After a cardiac arrest on October 20 at approximately 1 :30 a.m., Mr. Huncharik was admitted to the Intensive Care Unit at Holy Spirit Hospital. The cardiac arrest led to an oxygen deficiency to Mr. Huncharik's brain, known as an anoxic encephalopathy. He has been totally unresponsive to external stimuli since October 20. On October 30, 2006, he was moved to Select Specialty Hospital for the purposes of weaning him from a ventilator. This was successful on November 7 and he is awaiting discharge to a full-time nursing facility. Mr. Huncharik has lost a substantial amount of weight and has only involuntary/reflex movements. Without question, he can neither communicate with others or make decisions. He certainly could not handle his own financial affairs. The current diagnoses are anoxic encephalopathy and respiratory failure. The prognosis is poor. I would estimate that he has a ten percent chance of recovery. For your information~ I have attached copies of the admitting and discharge summaries for my patient as well as related documents supporting my statement that my patient is unresponsive and'certainty,unable to manage his affairs or to make decisions about his life or his medical care. I personally examined the patient today and there has been no change in his unresponsive condition. He is in need of the appointment of a guardian. If the Court would require additional infonnation, I will be happy to provide it. In my observation, Mr. Huncharik's wife, Sheria! Huncharik, is attentive to her husband and has actively participated in his care on a daily basis. All of my opinions in this letter' are given with a reasonable degree of medical certainty. I verify that the statements made in this letter are true and correct to the best of my knowledge, information and belief.,' I understand that false statements made herein are made subject to the penalties of 18,Pa. e.s. f4904, relating to unsworn falsification to authorities. , , ::p;:a~=y J Richard Evans, D.O. , [Mrs. Huncharik says it may not be Dr. Evans who signs] REldkw Enclosures (C.V.; medical records) RICHARD G. EV.\SS III . Home Address: Work Address: 351 Futurity Orive Camp Hill PA liOll puUtJcnar-f & Critical Care Medicine Associates 16j1 North Front St:'eat Har='.sburg P A 17102 Marltal Stat~s: Personal : Wife - Cheryl An:1 Child=an - Arianne. ~at:"ick.. ;x Oii~lia Bir::'1date - May g. Height 5:6" Weigh: 165 pounc3 1_. . ..... .,,"". ?R.:)E'SSSIONAL EX?E~ISNC=: :::i~ical Assistant ?rores3cr of ~edic:'-le.. P'.l111ona:-1 ar.c. Critc3.1 ::ara :Je;t.: ?~r:~ State Unlversi:-/.. Milt:;n S.. H==sns1 ~edic.:l ~ent=::-.. H==E~S:t." P.;.. 19;3. - P:-9sent. .;C::'~/: Stat!. Har=:.sbur:; EOSpl:al! Ha==~5=ur;, ?; " :u.J..i- 1S'S3 - ?=:,ser::. Ac-:iva star:,.. Pol:tc~:"-"lic Me'=~c31 Ca~:er. E3.==isbu:.;.. ?~.. Jttl:t 1~g3 - ?=S3:r.:. .;c:i'V.a Staf~.. Holy Spir:t Hospital.. Camp Hili.. PA.. Jul:t 1993 - ?==se~t. ~.c-=~/: stat:.. HeaI::.~ Scut.~ Rel:a1: Hcs;ital.. Mecr:a~:=s=u=;.. PA: ='9~'5 - ?=:.::r::. .:;''=::l'!,,''e .:ita=:. Slue :<ic.;e Ha'!,.€!:1 )1-:5-::- ;:arnp :ii:l.. ?;.. 19-:4 - Pr=sa~-:. A53is\:!nt S~a::! Adul: ::1.tans~'le Ca== :rll:t. :3a:3:n";e= !"'!ecical C~n:==. Dan~/ille, PA, 1990 - Prasent. Ass~stant Staff.. General ::1tar:1a1 Mec:iciJlS: Ge:siI:ga= Xec:c.3.l C:r:te=. Da:1ville,. PA, 1989 - 1S90. GRA~t:A:'E: EDUCATION ;ello'..rship f pulmonar! Medicine, Ge:s:~ge: N;:d.:.:~ ;:3n:::,. :Jan'r.lle. ?;.- July 1991 - June 1993. :nte:nal Medicine Residencv. Ge~ince::: ~ed.:cal Cante:. ~an'Jilie. P.~. July 198.8 - June 199i ~ - ;?' rnterns~ip, Metre Healt..i. Cente:, E:r:e. Pa. July lSS7 - June 1988. MED!C.~!. EDUCA':'ION Coctcr or Osteopathic Medicine. Philadelphia College or Osteopat~l': ~ec.iC:''1e- Philadelphia, PA, June 19B7. UNDE:RGRADUATE E:OUCATION Bachelor or Science. Biology, Universlty of Sc:::-anton. Scranton. P A. June 198::. ME!)I~AL :'ICENSUR::: I Penasyivania, License N'umbe:::-: OS-.jOb501-L, 1990. - .- ~-, ~.,,"~".!- Richard G. Evans m. D.O. . - '. ,-~... '~'.' ., .. Cm:1cu1:um V1tQ. }~, Page two .' ,,~;/~c ';~~'- ." ,-.. ~... .-....~~;+, .~,-.,'1~"'~: ~.};~Jf~~' '. ..-'. ,;" . ,cL~~~~~t~..: >.,;, . -~"':':tl"i,S ,~. ,;1" . {;~T~~~~fi~l:~::,.. ," ..,.' -.... :::::RTIFICATION :;iplcmata il1 ?cimcnar] Jisaase. A.Itle_~,=~" 3::=:: :f !n:anal :1adic:ne. ~'?9=5. ~u:n=e= 11977: .~r.S=:=3n 3ca=d -;f ::1~==:1~ >i-==:c:;-.s ~ =i?l:::l.?.:: ~.??:. :r...:.:::c'== ~2'~~-3. :ra-=~r:al 3ca==':: :;.;~~C~=.::::: :1=c.:.c'::': :::::a~:~:=:'.. ::;:~':::t~::=.. -'=~~.. :!-:;NORS ~\;::Cr3 :'i~c .~::cr:<; ~:.3i.~; -!:tlZ':'; .~:n::=:::!::3.. . ...._....~- ...... --: -..;... ~:;9G ::.::.::. .~. ~ .;t: 3-: .......... . ~ ,j~,;: PROFESSIONAL COMMITTEES :.3;ec:.al Care Committee~ H91y Spirit Hospital! 1996 - ?=ess:1':. Cancer Committee! Polyclinic Medical Center, 1994 - -19915. Pneumonia Pncckout Committee - Harrisburg Hospital. Sept" 1993" CPR Committee, Geisinger Medical Center 1990 - 1991. Adult Intensive Care Unit Quality Improvement Committee! Geisinger Center! 1991 - h'esent. 9 ~ ......:;..... . 'F ,""__ . ...--., '- PROFESSIONAL MEMBERSHIP .; . : ...:;:;.:~:r~r Mea..cal._. "'. "'f.!~~'i '::>,:sfq11r ':,:jr, ';':-':'~c~ , . i '...~ t' - .. "': Ame:i.can Diplomate Society American College of Physicians American College of Chest physicians So<;:iety of Critical Care Medicine American Thoracic Society ??"ESENTA~Io~rs - ::creign .Body Aspir300n and Pcst-C:ibstructv,: ?~au:ncnia as ~ ~ani.festa-:io:1 ~-= Factitious Disorder t Evans! Richard and Fisk.. DaVid" Poster finalist at ACP National Meeting '"rlashiI:gtcn DC 1.99: ?:rt:=~t Prefe=ence 0: Bronchcdilat::r D:l:'~l~r-.t ::=.r:CS3. :;.g= :iloln:nger." :<:.!: Aibertinin ," R. ! Evans, R" t ':' ~a=e'."s ;-;:. ? . Poster Presentati~n . American Thoracic Society Nati.::r.al :4teetin.;.. 3cston MA. May 1994: current submitted for. publication. Skeletal and Neuromuscular Disease of The Respirato:y system - Geisinger Medical Center Continuing Medical Educations! April 1993. .~r:tbulatory pulmonar-! !unction Testing, 8eisir.gar Medi:::a1 Center. Con~ui!l~ Medical Education Course, April 1992. " ..- ~;, . REFERENCES i~ ~. ' . 1 <, Excellent professional 'and personal references will be furnished under'separate cover .. -./ HISTORY AND PHYSICAL ADM. DATE: 10/30/2006 ADMITTING DIAGNOSES: 1. Anoxic brain syndrome. 2. Ventilator dependency. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old white male who was admitted to Harrisburg Hospital on 08/21/2006. He had multiple medical problems including ventilator failure, adult respiratory distress syndrome. methicillin resistant staphylococCus, multifactor encephalopathy, acute on chronic renal failure, and ankylosis spondylitis. He was admitted to Select Specialty Hospital on 10/04/2006. He slowly improved. His mental status improved. He was taken off the ventilator. A Jack's was put in. He started physical therapy. On October 20, 2006, he developed an acute bradycardia. Cardiopulmonary resuscitation occurred with reverse bradycardia. He was reventilated and taken to SICU. The ten days he was in SICU, cultures were done. There was no evidence of recurrent methicillin-resistant Staphylococcus aureus; although, he did have worsening of an MRI with severe metabolic encephalopathy consistent with anoxic brain syndrome. This was also confirmed by EEG. He was followed by Dr. Dukkipati and Dr. Evans in Moffit Heart and Vascular Group. He is transferred back to Select Specialty Hospital on a ventilator today. He is presently on full ventilation with tube feeding and not responding. PAST MEDICAL HISTORY: Consistent with ankylosing spondylitis. He has significant problems from his long hospitalization in Harrisburg in August of this year including a ventilator failure with adult respiratory distress syndrome, methicillin-resistant Staphylococcus aureus sepsis, multifocal encephalopathy, acute on chronic renal failure with hemodialysis, prior history of ankylosing spondylitis, chronic anemia, acute pneumonia, history of bowel obstruction, history of hypertension, peptic ulcer disease, and history of gout. MEDICATIONS: 1. Guaifenesin 200 via the tube four times daily. 