270045381
BH
6676757
650129
10/10/1997 12:00:00 AM
LEFT PROXIMAL HUMERUS FRACTURE .
Unsigned
DIS
Report Status :
Unsigned
DISCHARGE SUMMARY NAME :
JUNK , KACHOLERA
UNIT NUMBER :
482-31-51
ADMISSION DATE :
10/10/97
DISCHARGE DATE :
10/23/97
PRINCIPAL DIAGNOSIS :
Left proximal humerus fracture .
ASSOCIATED DIAGNOSIS :
Adult-onset diabetes mellitus x 40 years , history of silent myocardial infarction , coronary artery bypass graft ( three vessels in 1987 ) , history of chronic , stable angina pectoris , Fournier 's gangrene versus necrotizing fasciitis , congestive heart failure in 03/97 while in the hospital for a rib fracture , glaucoma , diabetic retinopathy with blindness in the right eye , history of gastric stapling , left rib fracture , right femur surgery .
PRINCIPAL PROCEDURE :
Left shoulder hemiarthroplasty .
OTHER PROCEDURES :
Upper endoscopy x 2 .
HISTORY OF PRESENT ILLNESS :
The patient is a 65-year-old male with a past medical history of diabetes mellitus , three-vessel coronary artery bypassgraft , congestive heart failure , who presents with a humeral fracture .
The patient is admitted for preoperative and orthopedic evaluations .
The patient presented with a comminuted fracture of the proximal left humerus when he slipped over the stairs , about to board an airplane back to Jeglas Blvd. , Jolouisrowarlihis , Alabama 86071 .
The fracture was seen by Orthopedics and was reduced .
During conscious sedation , the patient developed bigeminy ( the patient was sedated , did not feel chest pain or shortness of breath ) .
The patient presented to Bri Health in order to be evaluated for preoperative clearance .
He was reported to have had a myocardial infarction in the past ( EKG positive for ischemia , exercise tolerance test positive , cardiac catheterization positive , the patient is now status posta three-vessel coronary artery bypass graft in 1987 ) .
The patient also hada history of arrhythmia , found approximately ten years ago , unknown what type .
The patient was on coumadin recently , ? whether for the arrhythmia .
Coumadin was reportedly discontinued approximately six months ago secondary to planned surgery for diabetic retinopathy and glaucoma .
The patient did not have chest pain until approximately 1-1/2 years ago , when he began to have chest tightness ( pressure ) approximately every three months with stress .
The patient has no chest pain when walking slowly and can walk approximately 1.5 miles .
He can climb approximately three flights of stairs before becoming short of breath .
He does become slightly short of breath when lifting furniture .
On the day of admission , when he fell , the patient was experiencing no chest pain , no shortness of breath , and had no loss of consciousness , no head trauma with fall .
REVIEW OF SYSTEMS :
No fevers or chills , no chest pain , no shortness of breath .
The patient has stable three-pillow orthopnea and occasional paroxysmal nocturnal dyspnea .
He has a chronic cough with clear sputum .
No hemoptysis , hematemesis , abdominal pain , black or tarry stools , dysuria / frequency/urgency .
PAST MEDICAL HISTORY :
Some type of cardiac arrhythmia , diagnosed approximately ten years ago .
History of coronary artery disease status post silent myocardial infarction in the past and three-vessel coronary artery bypass graft in 1987 .
The patient has been experiencing chronic , stable angina pectoris over the past one to one and a half years approximately once every three months .
History of congestive heart failure , diagnosed approximately eight years ago .
Diabetes mellitus for approximately 40 years .
Fournier 's gangrene versus necrotizing fasciitis .
Glaucoma .
Diabetic retinopathy with the patient blind in right eye .
PAST SURGICAL HISTORY :
Cholecystectomy .
Status post gastric stapling .
Left rib fracture .
Right femur surgery approximately two years ago .
Righteye surgery for glaucoma in 05/97 .
Laser surgery for retinopathy .
MEDICATIONS ON ADMISSION :
Humulin 70/30 with 30 units subq.q.a.m. and 20 units subq.q.p.m. Vasotec 20 mg. q. a.m. Prozac 40 mg. q.d. Lasix 40 mg. q.d. K-Dur approximately 28 ? mEq q.d. Atropine 1% 1 GTT OD b.i.d. Ocufen 0.03% 1 GTT OD t.i.d. Ventolin metered-dose inhaler .
ALLERGIES :
no known drug allergies .
TOBACCO :
Formerly smoked 3 packs per day x 25 years ; 2 cigars per day x approximately 6 months .
He quit all tobacco approximately 27 years ago .
ETOH :
Rare .
SOCIAL HISTORY :
The patient is retired , lives with his wife and one son , who is 47 years old and had multiple myeloma and renal failure .
PHYSICAL EXAMINATION :
The patient is alert and oriented and has a sling for his left humeral fracture .
Blood pressure 120/70 , temperature 97.8 F , pulse 68 , respirations 22 , Sa02 on 2 L 94% .
