Document 6425762

HISTORY AND PHYSICAL
PATIENTt
MR
#:
DISCHARGE
DATE:
ADMISSION DATE: 02/ 04/2003
Job
P/T:
L
LOCATION:
PCfT
320D
CHIEF COMPLAINT :
Mental statue change.
HISTORY OF PRESENT ILLNS39: The. patient is a 45 - year - old^,obeae femme
:with a history of chronic : ventilatory dependency and steroid d^peadeacy,
carbea dioxide retainer,. chronic obstructive pulmor:ary . dicaease , history of
diabetes mellitue ;. óa:^in,sulia and oral hyperglycemic .$geá£s, questionable
bipolar disorder , hiátá^y"of anxiety and left foot^c+erTEulitis . and anemia
- aecretioa :
She.is , noted to. have; chaage in
with trouble with
mental status and wis. referred to the Emergencg Ra^.fi^r eváluation.
° In the Emergency Róáñi ,.; tie patient had a pS. of 7.°2.9^" caY^on.:dioxide
° partial pressure S'S^,^ oxygen - pártial pressure 71; btcárbonates of 40 on 40$
°
_
° FI02.
°
°
'
° PAST HISTORY :
ó
F1
.
As. aliov$.'
'
PAST SIIRGTCA7. HISTÓÁ3C: Thé patient leas a trach^óstbmy• ánd seta by Mouth.
MEDICATIONS :
Combiden^ ,, Valium, Lasix , prednisoae ;•• Cólace, Protonix,
Neuroatin 300 millgré^má p.o. q. am .and
Prozac 40 milligrams p?:o, q.d .
1200 p . o. q. at bédtims ;' Glípizida 7.5 milligrams p.:o+ cÍ.d :; Glucophage XS,
2 grams p.o . g. 5 .pm and Lántus insulin 30 units subcutaneous q. at
The patient wás also receiving Biaxin and Ceftin at the nursing
bedtime .
home, it was day 3 of both antibiotics.
ALLERGIES :
NO KNOWN DRUG ALLERGIES.
REVIEW OF SYSTEMS: The patient has a complaint of left foot pain and left
She denies any ahortaesa of breath.
hip pain .
PHYSICAL EXAMINATION:
VITAL SIGNS : Temperature Blood pressure 136J7S, pulse 96 and
respirations 16.
Pupils equal , round, reactive to light 3114
HEENTs __,. Ai%icteric aclerae .
accommodation .
Normocephalic , átraumát^ c3`amfum:
NSCR :
noted.
Supple., no jugular venous diatantion noted .
CHEST :
Reveals air entry bilaterally.
HEART :
Reveals distant " heart sounds .
No lymph nodes are
Otherwise unremarkable.
HISTORY AND PHYSICAL
PATIENT:
MR #:
LOCATION: PCU
ABDOMEN : Markedly obese with hyperreaonant bowel sounds .
nondiatended. .
NonEender,
RECTAL: Unable to do a rectal evaluation and evaluate for any coccyx
decubitus ulcers at this time. ,.
EXTREMITI83 :
Leeft foot with a small ulcer whioh has ';a dry .. dressing ón,
and complaint of° le-ft hip pai:i on palpation . . Pulses are 2+ bilaterally.
. 1" ^ .1.
LABORATORY DATAe •':., Her admission laboratory examinatioá^ : revealed WBC .
21, 000, H&F3 , 14.•x/46 á9, xrlatelet count 382 , OOO,.^ ebdium wad 145, potassium
5.3, chloride 4^k,+.' bicarbonates 42, blood urea sütrcigea/ creatinine 35/1.0,
glucose 181, ABT,f^1tiT-79/51 .
Alkaline phoephatgs'e,1,15. Electrocardiogram..
o. revealed sinus- tgchycardia , otherwise •nonspecifa .¢or..aay ischemia. ChesC:,
o'
o' x-ray is peadiñg ;, but, possible infiltrate is aostiad on ; the,Emergency Room .
0 note.
0
0
0 ADMITTING DIAGNOSIS:
0
.