2. Reglan 10 mg every eight hours. 3. Norvase 5 mg by mouth daily. 4. Epogen 20,000 units on Tuesday. 5. Nexium 40 mg daily. 6. Senokot daily 7. EyedropS 8. Lovenox 40 mg daily. 9. Lopressor 5 mg intravenous every eight hours. 10. Natural tears. 11. Ativan as needed. Page 1 of 3 SELECT SPECIAL TV HOSPITAL Central P A-Camp Hill Location Camp Hill. PA 17011 NAME: HUNCHARIK, JAMES MR#: 1823 PT#: 11636 AP: KENNETH CONNER HISTORY AND PHYSICAL HISTORY AND PHYSICAL ADM. DATE: 10/30/2006 12. Combivent metered dose inhaler 6 puffs four times daily. FAMILY HISTORY: His parents are both alive. His mother is well. There are no significant problems. His father does have a history of cardiac disease. There is no history of diabetes or cancer. SOCIAL HISTORY: He was living with his wife. He was not working at the time. He did chew tobacco, but did not smoke prior to these hospitalizations, and he had an occasional alcoholic beverage. He had no known drug allergies. . REVIEW OF SYSTEMS: Unobtainable at this time and there is nothing acute or unchanged from the HPI or differences that are not noted. Since the patient is unresponsive. PHYSICAL EXAMINATION GENERAL: A 59-year-old white male who was unresponsive. VITAL SIGNS: Temperature 99, pulse 100, respirations 30, and blood pressure 158/91. SKIN: Dry. HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic. Conjunctiva pink. Sclera nonicteric. Pupils are equal, round, reactive to light and accommodation. Extraocular muscles are intact. Oral mucosa was clear. NECK: Supple. LUNGS: Decreased breath sounds with poor effort. No wheezing was appreciated. CARDIAC: Atrial rate of 100, there were no murmurs or gallops appreciated. Page 2 of 3 SELECT SPECIAL TV HOSPITAL Central PA-Camp Hill Location Camp Hill, PA 17011 NAME: HUNCHARIK, JAMES MR#: 1823 PT#: 11636 AP: KENNETH CONNER HISTORY AND PHYSICAL ......... HISTORY AND PHYSICAL ADM. DATE: 10/30/2006 ABDOMEN: Soft, there was no guarding or rebound. He did have positive bowel sounds. PROSTATE: Deferred. EXTREMITIES: Showed trace of edema. There was no calf tenderness. NEUROLOGIC: No focal or neuro findings. He was sedated as well as unresponsive. He did not move any extremities. There were no pathological reflexes. IMPRESSIONS: 1. Status post cardiac arrest with sinus bradycardia and anoxic brain encephalopathy. 2. History of ankylosis spondylitis. 3. History of acute respiratory distress syndrome and ventilator failure. 4. History of methicillin-resistant StaphylococcuS aureus sepsis. 5. History of pneumonia. 6. Chronic anemia. 7. Hypertension. 8. History of acute renal failure and was dialyzed prior. 9. Gout. PLAN: The patient is being admitted and is on the ventilator. We will start supportive care. We will continue to treat aggressively, ventilatory and antibiotics, and hope for some encephalopathic reversal. JRlmd DOC #: 4070 D: 10/31/200608:06:30 CST T: 10/31/200609:58:46 CST Page 3 of 3 SELECT SPECIALTY HOSPITAL Central PA-Camp Hill Location Camp Hill, PA 17011 NAME: HUNCHARIK, JAMES MR#: 1823 PT#: 11636 AP: KENNETH CONNER HISTORY AND PHYSICAL Referred By: Tentative Diagnosis: Type of Trac:ing: Routine: Sleep: Other: Length of Tracing: Type of Electrode: Activation: Sedation: Or. Kerawala Case I x /bedside 20 minutes 22 disc, 1 EKG, T1 and T2' None. None. r REPORT: The patient is a 59-year-old man with a history of hypoxic encephalopathy. This electroencephalogram was done at the bedside and ccnsisted. of comatose recording. No discernible posterior dominant alpha background rhythms were seen. No discernible elec:trocE!rebral rhythms above 10 microvolts were seen. No epileptiform discharges were seen. Hyperventilation was not performed. Photic stimulatio/1 was rll)t performed. IMPRESSION: Abnormal. This eledroencephalogram demonstrates background suppression and is s_lgge!Sliv,; of a severe diffuse encephalopathy. Clinical correlation is advised. RAVI DU~J<IPATI, MD RD/kjb DOC #: 675456 0: 10/23/2006 2:55 P T: 10/24/2006 9:33 A 000119392 Page 1 of 1 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Huncharik, James AGE: 59 MR#: 337248 OA 71:;: 10/23/2008 R-::>OM SlC:U230 0" E~eCTROENcePHA~OGRAPH R::':PORT coPy SERVICE DATE: 10/20/2006 ECHOCARDIOGRAM COMPLETE, 2D, M-MODE, PULSED DOPPLER ANrJ COLOR FLOW DOPPLER INDICATION FOR PROCEDURE: The patient is a 59 year old male with pneumonia, status post respiratory arrest with resultant bradycardia and acute renal failure. TWO DIMENSIONAL FINDINGS: 1. The overall quality of the study is fair. 2. The patient's left ventricle was normal size with low normal systolic function and an estimated ejection fraction of 50%. The septum appears to be D-shaped but there are no obvious wall motion abnormalities in the myocardial segments visualized. 3. The patient's left atrium, right atrium, aortic root and right ventricle appear normal size. The patient's right ventricle is normally functioning. 4. The patient's mitral valve leaflets are mildly thickened with adeqUlitel h!aflet e)eclJrsion. 5. The patient's tricuspid and pulmonic valves appear structurally norma!. 6. The patient's aortic valve is mildly calcified. There i!l adequate leliflet excursicm,' cannot determine from this study if this is a trileaflet valve. 7. There is no obvious pericardial effusion. DOPPLER FINDINGS: 1. Doppler interrogation to the mitral valve reveals mild mitral regurgitation. 2. Doppler interrogation to the aortic valve reveals no siignificant aortic stenosis ;lInd trivial insufficiency. 3. Doppler interrogation to the tricuspid valve reveals trivial to mild insufficiency with a TR max velocity of 3.5 meters per second which is an estimated PA systolic pres:sure of approximately 60 mmHg. 4. Doppler interrogation to the pulmonic valve reveals no significant pulmonic in:;ufficiency. IMPRESSION: 1. Normal left ventricular size with low normal systolic function. Estimated E!jection fraction of 50% with D-shaped septum. 2. Mildly thickened mitral valve leaflets without significEmt sterlosis and rnild insufficiency. 3. Mildly sclerotic aortic valve without significant stenoEiis and trivial inSlJfficienc;y. ..... Trivial tricl./spid rE>gl.lr,gitation witn now evidence for at least moderate pulmonary hypertension. 5. Normal right sided heart structures including normal right ventricular function. 6. When compared to the patient's prior study dated October 16, 2006, overalll~lft ventricular function has not changed. Valvular function is also similar. There is now, however, evidence for moderate pulmonary hypertel1sion and RV pressure o"erload. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 ECHOCAROIOC RAM REPORT CO~"Y Page 1 of 2 ----...........- .......,..........------ NAME: Huncharik, James MR#: 337248 ROOM: SICU2.30 01 SOC, SEe # 202-38-8~?:3 NAME: MR#: Huncharik, James 337248 KSR/et DOC #: 675079 0: 10/20/2006 T: 10120/2006 3:09 P cc: KENNETH B CONNER, MD KEITH S. RICE, M.D. HOLY SPIRI-T HOSPITAL Camp Hill, PA 17011 ECHOCAROIOGRAM REPORT Administratively Signed JEFFREY S MANDAK, MD 10/25/2006 17:23 c ------..