HEENT :
Right-sided ptosis , right eye not reactive to light , cataract present , patient blind in that eye , left eye reactive to light , cataract also present in that eye .
Extraocular movements - conjugated eye movement intact .
Oropharynx moist , without lesions .
Mild right facial droop .
Sensation intact .
No slurred speech .
Cardiac :
regular rate and rhythm , no murmur appreciated , normal S1 and S2 .
Chest / lungs :
The patient is diffusely wheezy upon presentation .
Abdomen distended , mild tenderness on the left , bowel sounds present , nohepatosplenomegaly .
Extremities :
1+ edema of the ankles , pulses present bilaterally .
No calf tenderness .
Rectal :
Guaiac negative .
Neurological :
Non-focal , except unable to assess left upper extremity secondary to the patient 's broken humeral fracture .
LABORATORY DATA :
sodium 135 , potassium 4.1 , chloride 101 , C02 28.4 , BUN 17 , creatinine 1.0 , glucose 302 , calcium 8.6 , phosphorus 2.5 , magnesium 1.6 , total protein 6.7 , albumin 3.3 , globulin 3.4 , uric acid 6.3 , totalbilirubin .7 , alkaline phosphatase 93 , SGOT 20 , LDH 258 , CPK 95 , whiteblood count 15.3 , hematocrit 49.7 , platelet count 159 , MCV 98 .
RADIOLOGIC STUDIES :
Chest x-ray 10/10/97 :
Elevated left hemidiaphragm of uncertain etiology or duration .
Postoperative changes of the sternum and media stinum were seen and no acute pulmonary disease was visualized .
The patient also had a shoulder film done on 10/10/97 that showed a severely comminuted fracture of the proximal left humerus with proximal distraction .
A lucency and irregularity of the glenoid , possibly representing a fracture , was also seen , and a CT scan was therefore obtained in order to evaluate this area .
This CT scan , done also on 10/10/97 , again showed the severely comminuted fracture of the proximal left humerus .
Two major fracture fragments were seen at the humeral head , articulating with the glenoid fossa .
The fracture fragments retained their proper site of articulation with the glenoid fossa .
Innumerable smaller fracture fragments were interposed between the fracture fragment and the distal humeral shaft .
The glenoid fossa was intact .
No scapular fractures were present .
EKG :
normal sinus rhythm at 72 beats / minute , intraventricular conduction delay , Q - waves seen in II , III , and AVF with probable old inferior myocardial infarction .
T - waves were also noted to be inverted in I and AVL .
Ventricular bigeminy was also seen .
HOSPITAL COURSE AND TREATMENT :
1. ORTHOPEDICS :
The patient has a severely comminuted fracture of the proximal left humerus .
He is status post a hemiarthroplasty on 10/17/97 .
He received Ancef preoperatively .
Physical Therapy has been seeing the patient and putting him through passive external rotation to the neutral position of the left shoulder and forward flexion with physical therapy assistance .
Brittle bones were noted during the operation .
A bone density scan would be recommended as an outpatient , in order to evaluate this .
2. NEUROLOGICAL :
The patient has right facial droop , right ptosis , stable and present for greater than one year .
3. CARDIOVASCULAR :
No chest pain , no shortness of breath , 1+ ankle edema .
The patient was ruled out for a myocardial infarction , given his fall at the airport and bigeminy seen on electrocardiogram that he developed during conscious sedation during reduction of the fracture .
Cardiology was consulted and aspirin and beta blocker added to his regimen , as well as chest wall nitroglycerin around the time of surgery , which was subsequently discontinued .
An adenosine SESTAMIBI was performed on 10/12/97 , which showed a negative electrocardiogram for ischemia and cardiac perfusion scans , with a moderate-sized , dense , fixed inferior defect indicative of scar .
A small / moderate-sized , mild-intensity , reversible posterior lateral defect was also seen , indicative of mild / moderate ischemia .
An echocardiogram was performed on Columbus Day which showed an ejection fraction of 50% , left atrial enlargement , thickening of the aortic wall consistent with atherosclerotic changes , left ventricle size , and systolic function within normal limits .
Cardiac monitor was placed on the patient , given the bigeminy , and he did rule out for myocardial infarction .
Cardiology recommended that in addition to the medications already stated above , his hematocrit be kept greater than 30 .
After his procedure on 10/17/97 , elevated CPKs were noted on 10/19/97 to 10/20/97 , and the first level was 744 , CPK # 2 635 , and CPK # 3 461 .
MB fractionations of the CPKs were all negative and were thought to be secondary to the patient 's beginning physical therapy on 10/19/97 , and all muscular in origin .
4. GASTROENTEROLOGY :
GI was consulted on 10/15/97 for melena , decreased hematocrit prior to his humeral fixation surgery .
Upper endoscopy x 2 were done .
The first was on 10/15/97 , which showed clotted blood in the esophagus .
The stomach had evidence of prior surgery and old blood in the stomach .
It was thought that the blood in the esophagus was secondary to a possible Mallory-Weiss tear .