'
N
1. MSNTAL STATU3 ` CHAATGE.
2.^HISTORY OF CHROÑIC OBSTRUCTIVE FULMONARY DI3EF3$ WITH . CARBON DIOXIDE
PARTIAL PRE3SLTRÉ ^QF : 85.
PLAN :. The patient now neurologically is stable, will go ahead and
continue ventilatory support and monitor arterial :blood geese .
We will
q.
6
hours.
also treat her with Zosyn 3.3 75 grams intraveaous .piggybaek
Obtain - blood cultures , +^ ^- get a left foot x-ray sad left hip x-ray
We c6311 continue her current
to rule out any fractures or osteomyelitis .
medication and hold potassium secondary to elevated potassium on
admisaian . We will repeat her SMA7 sad CBC in the morning and reevaluate
the patient after this is done. Will continue Lasix at this time and the
•patient will be isolated for history of methicillia resistant
Staphylococcus aureus , VRE, añd C-difficile.
DP/ab
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T= 02/OS /2D03 7sá.9 A
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PAGE 2
RIIN DATES 08/02/06
RUN TZl^^ 1758
Summary Discharge Report
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Date
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1710
0655
^
UNR ^ 0337 Reference Units
(4.8-10 . 8) Ous^3
p4s'6
(4.7-6.1 ) ^
(14-18) g/dL
(42-52) f
(80-94) fL
(27-31) p9
(33-37) g/8L
(11.5-14.5) k
(130-400) mm^3
(7.4-10.4) fL
W8C
RBC
8GB
ACT
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MCBC
RDW
PLT
MFV
COMMENT
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APR 5
0515 Reference Units
APR 6
0520
'--------APR 7 ------_--1220 0429
AOTOMATSD DIPF RSQUIR83 !0)IFF VERIFICATION.
MDZPF TO FOLLOW.
At7TOMATBD RIFF RSQIIIR89 4IDIPF VERIFICATION.
pIDIFF TO FOLLOW.
ADTOMATSD DIPF 1t8QUIR8S MDIFF VERIFICATION.
MDIFF TO FOLLOW.
f NBUTROPSIL
k LYMPRS
k MON09
k 80SINOPHIL
k SASOPHIL89
ABSOLU173 NSD
^^^^^ as^YS^
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2.4
0.3
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64
(42.2-75.2) 4
(2o.s-sl.i) +
(1.7-9.3) 4
(0-6) &
(0-2) ^
tntn^3
(1.4-5.5)
(O.S-0.6 ) pytt^3
(0.0.-0.2) mm^3
(42-75) &
(D-3}
(20-51)
;P,at ed^:^^_
....
SURGICAL PATHOLOGY REPORT
VAME:
SURGICAL
^:
LOCATION:
PCU
AGE: 56 SEX : M
ROOM : 224-01
DATB COLLECTED : D3/23 / 04
03/23/04
DATE RECEIVED .:
ACCT #:
MED REC #:
SU9MITTING PHYSICIAN:
ATTHNDING PHYSICIAN:
OTHER PHYSICIAN:
Tisaws r
A. Liver,
NOS - CT GUIDED NEEDLE BIOPSY
Cliaical History
,PRS-OPERATIVE DIAGNOSIS :
3 cm: hepa[ Sc lesion
POST -OPERATIVE DIAGNOSIS :
Rbceas vs Tumor va Infarct
OPERATION: CT guided biopsy
CLINICAL HISTORY :
56 yo. with hepatic lesion
arrera HINAL DIACSiO8I8
+ rr sere
^Lr+a.aAlt o3/ 2a/oa 2226>
Liver (CT-guided needle core biapey):
- Chronic hepatic abscess , organising.
- No tumor eeen.
- No amoeba or other parasites eeen.
- No viral inclusion seen.
- No granulomata seen.
- Levels are examined.
CPT Code: 88305
Primary PatholoQlst:
Gross Daaeriptioa
<LAB.BAH 03 / 23/04 2131>
Specimen ie received in formalin labeled with the patient's name,
CT-guided biopsies and.conaieta of multiple cylindrical cores of taasllahgray and white tissue ranging in length from 0.5 to 0.8 cm, averaging
The specimen ie filtered and exitirely submitted ixi
X0.1 cm in diameter .
one block.