--- KEITH.;j. RICE, M.D. Page 2 of 2 NAME: Huncharik. James M R#: 337248 ROOM- SlCU230 01 SO: SEe ~~. 202-36.e4~:3 COpy ADM. DATE: DISCH.OA TE: 10/20/2006 Mr. Huncharik was sent to the Holy Spirit HospitallCU with severe bradycardia, respiratory failure, status post intubation, methicillin-resistant Staph aureus sepsis, multi-faceted encephalopathy, renal failure that had resolved, history of ankylosing spondylitis, and anemia secondary to chronic disease. Mr. Huncharik was a 59-year-old male who had been in Select Specialty Hospital from the 10/04 until last evening. He had been transferred to Select from Harrisburg Hospital where he was admitted on 08/21. At that time, he came to the hospital with shortness of breath, chest discomfort, back pain and was anemic. Because of the pain, he was put on Telemetry floor and was seen by cardiology and GI. His hemoglobin was as low as 6 at the time and his renal functions were fairly reasonable. He, subsequently, went into respiratory distress a day later and actually had to be transferred to the Intensive Care Unit and intubated. He developed pneumonia and had to be treated for that. He had multi-attempts at weaning of the ventilator and subsequently had to be trached as well as a PEGG placed. He did end up with methicillin- resistant staph aureus in his sputum, also had sepsis. He also ended up requiring dialysis because of significant renal failure. Also. ended-up having effusions that needed multiple tappings and continued to have a lot pains issues that were secondary to ankylosing spondylitis. Well, he was Harrisburg Hospital he was found to have encephalopathy secondary to his medical issues and prior to his transfer to Select Specialty, he began to improve respiratory- wise and the goal was to eventually wean him off. While at Select Specialty, he made significant gains. He got to the point where we actually wean him the ventilator and put Jackson in his trach. He was also at the point where he had just started taking oral fluids and there was very strong discussion to continue to pick up his intensity of PT. All of sudden yesterday evening, he was to be bradycardic with a pulse as low as 20s and ER attending had to rush in to see him. They subsequently had to put him back on the ventilator and he did respond to atropine but did respond to epinephrine that was given. Based on the critical state in which he was in, he was subsequently transferred to the leu for continued care. CONDITION OF PATIENT UPON DISCHARGE: Page 1 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Huncharik, James MR#: DR.: CLAUDETTE JATIO, M_D_ DISCHARGE SUMMARY ORIGINAL NA-i1E: MR;4; Huncharik, ,;,-1Ies CJ/sac DOC #: 675965 D: 10/20/2006 1: 16 P T: 10/26/200610:18 A 000118891 cc: CLAUDETTE JATTO. M.D. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 DISCHARGE SUMMARY O,M.D. Page 2 of 2 NAME: Huncharik. James MR#: ROOM: DR.: CLAUDETTE JATTO, M.D. ORIGtNA~. ':LUBINA N KE~.:J..\~ALA Fr'>: Me.j c,ll 8.,,3':; ::'j , ::: 5 06 3. ') ;;a..::l: '";,f J ADM. DATE: 10/20/2006 55 #: 202-38-8433 REASON FOR CONSUL TA T10N: Cardiopulmonary arrest. HISTORY: Mr. Huncharik is a 59 year-old patient who is transferred to Holy Spirit Hospital Surgical Intensive Care Unit with the fOllowing diagnoses: A. Pneumonia/respiratory failure/resolving ARDS. B. Chronic ventilator weans/status-post tracheostomy. C. Acute renal failure/hemodialysis; resolved. D. MRSA sepsis. E. History of diabetes. The patient was transferred to the Surgical Intensive Care Unit last evening after being found unresponsive and bradycardic. His pulse/heart rate was defined as being 15 bpm. A Case I was called. The patient's respirations were supported with a bag-valve mask. CPR was initiated, and he received therapy with atropine and epinephrine. producing a heart rate of 134 bpm. Reviewing his admission History and Physical and Discharge Summary from Pinnacle Health System, he apparently has no prior cardiac history, and there were no cardiac issues noted during his acute hospitalization. He was apparently seen by our practice at Harrisburg Hospital for reports of chest pain. Based on the Discharge Summary, it was felt that the discomfort was related to anemia and. as stated. there were no suspected cardiac issues during that hospital admission. The patient's telemetry strips during the Case I were reviewed. They exhibit extreme sinus bradycardia with 2:1 atrioventricular conduction and a narrow QRS complex. The care notes were also reviewed from the patient's stay in Select Specialty Hospital. His respiration was essentially supported with a trach collar which he was on at the time of the event. Apparently, he did not require ventilatory support at this stage in his hospitalization. There were reports of thick tan-colored sputum with associated rhonchi, but the patient apparently was not in respiratory distress when he went to sleep. He had received Ativan and Percocet, but this occurred hours before the event. No history is obtained from the patient as he is currently unresponsive. PAST MEDICAL HISTORY: Significant for: 1. Ankylosing spondylitis. 2. Multiple spinal surgeries. Page 1 of 3 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Huncharik, James MR#: 337248 ROOM: SICU230 01 CONSULTATION REPORT DR.: WILLIAM APOLLO. M.D. COPY TO: RUBINA N. KERAWALA, M.D. To ~UBrNA ~ KERAWALA From Med. : ~eCC~~3 10/::5 06; 20 ':..Oag<:' ':::?f :3 NAME: Huncharik. James MR#: 337248 3. History of hypertension. 4. History of gout. 5. Small bowel obstruction status-post surgical repair. 6. Peptic ulcer disease with history of GI bleed. 7. Status-post knee replacement. 8. Anemia of chronic disease. MEDICA TIONS: Current medications include Duragesic patch 175 mcg every 72 hours, Lasix 40 mg IV daily, guaifenesin 200 mg four times a day. heparin 5,000 units every 8 hours. Reglan 10 mg IV every 8 hours, Norvasc 5 mg per day, Procrit 20,000 units every Tuesday, Protonix 40 mg per day, Senokot 1 tablet daily, Xalatan eyedrops, tube feedings, and multiple prn medications. SOCIAL HISTORY, FAMILY HISTORY, REVIEW OF SYSTEMS: Cannot be obtained. PHYSICAL EXAMINATION: Examination reveals a pleasant patient who currently is in no cardiopulmonary distress. His blood pressure is stable on low dose dopamine, and telemetry reveals sinus tachycardia at 106 bpm. HEENT: Examination of the head reveals no specific trauma. NECK: The neck reveals a tracheostomy in place with the patient being mechanically ventilated. Jugular venous pressure is normal. There are no carotid bruits. LUNGS: Clear, with scattered rhonchi. HEART: Regular and tachycardic, with no significant murmurs. ABDOMEN: Soft. There is evidence of prior surgery. EXTREMITIES: SKIN: No clubbing, cyanosis, edema, or stasis changes. Warm and dry. NEUROLOGIC: The patient is completely unresponsive. There were reports of some decorticate posturing earlier in the morning to painful stimuli, but I am obtaining no response to such stimuli. The patient has an intact corneal reflex. Review of diagnostic studies include a chest x-ray showing improvement in the patient's overall lung fields compared to prior studies. Page 2 of 3 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Huncharik, James MR#: 337248 ROOM: SICU230 01 CONSULTATION REPORT DR.: WILLIAM APOLLO, M.D. COPY TO: RUBINA N. KERAWALA, M.D. To {UB-NA N KERA~ALA ~Y)m Med~ca: Recoras :J':5 ~6 13:21 Plg0 :1 f -:: NAME: MR,#: Huncharik, James 337248 Laboratories reveal white blood cell count 15, hemoglobin 9.4. hematocrit 29.8, platelet count 463. Basic metabolic profile reveals hyponatremia with a sodium of 127. The BU N is 20, with creatinine of 0.9. Troponin level is mildly positive at 0.3. IMPRESSION: Mr. Huncharik is a 59 year-old patient with multiple medical problems as noted. He suffered a cardiopulmonary arrest which is likely respiratory in origin with secondary bradycardia due to hypoxemia. SUGGESTIONS: 1. Continue supportive care. 2. Obtain serial cardiac enzymes and electrocardiogram to rule-out myocardial injury. 