A second endoscopy was also performed several days later , in order to rule out a gastric ulcer , and also because the patient had had another episode of melena .
A gastric ulcer was found and this was biopsied and pathology is pending at this time .
This report needs to be followed up , and will be available at Bri Health in the Pathology Department some time within the next three to seven days .
The patient also needs a repeat endoscopy and a GI follow-up appointment inapproximately two months .
I have spoken with the patient in detail , and he will be getting in touch with his primary-care physician , Dr. Fordwoodall Stick , in Ranegei Pkwy , Verertliet , South Carolina 62156 .
The patient is to arrange follow up with a GI doctor in Jotar Boulevard , Cunahtampfordama , South Dakota 62848 through his primary-care physician .
The patient was initially on Cimetidine and Carafate here at Bri Health , and then switched to Prilosec 20 mg bid .
5. PULMONARY :
The patient 's admitting chest x-ray showed an elevated left hemidiaphragm consistent with atelectasis versus splinting on that side .
Incentive spirometry was started .
Albuterol and Atrovent nebulizers were done .
The patient received chest physical therapy bid .
6. ENDOCRINE :
The patient needs still better diabetes control .
He has been somewhat noncompliant with his diet ( eating Pringle 's in the room ) .
His NPH was recently increased today ( 10/23/97 ) to 24 units in the a.m. and 14 units in the p.m. with CZI sliding-scale coverage .
7. INFECTIOUS DISEASE :
The patient urinalysis on 10/19/97 showed moderate occult blood , pH 5 , albumin 1+ , white blood cells present , 2-50 red blood cell , 10-20 white blood cells , few bacteria , and moderate bladder epithelial cells .
Floxin 200 mg po bid was begun .
However , his urine culture from the same day remained negative , and this was discontinued two days later .
A repeat urinalysis on 10/22/97 was negative .
8. RENAL :
After the patient 's procedure , he was felt to be volume overloaded .
He was given Lasix 40 mg IV x 1 and also had Nitro paste around the time of his surgery and beta blocker .
The patient became slightly hypotensive on the night of 10/18/97 with systolic blood pressures in the 80s to 90s.
His BUN/ creatinine rose from 16/1.2 on 10/18/97 to 25/1.9 on 10/18/97 to 22/9.1 to today 's labs , which are 15/0.7 on 10/23/97 .
9. HEMATOLOGY :
The patient transfused 2 units on 10/15/97 for a hematocrit of 27.6 .
The patient transfused 2 units of 10/16/97 for a hematocrit of 30.03 .
The patient transfused 1 unit on 10/18/97 for a hematocrit of 29.4 .
The patient transfused 1 unit on 10/19/97 for a hematocrit of 27.9 .
The patient transfused 2 units on 10/20/97 for a hematocrit of 28.2.10 .
FEN :
Repleting potassium , magnesium , phosphorus as needed .
The patient was noted to be slightly hyponatremic over the past few days , with sodiums in the 128-132 range , but this was secondary to elevated glucose fingerstick blood sugars .
CONDITION ON DISCHARGE :
Stable , good .
MEDICATIONS ON DISCHARGE :
NPH insulin 24 units subq. q. a.m. NPH insulin 14 units subq. q. p.m. CZI sliding scale on a q. a.c. and q. h.s. fingerstick basis with the following scale :
FBS less than 200 = 0 units of CZI FBS 201-250 = 2 units of CZI FBS 251-300 = 4 units of CZI FBS 301-350 = 6 units of CZI FBS 351-400 = 8 units of CZI FBS greater than 400 = 10 units of CZI .
Atropine sulfate 1 GTT 1% OD b.i.d.
Ocufen 0.03% 1 GTT OD t.i.d. Vasotec 20 mg. p.o.q. a.m. Prozac 40 mg.p.o.q. a.m.
Oxygen 2-4 L to keep Sa02 greater than or equal to 94-95% and wean as tolerated .
Colace 100 mg. p.o. t.i.d. Senokot 1 p.o. q. h.s. Nystatin powder to affected area t.i.d. Lopressor 25 mg. p.o. b.i.d. Atrovent 0.8/2.5 c.c. normal saline nebulizers q. 8 h. Albuterol 2.5/5 c.c. normal saline nebulizers q. 4 h. with q. 2 h. p.r.n. Percocet 1-2 p.o. q. 4 h. p.r.n. pain .
Prilosec 20 mg. p.o. b.i.d. Vexol 1% 1 GTT OD b.i.d. Lasix 40 mg. p.o. q.d. KCl 20 mEq p.o. q.d. Tylenol 650 mg. p.o. q. 12 h. p.r.n. Ativan 1 mg. p.o. q. h.s. p.r.n.
SAY REKE , M.D.
TR :
vr
DD :
TD :
10/23/97 3:05
Pcc :
NABETH NA GLYNCRED , M.D. MI T THULRO , M.D. / Fordwoodall Stick , M.D. 7922
Fordknoxtall Illinois