Dictated bvr
PRINTED : 1016104
FORM APPROVED
OMB N0 . D93 -0391
DEPARTMENT OF HEALTH AND HUMAN SERVICES
STATEMENT OF OEFICIENGES
1 PROVDERfSIJPPIJERICLIA
I
^
2 AMA-TIPLE CANSTRUCT(ON
^I^^^^Y
A. BUILDING 01 • MAIN BUILDNG 01
H.7MNG
7128104
STREET ADDRESS, CrrY, STATE, 21P Gx1E
NAME OF PROVIDER OR SUPPLIER
SU ATEMENT FDEF tENCiES
EACN DEFIGENCY MUST BE PRE E BY FULL
K 062 Continued Prom page 5
fi
d- At least 30% of the s dnkler heads
b
PREFIX
PROVIDER'S PLAN OF CORRECTION
K O62
throw hout the bu(Idin s'A'
&'B' exhibited Tustin end fined conditions
andlor showed accumulation of excessive dust
int and/or rime and leces of lactic ba s. The
exam les include but are not limited to residents
cloth srora a room oMIDe of the maintenance
director hone cables room trash chute
dischar a room, in the residents rooms and the
corridors hallwa on the nursin units.
o- Adhesive to es and laces of lasge
matedals were noted wre ed around/ fled to
ri us s 'nkler I es in the laund foldin
roo an Interview at that tim n to ee in
the area said that those are the r mn nts of the
decorative articles hen ed Burin a birthda a
amen ed in that room.
f- n were f t e
s rinkler i e in the trash chute disch a room
in buildin '13'.
-The s rlnkler i in venous
bcations throw howl the basement area exhibited
hea encrustation of the cello slot and were
noted rocs rusted underneath the la ers of the
slot. The maintenance su eNisor said that the
facilit is wnsidenn a Ian to overhaul the old
s dnkler i e s stem.
h-Electdc and as lines of the washin
machines n rlineswere bserved
tied u to and hun on the s nnkler ea In 5
location In he m
. -The buildin is artial ed with the
automatic exGn uishin s stem. A review of the
faciti maintenance records and interview with
the Director of maintenance and su ervisor of
mainten nce could not confirm that the s nnkler
i e s stem au es have been tested/calibrated
or replaced in the past 5 years.
FORM CMS^2567(02A9¡Prehour Vartians Obaokle
Event lD: YuRaG2t
If continueBon sheet Pape B 0111
PRINTED: 10/6104
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENTEe CFRt11(!F.
STATEMENT OF DEFICIENCIES
^1 ^^^^
¡X2 MULTIPLE CONSTRUCTION
X7 PROVIDER I3UPPLIER,CW
A. BUNAING 01 • MAIN aUILDOJG 01
712 10{
NAME OF PROVIDER OR SlN'PLIER STREET ADDRESS , CfTV, STATE, ZIP CODE
1
(XIj ID
NI
SUMMARY STATEMENT OF DEFICIENCIES
RECEED
R 1
PROYIDER' 9 PLAN OF CORRECTIDN
IN
CROSSREFERENCED E R U
(x5)
C AEIIDN
K 062
K 062 Continued From page 6
2.tr The facll' retards did not indicate that the
s rinkler i in Internal obstruction Invest atbn
has been conducted N accordance with NFPA
25. T f I n n
had no rewllection K the internal ins action of the
sprinkler piping had been conducted, in the past 5
A review of the faeili s records at that time
revealed that the 5- ar s rinkler s em test
report was net available.
71I.2(af (11
KQ64
K 064 NFPA 1 7 IFE SAFETY TAN
^^
Podable fire extin uishers are rovided in all
health care occu ancles In accordance with
9.24.1.
79.3.5.6, 9.7.4 . 1, NFPA 70
I
This STANDARD is not met as evidenced b
This requirement is not Met as evidenced by:
Based on observation on 07/22121m4 it was
t Toed the the tat I Tied to ens
All ortable fire extin ers in The f r
installed so that the to of the fire exti wisher is
no[ morethan 5feet 60i s ebovet oor
This w s found on fi t f five reside on;
'rn the twOdinge A' and '13' , as well as, In the
basement area.