3. Obtain an echocardiogram to assess left ventricular function. 4. I agree with Neurologic work-up to rule-out an ischemic encephalopathy. 5. We will attempt to obtain records from Pinnacle Health System regarding the consultations performed in that institution from a cardiac standpoint. WILLIAM APOLLO, M.D. WAlck DOC #: 675795 0: 10/20/2006 T: 10/25/2006 11 :50 A 000118848 cc: WILLIAM APOLLO, M.D. KENNETH B CONNER, MD RUBINA N. KERAWALA. M.D. Page 3 of 3 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Huncharik, James MR#: 337248 ROOM: SICU230 01 CONSULTATION REPORT DR.: WILLIAM APOLLO, M.D. COpy TO: RUBINA N. KERAWALA, M.D. ADM. DATE: 10/20/2006 SS #: 202..38-8433 REASON FOR CONSULTATION: Cardiopulmonary arrest. HISTORY: Mr. Huncharik is a 59 year-old patient who is transferred to Holy Spirit Hospit~11 Surgical Intensive Care Unit with the following diagnoses: A. Pneumonia/respiratory failure/resolving ARDS. 8. Chronic ventilator weans/status-post tracheostomy. C. Acute renal failure/hemodialysis; resolved. D. MRSA sepsis. E. History of diabetes. The patient was transferred to the Surgical Intensive Care Unit last evening after being f,)und unresponsive and bradycardic. His pulse/heart rate was defined as being 15 bpm. A Case I was called. The patient's respirations were supported with a bag-valve mask. CPR was initiated, and he received therapy with atropine and epinephrine, producing a hecut rate of 134 bpm. Reviewing his admission History and Physical and Discharge Summary from Pinnacl(~ Health System, he apparently has no prior cardiac history, and there were no cardLa.c issues noted during his acute hospitalization. He was apparently seen by our practice at tiarrisbl.lrjJ Hc,spital for reports of chest pain. Based on the Discharge Summary, it was; felt that the discomfort was related to anemia and, as stated. there were no suspected c:ardiac issues during that hospital admission. The patient's telemetry strips during the Case I were review/ad. Th,:!y exhibit extreme sinus bradycardia with 2: 1 atrioventricular conduction and a narrow QRS complex. The care notes were also reviewed from the patient's stay in Select Specialty Hospital. His respiration was essentially supported with a trach collar whi(:h he was on at the time of the event. Apparently, he did not require ventilatory support at this stage in hi!; hC1spitalizaticm, There were reports of thick tan-colored sputum with associated rhonchi, but the patient apparently was not in respiratory distress when he went to sleep. tie had rE~ceived Ativan and Percocet, but this occurred hours before the event. No history is obtained from the patient as he is currently unresponsive. PAST MEDICAL HISTORY: Significant for: 1. Ankylosing spondylitis. 2. Multiple spinal surgeries. Page 1 of 3 HOLY SPIRIT HOSPITAL Camp Hill. PA 17011 CONSULTATiON REPORT NAME: Huncharik, James MR#: 337248 ROOM S1CU230 01 DF,.' W1L:..IAIVAPO_LO M.C' Cooy NAME: Huncharik, James MR#: 337248 3. History of hypertension. 4. History of gout. 5. Small bowel obstruction status-post surgical repair. 6. Peptic ulcer disease with history of GI bleed. 7. Status-post knee replacement. 8. Anemia of chronic disease. MEDICATIONS: Current medications include Dursgesic patch 175 mcg every 72 hours. Lasix 40 mg IV daily, guaifenesin 200 mg four times a day, heparin 5.000 units every 8 hours, Reglsn 10 mg IV every 8 hours, NOIVase 5 mg per day, Procrit 20,000 units every -ruesday, Protonix 40 mg per day, Senokot 1 tablet daily, Xalatan eyedrops, tube feedings, and multiple pm medications. SOCIAL HISTORY, FAMILY HISTORY, REVIEW OF SYSTEMS: Cannot be obtained. PHYSICAL EXAMINATION: Examination reveals a pleasant patient who currently is in no cardiopulmonary distress. His blood pressure is stable on low dose dopamine, and telemetry revE~als sinus tachyciardia at 106 bpm. HEENT: Examination of the head reveals no speCific trauma. NECK: The neck reveals a tracheostomy in place with the patient being mechanically ventilated. Jugular venous pressure is normiiil. There are no carcltid bruits. LUNGS: HEART: Clear, with scattered rhonchi. Regular and taehycardic, with no significant murmurs. ABDOMEN: Soft. There is evidence of prior surgery. EXTREMITIES: SKIN: NEUROLOGIC: No clubbing, cyanosis, edema, or stasis changes. Warm and dry. The patient is completely unresponsive. There were rt2pOrtS of sr.1rTle decorticate posturing earlier in the morning tC) painfUl stimuli, bLlt I am obt:lining no re$ponsa to such stimuli. The pationt has an inta..~ corneal reflex. Review of diagnostic studies include a chest x-ray showing improvement In the patier'lt's overall lung fields compared to prior studies. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 CONSUL'" A TIC)fI, REPORT Page 2 of 3 --~------ NAME: Huncharik, James M R#: 337248 ROOM: SICU230 01 OR.- WILLl/\W APOL.:"C, M,D COpy NAME: MR#: Huncharik. James 337248 Laboratories reveal white blood cell count 15, hemoglobin 9.4, hematocrit 29.8, platl!IE!t count 463. Basic metabolic profile reveals hyponatremia with a sodium of 127. Tt.e SUN is 20, with creatinine of 0.9. Troponin level is mildly positive at 0.3. IMPRESSION: Mr. Huncharik is a 59 year-old patient with multiple medical problems as noted. He suffered a cardiopulmonary arrest which is likely respiratory in origin with seconclary bradycardia due to hypoxemia. SUGGESTIONS: 1. Continue supportive care. . 2. Obtain serial cardiac enzymes and electrocardiogram to rule-out myocardial injury. 3. Obtain an echocardiogram to assess left ventricular function. 4. I agree with Neurologic work-up to rule-out an ischemic encephalopathy. 5. We will attempt to obtain records from Pinnacle Health System regarding the consultations performed in that institution from a cardiac standpclint. Adminh3tratively Signed ROBEHT E MARTIN. MD 10/2f31200Ei '16:38 WILLIAM APClLLO, M.6:---'--'-- WAlck DOC #: 675795 0: 10120/2006 T: 10/25/2006 11 :50 A 000116848 cc: WILLIAM APOLLO, M.D. KENNETH B CONNER, MD RUBINA N. KERAWALA, M.D. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 Page 3 of 3 --_....-......'11. .-a___ CONSUL TA'""lON REPOF,T NAME: Huncharik, JamE~S MR#: 337248 ROOM: SICU230 01 0::,.. WILLIAM,A.::lOLLO, M.D CO~y SERVICE DATE: 10/16/2006 ECHOCARDIOGRAM COMPLETE, 20. M-MOOE, PUL.SED DOPPLER AND COLOR FLOW COPPLER ',' :". CLINICAL HISTORY: Respiratory failure. TWO DIMENSIONAL ANALYSIS: 1. Normalleft:,ventricular end diastolic diameter 5.4 em. 2. Concentric left ventricular hypertrophy with a wall thickness of 1.2 em. 3. Prominent aortic root diameter 3.8 em. 4. Normal left atrial diameter of 2.9 em. 5. Normal right atrial size. 6. Normal right ventricular size. .' REGIONAL WALL MOTION ANAL VSIS: 1. Low normal left ventricular function with no clear regional wall motion abnorll'!lalities. 2. Estimated ejection fraction 50%. 3. Normal right ventricular function. MITRAL VALVE: 1. Thickened mitral leaflets with adequate excursion. 