DATE OF ADMISSION: MM/DD/YYYY
DATE OF DEATH AND TIME: MM/DD/YYYY at 12:20 p.m.
ATTENDING PHYSICIAN: John Doe, MD
MEDICATIONS ON ADMISSION:
1. Aggrenox 2 tablets p.o. daily.
2. Folic acid.
3. B6.
4. B12 shots every month.
5. Glucosamine 2 tablets p.o. daily.
6. Motrin p.r.n.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Dyslipidemia.
3. Stroke in July (XXXX).
4. Left carotid artery 100% block by carotid dopplers.
FAMILY HISTORY: Mother died of leukemia.
SOCIAL HISTORY: No tobacco, no alcohol, and no IV drug use. The patient lives with his wife.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.6, pulse 64, respiratory rate 10, and blood pressure 138/68. GENERAL: The patient is sedated and intubated. HEENT: Pupils are equal, round, and reactive to light. CARDIOVASCULAR: Normal S1 and S2, irregular rhythm. No murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGICAL: SAS of 1.
HOSPITAL COURSE: The patient is a (XX)-year-old male with past medical history significant for stroke in July (XXXX) and atrial fibrillation, not on Coumadin, who presented to the emergency department after being found unresponsive and down by his wife. Wife states that the patient was cleaning the porch, but she did not hear from him for approximately 30 minutes, so she went to check out on him and found him to be unresponsive. As per the wife, the patient has had a headache for about a month and has had some changes in his habits and behavior also for the last month.
The patient was brought to the emergency department and intubated for airway protection secondary to patient’s mental status change. The patient was transferred to the MICU where he was found to have an MI with a troponin leak with a peak of 58. The patient was brought to the catheterization lab where he was found to have a 90% LAD occlusion and consequently had a drug-eluting stent placed. The patient’s CAT scan on MM/DD/YYYY showed an old right posterior parietal infarct with a questionable acute right parietal infarct.
Neurology was consulted and started the patient on heparin drip and wanted a goal PTT of 65-80. Cardiology started Plavix and recommended to continue with the aspirin as well given the patient’s new stent. A repeat CAT scan on MM/DD/YYYY showed a worsening CVA picture with multiple infarcts. The family at that time changed the patient’s code status to DNR/DNI on MM/DD/YYYY.
The patient had been having issues with agitation throughout his hospital stay, which were fairly well controlled with Haldol and Ativan. The patient was extubated on MM/DD/YYYY and sent to the step-down unit with nasal trumpet for airway protection. Throughout his hospital stay, the patient developed what appeared to be aspiration pneumonia.
The patient declined very quickly to the point where palliative care was consulted. At that time, the family decided to change the patient’s status to comfort measures only. Therefore, the patient was transferred to a regular floor and all medications including antibiotics and tube feedings were held, and the patient was maintained on a morphine drip titrated to comfort along with Haldol and Ativan to help with any agitation. The patient’s family dealt with the palliative care physician along with the chaplain in order to help deal with the difficult events. The patient also had lab draws stopped at the time that the patient was made comfort measures only.
The patient passed away on MM/DD/YYYY. At that time, we were called to see the patient. We evaluated the patient and found his skin to be warm. His pupils were fixed and dilated. He had no oculocephalic reflex. There were no heart or lung sounds. He did not respond to any painful stimuli. The patient was pronounced dead at 12:20 pm on MM/DD/YYYY. The family was informed. The attending was contacted and an autopsy was offered but refused by the family. The chaplain and the palliative care physician also came and spoke with the family.