The findings Include:
FORM CM&2587(0299) Pr¢vious Vwaiane 0óadele
I
Event lD: nRSasr
If conlinue9an sAaet Paye 7 of t t
PRINtED: Ta6ro4
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ru
STATEMFM OF DEFICIENCIES
1 pR OtaVSUPPUERlCUA
IDENTIFICATION NUMBER
{x310ATE SURVEY
(7(2) MULTIPLE CONSTRUCTION
ABUL[NNG 01-MAIN BUILDING 01
8. WING
NAME Of PROVxIEROR SUPPLIER
Xd ID
7128104
STREET ADDRESS , CRY, STATE, ZIP CODE
SUMMARY STATEMENT OF DEFICIENCIES
10
PROYWER'S FLAN OF CORRECTION
(EAGN CORRECTOE ACTION SHOULD eE
P61
^iETKT1
I NT
K 084
K 064 Continued From page 7
'I• n 7l2272004, itwasotuervedthat rtabla
fire extin uishers are installed on the walls on all
fhe floors kitchen and basement areas. When
measured the facili s maintenance su arvisor
Burin the life safe tour the ma on of these
fire Dxiin ulshers was mounted on the Is with
their o mos ortian at " t ^
above the floor In Ileu of the re ulrad 60 inches.
Exam les Include but are not limited to the
corcidors on the 1st throw h 5th floors of the
buildin s'A" and B% in the North and South
staircases, basement areas and in h eical
therapy/ occupational therapy section.
li-The ortable fire extin uisher5 in the followin
bcations in the 'B' buildin were mounted with
their t0 ortion at 64 "-70" hi h from floor. on the
5th floor near the trainin toilet near nurse station
and near north taircase on the 4th Boor near
room 406 in the dinin room near south end
north at i on the 2nd floor near the n
station and on the first floor near room 106, and
In the dining room.
i-T e w I un oAabla fire ezfin fishers in he
ends of the oorrido In ximi f h se
exR doors on fist throw h 5th floors in bu8dln W
to moat rtian of the eMin wisher was 5'-9'
5'-t ^', in excess of the re wired 60 inches from
the floor.
N- One
rYaWe fire extin wisher C02 a in
the elevator machine room in buildin 'A' was
noted stored directly on the floor.
LSC 18.3.5.6, 19.3.5.6, NFPA 10, 711.2 (a)(1)
FORM CMS^R567(02.09) Prariale VersiOna OOSOIete
EwM10: Wap02t
If continuelion sheet Paae 8 of 11
9 (Pages 33 to 36)
^- February 8, 2005
THE WITNESS: Is that hQe? Here
1
2
it is.
MS. It would be the last
3
3
6
pages.
5
Okay, yes, I love it in front of
me now.
Q, SY h1R. :That's something
that you have airudy reviewed.
A. Correct.
Q. Yü?
A. Yes.
Q. Did you make any determination as
to whether you disagreed with the three
items, A, B and C listed in Paragraph 3 by
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t4
t5
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A. Xes, I agree with those critteisms.
Q. Were there also optaions that you
have ruched lathe matter?
A. Yes. ^
Q. Item Nnmber A, 3A, says the
ataadard of care required the phyilelaa to
4
5
6
7
8
9
10
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13
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complgwith that
A. No.
Q. Would those opialoas that you have
just given methen be fn addition to chase
that you have itemized oa Page 2 of the
letter in your handwritten aotatioaa coaceraing
the traaafusion, the diseont [nuauce of
Iategrilia and the fact no c.b .c was taken
prior to 2324?
A. I think tbat Item C in terms of
the surgical rnasult is in addidon to what I
have listed is my haadsvrittea notes . llama A
and B are basically arore generte references
to what I'm referring [o is terms of my
16
17.
18
19
Items 1 , 2 and 3.
Q. All right. So Ia terms of Items
3(a) sad 3(b), if we were to talk about your
apec[fics in those, we wonld go back to the
list, Items I , 2 and 3 oa PAge 2 of the
letter, those would be your critieistm of Dr.
21
22
23
24
25
patient's hypotension in a timely fashion . Is
that an opinion that you held? ^
A. Yü.
Q. Did Dr. _
ataadard of care?