2. Mild mitral insufficiency. 3. Delayed left ventricular relaxation (0.6/0.7 meters pE~r second). AORTIC VALVE: 1. Thickened trileaflet aortic valve with adequate excursion. 2. No aortic insufficiency. 3. Peak aortic outflow velocity of 1.2 meters per second "RICUSPID VALVE: 1. Trace tricuspid insufficiency. 2. Peak tricuspid regurgitant velocity 2.8 meters per second. 3. Pulmonary artery pressure of 39 millimeters of Mercury. PULMONIC VALVE: 1. No pulmonic insufficiency. 2. Peak pulmonic outflow velocity 0.8 meters per secol,d. CONCL.USIONS: 1. Normal left ventricular function with no regional wall motion abnormalitieE~. 2. Concentric left ventricular hypertrophy with delayed relaxation. 3. Mild mitral insufficiency with normal left atrial diameter. 4. Trace tricuspid insufficiency with normal right atrial und right ventricul:3r sizes; mild pulmonary hypertension. Page 1 of 2 HOL. Y SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Huncharik, James MR#: 337248 ROOM: SOC SEe #: 202.3E-843~, :=CHOCAROi';)GRA.iV RE~ORT co;;:y NAME: MR#: Huncharik, James 337248 5. Prominent aortic root diameter. WAJjg DOC #: 674003 0: 10/16/2006 T: 10/1612006 10:50 A 000117509 cc: WILLIAM APOLLO, M.D. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 ECHOCARDIOGRAM REPORT Administratively Signed TIMOTt-IY P WALSH, MD 10/17/~~006 14:43 WILLIAM APOLLO. M1i.- Page 2 of 2 ---.........-...__."'17"""'<1 r ...__w'............_ NAME: Huncharik, James MR#: 337248 ROOM: SOC. SEe # 202-38.8433 COPY Huncharik, James Sex:M BO:09/02/1947 MR#:202388433 Page , of 2 DEdollll!~ P~~9-e PT#:270045570 SUMMARY P Oct 09, 200611:56 PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 SUMMARY REPORT Admitting Physician: KENNETH B. CONNER, MD Date Dis: 10/04/2006 Date of Op: DIAGNOSES UPON DISCHARGE: 1. Acute respiratory failure currently ventilator dependent. 2. Acute respiratory failure secondary to ARDS. 3. Large left pleural effusion. 4. MRSA sepsis. 5. Significant severe anemia requiring multiple transfusions. 6. Acute renal failure and chronic renal failure currently on hemodialysis. 7. Ankylosing spondylitis. DISCHARGE MEDICATIONS: Combivent two puffs q.4., Nexium 40 mg via PEG daily, Fentanyl patch 150 mcg q.72., Heparin 5000 units subcu q.8., eye drops into both eyes q.h.s., Reglan 10 mg IV q.8., Lopressor 5 mg q.6., Senokot one tablet daily, Tylenol p.r.n., Dulcolax p.r.n., Ativan 4 mg IV q.2. p.r.n., insulin sliding scale, vancomycin 1 gm IV q.72. hours, calcium acetate 667 one tablet via PEG t.i.d., Cipro 200 mg IV q.12., Epogen 20,000 units subcu q. Monday, lorazepam 4 mg IV q.4. p.r.n. The patient has been in the hospital from August 21, 2006 up until October the 4th. This has been a long admission where he has had a complex stormy course, which is extremely hard to summarize in one review. The essential summary is that he came .in on the 21st when he was admitted for being short of breath, having a cough, fever, and back pain as well as some mental status changes. He was found at the time to have significant hypernatremia, anemia. Blood culture, sputum cultures were obtained. He was found to have MRSA sepsis and had to be started on IV antibiotics. In the process his respiratory failure significantly worsened and he had to be intubated around the 25th of August and was transferred to the lCU. He was extubated on the 29th of August, but there was a lot of confusion that was still observed. He was felt to have some degree of metabolic encephalopathy. However by September the 1st he became significantly hypoxic and had to be re-intubated and placed back on a ventilator. His overall mental status continued to wax and wane. He had the second weaning attempt where by September 14th he was more awake, more alert, and was extubated. However by the 18th this status changed again and had to be re-intubated and at this point it became obvious that he was having ongoing respiratory issues. Chest x-ray and CT scan confirmed that he had significant ARDS and he .w~s treated with steroids, IV antibiotics, ventilator support, nebulized treatments. He had multiple EEGs that were done that showed slow background activity consistent with a metabolic encephalopathy. There were multiple services that were on board to help with his care. He was initially on the Conner, Rich service but had to be transferred to Dr. Farzin's service in the lCU with a lot of his respiratory issues. The neurologists were also consulted because of his overall decline in mental status. He also had an 10 consultation and followthrough because of his MRSA sepsis and recurring pneumonias while he was on the admission here. His kidney function significantly declined https://ipssrvl.pinnac1ehealth.org/https/O/NET ACCESS2.SMSHEAL THCONX.NET/P ... 11/15/2006 Page 2 of2 whi~e he was on this admission and it got to the point were he did have to commence on dia~ysis. His acute rena~ fai~ure was fe~t to be ~ikely secondary to acute tubu~ar necrosis and at this point in time he is going to be getting dia~ysis. He had a ~ot of cha~lenges with anemia on this admission requiring multiple transfusions too numerous to sit down and count and as recently as yesterday he received another two units of blood. His hemoglobin is just at 9. As he is being discharged today, he is clearly a sick patient with multiple medical issues. The family is fully aware and in the picture of his overall status. He hope is that when he goes to Select Specialty with time his overall mental status may hopefully improve and he may hopefully require less ventilatory support. He does have a PEG and a tracheostomy that was inserted on this admission and so access to feeding and nutrition at this point is not an issue. Time it took to review the entire chart has been over forty minutes. Patient: Huncharik, James c: KENNETH B. CONNER, MD CLAUDETTE JATTO, MD CLAUDETTE JATTO, MD OD: 10/04/2006 1980830 DT: 10/09/2006 /lj Of: Page created Wednesday. November 15, 2006 8:12 AM For: DBOWSE Too of Page https://ipssrvl.pinnac1ehealth.org/httos/OINETACCESS2.SMSHRA T ,THrONY NPT IP 11 /1 "/")(\(\t::, -" HISTORY AND PHYSICAL ADM. DATE: 10104/2006 ADMITTING DIAGNOSES: 1. Ventilator failure status post adult respiratory distress syndrome secondary to pneumonia. 2. Methicillin-resistant Staphylococcus aureus sepsis. 3. Multifactorial encephalopathy. 4. Acute on chronic renal failure with hemodialysis. 5. Ankylosing spondylitis. 6. Anemia secondary to chronic disease. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old white male admitted to Harrisburg Hospital on 08/21/2006. At that time he was seen in the emergency room for shortness of breath, chest discomfort, back pain, and was noted to be anemic. Because of his pain, he was admitted to the telemetry floor. He was seen by cardiology and GI. His hemoglobin and hematocrit was 6.5 and 20.1. At that time his BUN and creatinine were 24 and 1.5. His sodium is 116 and potassium is 61. He was admitted to the seventh floor cardiac unit of Harrisburg. These numbers were corrected. He was ultimately seen by the Moffitt group and cardiac disease was ruled out. It was felt that his chest pain was secondary to anemia. He did have some respiratory distress after getting fluids and all. He developed pneumonia and was transferred to the intensive care unit. He was seen by Pennsylvania GI at that time. They held off on performing endoscopy until he was stabilized. Ultimately, they performed endoscopy and found some mild gastritis. It was felt that his severe anemia was due to chronic disease. Because of his ankylosing spondylitis, he was on some immunosuppressive drugs, as well as Indocin, and this may have been a contributing factor to his anemia. He was transfused. The anemia resolved. He did develop progressive respiratory distress, and was seen by Dr. Myers and Dr. Evans, and ultimately he was intubated and started on intravenous antibiotics. He did have methicillin-resistant Staphylococcus aureus in his sputum, but he did not fare well and continued to have terrible wean trials and increasing compliance, suggesting adult respiratory distress syndrome. This diagnosis was made, and he was treated appropriately. He did develop some effusions and had some tappings done. Ultimately and progressively. over several weeks, he improved, and weaning has been much more successful. Because of significant pain related to his ankylosing spondylitis and lying in bed. as well as other problems, he did receive a fair amount of pain medications and sedation. While being intubated, he did have a multi-factorial encephalopathy, as diagnosed by neurology. A CT scan was done at Harrisburg, which showed a small pontine infarct. It was felt that this has no contributing factor to the present situation. Cultures were done several days ago. The sputum, after chest x-ray. showed improvement. and showed Serratia marcescens. which is sensitive to Cipro. which he is on presently. His blood cultures on 10102/2006 were normal. He was transferred to Select Specialty Hospital for intensive and aggressive respiratory care, antibiotic care, cognitive, and beginning of therapies. Page 1 of 4 SELECT SPECIALTY HOSPITAL Central PA-Camp Hill Location Camp Hill, PA 17011 NAME: HUNCHARIK, JAMES MR#: 1823 PT#: 11616 AP: KENNETH CONNER HISTORY AND PHYSICAL I \. \ "--. ,-----,. HISTORY AND PHYSICAL ADM. DATE: 10/04/2006 PAST MEDICAL HISTORY: 1. Ankylosing spondylitis with prior surgery. 2. Recent bowel obstruction. 3. History of hypertension. 4. Pneumonia several times in the past due to immunosuppression. S. History of gout. 6. Peptic ulcer disease. ALLERGIES: No known drug allergies. MEDICATIONS: Are on the chart at the time of transfer. FAMILY HISTORY: His parents are both alive. His mother is well. There are no significant problems. His father does have a history of cardiac situations, but is alive and well. There is no history of diabetes or cancers. SOCIAL HISTORY: He lives with his wife. He does not work. He does walk at home as his major activity. He had been seeing Dr. George Kunkel for his ankylosing spondylitis. He has been followed by Dr. Esposito and Dr. Faries, as well for bowel obstruction and recurrent cOlonoscopies, and there is some thought that he may have had Crohn's disease at some time. He does not smoke or drink. REVIEW OF SYSTEMS: Essentially unobtainable at this time. I do know the patient pretty well, and his major complaint has been pain. Breathing difficulties, level of consciousness, and awareness have progressively improved since he has been less sedated, even in the last several days. GI: He is being fed nutritionally with tube feedings. RENAL: On dialysis. NEUROLOGIC: He has no focal neurological complaints. PHYSICAL EXAMINATION GENERAL: Cooperative but somewhat lethargic 59-year-old white male. He does have some grimacing when moving his arms or legs. Page 2 of 4 SELECT SPECIAL TV HOSPITAL Central PA~Camp Hill Location Camp Hill, PA 17011 NAME: HUNCHARIK, JAMES MR#: 1823 PT#: 11616 AP: KENNETH CONNER HISTORY AND PHYSICAL '-.....-" HISTORY AND PHYSICAL ADM. DATE: 10/04/2006 VIrAL SIGNS: His blood pressure is 155/95; respirations are 29. heart rate 1 00. His temperature was 1 02.1, but is presently 99.4. SKIN: Dry. HEAD, EARS, EYES, NOSE, AND THROAT: Head normocephalic. Eyes: conjunctivae pink, sclerae anicteric. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Oral mucosa was negative. NECK: Supple. No appreciable bruits. CHEST: Symmetrical. LUNGS: Decreased breath sounds with some rhonchi and poor effort. CARDIAC: Heart regular rhythm of about 100. There were no appreciable murmurs or gallops heard at this time. ABDOMEN: Mildly distended and tender. There was a percutaneous endoscopic gastrostomy site tube that showed no evidence of any significant inflammation. Bowel sounds were normoactive. RECTAL: Deferred at this time since it is not indicated. EXTREMITIES: His extremities had +2 edema bilaterally. There were no pulses appreciated. There was no calf tenderness noted. NEUROLOGICAL: The patient moved all extremities slowly. He was lethargic. He did not follow commands very well, but he was more appropriate than he was several days ago when I saw him at Pinnacle. SELECT SPECIAL TV HOSPITAL Central PA-Camp Hill Location Camp Hill, PA 17011 Page 3 of 4 NAME: HUNCHARIK, JAMES MR#: 1823 PT#: 11616 AP: KENNETH CONNER HISTORY AND PHYSICAL -,." ---/ HISTORY AND PHYSICAL ADM. DATE: 10/04/2006 IMPRESSION: Multi-system disease failure in a 59-year-old male with ankylosing spondylitis. He was admitted to Harrisburg Hospital with chest pain and severe anemia. The anemia was due to chronic disease and mild gastritis. SECONDARY DIAGNOSES: 1. Acute pneumonia with respiratory failure. intubation, and adult respiratory distress syndrome. 2. Continued ventilator failure. 3. Acute on chronic renal failure with hemodialysis, BUN going from 20 to 101, and starting to return down. 4. Hyperglycemia with insertion coverage. s. Multi-factorial encephalopathy. 6. Pons infarct. 7. Sputum culture positive for serratia on 10/0212006. JRljlc DOC #: 281766 0: 10/05/2006 08:07:23 CST T: 10105/2006 23:44:45 CST Page 4 of 4 SELECT SPECIAL TV HOSPITAL Central PA-Camp Hill Location Camp Hill, PA 17011 NAME: HUNCHARIK, JAMES MR#: 1823 PT#: 11616 AP: KENNETH CONNER HISTORY AND PHYSICAL );S>FA :ARZ.~ MD ~r)m:P~n~ac~aHeal~~ C ~3 ;' .~: 1 ) :-.~ j ;::::a;~e ~). PINNACH.HE.ALTH HUNCHARIK. JAMES RM#: ICU7ICU-04 MRN. 202-38-8433 CASE: 00270045570 DOB: 09/02/1947 ADM: 08/21/2006 PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 CONSUL TA TION REPORT Date of Dictation: 09/20/2006 Date Dis: REASON FOR CONSULTATION: Abnormal EEG and CT scan. for opinion. PHYSICIAN REQUESTING CONSULTATION: Franklin J. Myers, III, M.D. HISTORY: Mr. Hunckarik is a 58-year-old right-handed white male who has been in the hospital since August 21 , 2006. when he was admitted for shortness of breath. cough. fever and back pain as well as mental status changes. The patient has been treated over this period for hyponatremia, anemia. as well as pneumonia and hyperkalemia. The patient's course was also complicated by MRSA sepsis. for which he had to go on antibiotics. The patient was intubated on 08/25/2006 due to sepsis. He was extubated on the 29th of August and was noted to be confused. He was felt to have metabolic encephalopathy. He was more clear by August 31 st; however. he developed hypoxia again and was re-intubated on September first and sedated with Ativan and Fentanyl. By September 10th the patient was nonres~onsive. He gradually improved to where he was awake and alert by September 14th. By September 18t he again became poorly responsive. He was recently extubated and noted to be confused. He was reintubated one day ago and has received quite a bit of sedation over the past twelve hours, including Fentanyl 100 mcg which he received around 3:30 a.m. last night and Ativan 4 mg at 11 :00 a.m. and 20 mg around 4:00 p.m. At this time. the patient is not responsive to verbal commands. The reason we were asked to see him is that a few days ago he did have an EEG which interpreted. myself. as showing slow background activity at 5-6 cycles/second. consistent with a metabolic encephalopathy. On September 19th he had a head CT scan which was read as showing low attenuation in the pons. We are being asked to see him for opinion. Current medications include Bumetanide. vancomycin, Ativan. Fentanyl PRN. esomeprazole. metoprolol. insulin, metoclopramide. Ambien and Hydralazine. The past medical history is positive for chronic back pain due to ankylosing spondylolysis. The patient has a history of bowel obstruction. He has hypertension as well as gout and a history of GI bleed and insomnia. During this hospitalization the patient had renal failure. for which he started having dialysis. He had pneumonia and MRSA sepsis. for which he has been on antibiotics. The patient undergoes dialysis and is intubated. ALLERGIES TO MEDICATIONS: NONE THAT WE KNOW OF. Family history shows his father died at a young age due to heart disease. His mother is living and well. Social history shows the patient has a positive smoking history and alcohol use daily. He is married and CONSULT CONSULT CONSULT COpy FOR: SAFA FARZIN, MD "J ;::AF~ ;:- A.P.:: . N iVlD FromPinnaC:9Heal~h )9/2:/06 18:03 2I;;'.g2 3 ){ ~'> PINNACLEHE./\LTH HUNCHARIK, JAMES RM#: ICU7ICU-04 MRN. 202-38-8433 CASE: 00270045570 DOB: 09/02/1947 ADM: 08/21/2006 CONSUL TA TION REPORT Date Dis: lived with his wife prior to admission. The review of systems is unobtainable because the patient is obtunded. FINDINGS: On physical examination today, his blood pressure is 140/65. Pulse is 75/minute and regular. Respiratory rate is 15. Temperature is 35.8 degrees C. His lungs are clear with intubation and ventilation. Heart sounds are distant but normal. Abdomen is soft and nontender, with normal bowel sounds. Neck is supple. He has a tracheostomy that appears uninfected. On neurological exam the patient does not follow verbal commands and withdraws to pain. He does not track with his eyes but closes his eyes to threat. On cranial nerve exam his pupils are 1.5 mm, round and reactive. Optic disks are sharp. He has no facial asymmetry. Hearing cannot be assessed. Tongue and soft palate movement appear to be midline. On motor system exam the patient's strength is about 3/5 but he does not move spontaneously and withdraws to pain. Deep tendon reflexes are brisk, especially in the lower extremities, with ankle clonus bilaterally. Sensory exam cannot be assessed. Coordination cannot be assessed. IMPRESSION: This patient has a number of medical reasons, including hypoxia, renal failure and sedation with Ativan that would certainly explain his encephalopathic picture. We re-reviewed his EEG and it is certainly consistent with his general medical status. We reviewed his head CT scan and he, indeed, has some low attenuation in the pons, but we believe that this is artifactual. You may want to pursue this by MRI, but I do not believe that is indicated at this time. Clinically I seen no convincing evidence of a pontine infarct with eye movement that is symmetrical and pupils that are reactive. All of his clinical status can be explained by his metabolic situation. DIAGNOSIS: Metabolic encephalopathy. RECOMMENDATIONS: Supportive care. Patient: JAMES HUNCHARIK c: RIFAAT BASHIR, MD SAFA FARZIN, MD REVIEWED AND ELECTRONICALLY SIGNED BY: RIFAAT BASHIR, MD 09/21/200616:12 CONSUL T CONSULT CONSUL T COpy FOR: SAFA FARZIN, MD ') 3AFA. .".-\R':'::I N MD From:PinnacleHeal~ 19/21 06 .8 ~4 Page 4 of ~ ~~ PINNACU;:H~LTH HUNCHARIK. JAMES RM#: ICU7ICU-04 M R N. 202-38-8433 CASE: 00270045570 DOB: 09/02/1947 ADM: 08/21/2006 CONSUL TA TION REPORT Date Dis: RIFAAT BASHIR, MD DD: 09/20/2006 DT: 09/20/2006 /ksc D#: 1969315 CONSUL T CONSULT CONSULT COpy FOR: SAFA FARZIN, MD '0 SAF A i:":.l..R.-=. N YlD r0rn.?in~ac: He~1 ~~ :) .)5 / 06,~ () . "_8 P~l'Ae :) f ,t ~'> PINNACU:Hl;/\LTH HUNCHARIK. JAMES RM#: ICU7ICU-17 MRN. 202-36-6433 CASE: 00270045570 DOB: 09/02/1947 ADM: 08/21/2006 PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 NEPHROLOGY CONSULTATION REPORT Date of Dictation: 09/05/2006 Date Dis: DATE OF CONSULTATION: 9/5/06. REASON FOR CONSULTATION: Oar Farzin requested nephrology consultation to assist with management of the patient's acute renal failure. HISTORY: The patient is a 58-year-old male with a history of ankylosing spondylitis, multiple back surgeries. hypertension. severe pneumonia x 2 in the past year. a history of respiratory failure, gout. who initially presented for admission on August 21 st secondary to fever, cough. and mental status changes. He has since been diagnosed with pseudomonas and staph aureus pneumonia. He has developed respiratory failure/ARDS. I was asked to see the patient as he was noted to have an increased creatinine. Upon review of the records it appears that the patient's creatinine was at its baseline at 0.8 on September 1 st. By the 2nd his creatinine increased to 1. On September 3'd his creatinine was 1.3. On the 4th his creatinine had increased from 2.6 to 2.7. Today his creatinine was 3.3. It appears that he received 200 cc of IV dye for two CAT scans on September 1 st. On September 2nd he developed hypotension with a decrease in the systolic blood pressure to at least the 80's. He has been on Levophed since the 2nd of this month. He also has been receiving antibiotics including cefepime. He was on an ACE inhibitor until September 2nd. The patient is currently intubated and sedated. He is not able to provide any additional history at this time. Therefore the history has been obtained from the medical chart. Past medical history is significant for ankylosing spondylitis, multiple back surgeries, history of bowel obstruction status post surgery, hypertension, severe pneumonia x 2 in the last year, history of respiratory failure. gout. peptic ulcer disease, history of Gl bleed. history of knee replacement with associated infection. Medications: The patient's medications currently include heparin 5,000 units subcutaneously every 8 hours, morphine 20 mg IV q. 4 hours, lorazepam 20 mg IV q. 4 hours, Flagyl 500 mg IV q. 8 hours, vancomycin 1 gram IV q. 12 hours, fentanyl drip, Reglan 5 mg IV q. 8 hours, ciprofloxacin 400 mg IV q. daily, Levophed at 10, Combivent q. 4 hours. cefepime 2 grams IV q. 12 hours, midazolam drip, normal saline at 10 cc an hour, pantoprazole 40 mg IV q. daily, and insulin drip. ALLERGIES: NO KNOWN DRUG ALLERGIES. Social history, family history, and review of systems: Unable to obtain as the patient is currently intubated and sedated. CONSULT CONSULT CONSULT COPY FOR: SAFA FARZIN, MD -.{ -{ ;o'Y fa SAFA fAR_r~ MD F~')m,~i~naclef~ea:~h 08;'05;06 ~ '19 ~age ~, '.' ~'> ~INNACLEH~.)\LTI-I HUNCHARIK. JAMES RM#: ICU7ICU-17 MRN. 202-38-8433 CASE: 0027004:5:570 DOB: 09/02/1947 ADM: 08/21/2006 CONSUL TA TION REPORT Date Dis: PHYSICAL EXAM: Vital signs: Blood pressure 105/45, pulse 98. He is afebrile. Respirations are 16. General: The patient is an older male on the vent, sedated, critically ill. HEENT: Head atraumatic, normocephalic. Eyes: Conjunctivae without injection. Sclerae anicteric. Oropharynx: The patient is intubated. Neck: No bruits or thyromegaly. Pulmonary: Lungs are with coarse breath sounds bilaterally. Cardiovascular: Normal S1 and 52. No murmurs, rubs, or gallops appreciated. Regular rate. Abdomen: Positive bowel sounds, soft. nontender, nondistended. Extremities: No clubbing or cyanosis. The patient does have some peripheral edema. Distal pulses are decreased but palpable. Neurological: The patient is unable to fully cooperate for a complete neurologic exam at this time secondary to sedation. LABORATORY STUDIES: The patient had labs today which revealed sodium of 138, potassium 5.2, chloride 108, bicarb 23. BU N 38, creatinine 3.3, calcium 8.2. magnesium 2.1. hemoglobin 7.6. hematocrit 25. IMPRESSION: Overall, my impression of Mr. Huncharik is that he is a 58-year-old male with a history of ankylosing spondylitis. hypertension, respiratory failure, severe pneumonia x 2 in the last year, gout, who is currently in the hospital for ongoing respiratory failure, now with acute renal failure. ISSUE: 1. Acute renal failure. Differential diagnoses include: Prerenal azotemia (less likely), ATN (most likely) given recent administration of IV dye as well as recent hypotension. rule out acute interstitial nephritis and obstructive uropathy. For now will check routine urine studies as well as a renal ultrasound. His electrolytes are adequate except for an elevated potassium. He was given Kayexalate. I will also change his tube feeds to Nepro given his acute renal failure and hyperkalemia. There is no acute need for renal replacement therapy at this time. will follow closely with you. 2. Anemia. Consider transfusion given the patient's poor pulmonary status to try to improve his oxygen carrying capacity. Will defer to the team for now. 3. Hyperkalemia. Change tube feeds to Nepro as noted previously. The patient has been given Kayexalate. 4. Pneumonia. The patient is currently on vancomycin. His level was 37 today. He is now in acute renal failure. I would recommend holding his vancomycin for now and redosing when his level is less than 15. Thank you for this consult and for allowing us to participate in the care of your patient. Please do not hesitate to contact us with any additional questions or issues you may have regarding Mr. Huncharik. Patient: James Huncharik c: SAFA FARZIN, MD CONSU L T CONSULT CONSUL T COPY FOR: SAFA FARZIN. MD o'SAFA ?ARZ[~, YD From Pln~acl~Health 09;05/06 ~O:?O ~age 4 of 4 ~'> PINNACH.H"/\LTI-l HUNCHARIK. JAMES RM#: ICU7ICU-17 M R N. 202-38-8433 CASE: 00270045570 008: 09/02/1947 ADM: 08/21/2006 CONSUL TA TION REPORT Date Dis: SANGEETA MITAL. MD SANGEETA MITAL. MD DO: 09/05/2006 DT: 09/05/2006 /Imf 0#: 1959167 CONSU L T CONSUL T CONSULT COPY FOR: SAFA FARZIN. MD Huncharik, James Sex:M BD:09/02/1947 MR#:202388433 Page 1 of 3 caP~il'lt t!1is-'?~S~ PT#:270045570 H&P P Aug 22, 2006 05:48 PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 HISTORY AND PHYSICAL Admitting Physician: JASNA BATTIN, M.D. CHIEF COMPLAINT: Shortness of breath, cough, fever, back pains, mental status changes. HISTORY OF PRESENT ILLNESS: This is a 58-year-old white male with history of chronic back pain and ankylosing spondylitis for a number of years who came to the emergency room due to patient's wife noticing mental status changes. The patient states that he has been coughing and had fever for about two days and patient tells me that this is what bothers him the most. On further questioning, he says that he has been having severe back pains but this chronic and he has been dealing with those pains with taking pain medications. In the emergency room, anemia worse than the previous admission was diagnosed along with pneumonia and electrolyte imbalance. Stool test for occult blood was checked and it was only very faintly heme positive. Patient denies any abdominal pain and states his last bowel movement was earlier today. The patient denies bleeding from anywhere. PAST MEDICAL/SURGICAL HISTORY: Back operations related to ankylosing spondylitis; recent bowel obstruction, status post surgery; hypertension; severe pneumonia two times in the past year; respiratory failure; gout; peptic ulcer disease; laminectomy; GI bleed; insomnia. MEDICATIONS: The medication list includes: Indomethacin 75 mg, one po bid; Probenecid 500 mg po daily; Prevacid 30 mg po daily; Oxycodone with Tylenol as needed; Fluoxetine 30 mg po daily; Cyclobenzaprine 10 mg po daily; lisinopril 20 mg po daily; Ambien 10 mg po daily; Xanax; Nifedical 90 mg po daily. ALLERGIES: NO KNOWN MEDICAL ALLERGIES. FAMILY HISTORY: Patient states that there is a cardiac condition on his father's side, with his father who died at a reasonably young age, however, his mother is still alive. Patient denies diabetes. SOCIAL HISTORY: Patient does admit to smoking cigarettes. Occasionally uses alcohol. He is married. Patient stated normally he walks at home without assistance. REVIEW OF SYSTEMS: Positive fever. No chills. No bleed that patient would be aware of. Patient is sleepy but awakens to voice. No nausea, vomiting or diarrhea. No constipation. No chest pain. Positive cough. No dysuria. PHYSICAL EXAMINATION https://ipssrv1.pinnaclehealth.org/https/0/NETACCESS2.SMSHEAL THCONX.NET/P... 11/15/2006 Page 1. of 3 VITAL SIGNS: Blood pressure is 116/50, pulse 88 and regular, respiratory rate 20, and temperature 36.1. GENERAL: This is a sleepy male. His skin is pale and dry. He does awake to voice and responds to some questions. HEENT: Benign, normocephalic, atraumatic. Pupils equally round and reactive to light and accommodation. Extraocular muscles are intact. Oropharynx: Mucosa is dry. Dentures are present. LYMPH: Lymph nodes in the cervical and axilla area not enlarged. NECK: No thyromegaly. No masses. CARDIAC: Regular rate and rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft, nondistended, nontender. Positive bowel sounds. decreased. No masses. No hepatosplenomegaly. BILATERAL EXTREMITIES: No edema, erythema, or cellulitis. Positive pulse. NEUROMUSCULAR: Nonfocal. LABORATORY: P02 on ABG is decreased 30. PC02 is 45. 02 sat is 66. The electrolytes show sodium decreased at 116, potassium increased at 6.1, chloride 81, decreased. C02 normal at 26.7, BUN 24, creatinine 1.5, and blood glucose 100. Urinalysis shows only 1+ leukocyte esterase with wac of 5 to 10, and bacteria 1+, and 2 to 5 epithelial cells. Complete blood count shows 12.9 wac increased with 88% left shift, neutrophils. Hemoglobin is 6.5, hematocrit 20.1, and platelets 238. TSH normal at 4.111, and C-reactive protein is moderately increased at 43.20. Blood cultures were taken, and results are pending. Chest x-ray shows pneumonia, and CT of brain shows no acute changes. IMPRESSION/PLAN Will admit this gentleman to. ,telemetry due to: 1. Pneumonia and hypoxemia. Will give non-rebreather mask and consult pulmonary. Will add him to to give us additional input to his respiratory management. Will give Rocephin. Will give Zithromax. The patient has had a history of prior respiratory failure. 2. Anemia. There is a possible GI pathology, although testing of stool in the emergency room shows only faint heme-positive results. Will transfuse packed red.blood cells and follow H H. 3. Hyponatremia and hyperkalemia. Will give normal saline solution and intravenous Lasix. 4. History of ankylosing spondylitis with chronic back pain. Will give pain control. 5. History of GI bleed. This is stable with possible new bleed in face of the patient's anemia. The patient is getting Protonix and GI consult. Patient: JAMES HUNCHARIK c: JASNA BATTIN, M.D. https://ipssrvl.pinnaclehealth.org/https/O/NET ACCESS2.SMSHEAL THCONX.NET /P... 11/15/2006 Page 3 of3 JASNA BATTIN, H. D . DD: 08/21/2006 1949271 DT: 08/22/2006 /jab/lmf/mgm D': Page created: Wednesday, November 15. 2006 8:12 AM For: DBOWSE Too of Page httnq. / /lnq~TV lninnac1ehealth.orIDhttns/OINET ACCESS2.SMSHEAL THCONX.NET IP... 11/15/2006