15
20
evaluate the Case of the
Page 35
^
Page 33
I
2
A. Yea.
Q. And is addition to those Items 1,
2 sad 3, you said yon would add 3(c) to
Page.3ó
Page 3d
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2
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Q. And do you believe that Dr.
acted in aecordapre with the'ataadard
of care fa evaluation of the cause of the
patient 's hypotension in s timely fashion ?
'A. No.
Q. You believe that be violated the
standard of can fn that regard?
A. Yes.
Q. Aad Ilem B says that the standard
of care requires A physician to provide
appropriate [resimeat for the patient's ^
hypotension Does that ín your opiniotl
constitute as accurate statement of the
standard of care?
A.' Yü.
Q. Did Dr. comply with [hat
ataadard of care iu applying appropriate
treatment for thepatieat's hypotension?
A. No.
Q. ^ Item 3(c) says that the standard
o care requtrü at a m y surg cZT
consult be obtained . Does [hat accurately _ _ _
state what you believe to be the applicable
ataadard of care?
A. Yü.
abtafa a timely surgical consult, right?
A. Correct.
Q. Would you add anything else then
to your erificitmi otDr. büidü
1
2
3
4
thosefonritems?
5
A. Yes.
6
Q. What?
7
A. Failure to obta(n the appropriate
8
specialty surgical aroasult . Dr. : is
9
a general surgeon . The appropriate .
10
consultation chould here bees with a vascular
I1
aurgeoa since this was a vascular catastrophe.
12
Q• Aaythiag else?
13
A. Yü. The treatment of Dr.
14
should - have included oagoiag bedside
15
evaluation and treatment of the patient nntll
16
such time that she was stable and her
17
conditloa had been resolved in a saHsfaetory
18 ^
maatler, and it appears to me sow from review
19
of [he tes [ imoay of the nurses, as well as
20
71 - -- YBr::
_ actually left the patieat . even though she was
22
still is an unstable aituaaoa in [he
23
iategsive care unit.
24
25'
Q. Yonr basis for that you say is the
NaRonwide Scheduling
lA (Pages 37 to 40)
-February 8, 2005
4
$
6
g^ 37
deposition testimony o[ the nurses and
?
A. And the medical records which
iúdicate that verbal orders were given which
would mean that he was sot on site at tbat
time. ^
4
$
6
7
8
Q. When you say on site, what do you
mean by on site?
7
8
. abdominal ultrasound Stan should Lave been
done and should Lave been ordered immediatey
9
10
Il
oatt the severe hypatenaton developed requiring
pressor support.
Q.. When was that?
A. 2142 is the fiat entry is the
cridttl tare flow sheet that indicates that
she blood pressure Is at shock levels. The
blood pressure was 58 over 27 ai 2142.
Q. So you are saying tbat Dr.
! should have ordered the CT scan at
2142?
A. Correct.
Q. Why would be do that at 2142?
A. Because you Lave a patient in
stock and your number one diagnosis is a
padent wbo bad as angiogram sad who Las
.received sadcoagntants and sad-platelet
agents is hemorrhaglcshock and you need to
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1$
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Page 79
1
2
3
A. Site, ri-t-e, meaning fa the
intensive care unit at the patient 's bedside .
Q. Well, those are two different
lacadoas. Do you mean apecificaóy tight st
the patient' s bedside or do you fuses vrithin
the urdíae care unit ftaelf, say 50 feet
from the. patient In a different room or fn
his office or where do yon mno?
A. A[ the bedside. ^
Q. And ís it your testimony that you
believe -that Dr. should Lave remained
at the bedside of this padent from ffie
completion of the catheterizatioa procedure
until A. Until the patient was stabilized
and until the eoadidon wu resolved sad
fully evaluated anti treated.
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Pogo 36 ^
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1$
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2t
2Z
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2$
Q. Do you have ioformadoo is the
depoaidon testimony that tells you witbin ^
[hat dare period, return of the padent to ^ ^
the care unit, cardiac care unit after the
catheterization procedure until the padent was
taken to the CT scan , between those time
periods Low mucó of [hat time Dr.'
spent In tht patient 's room?
A. No, I don't have that íaformadon .
Q. Let's go back for a moment to the
affidavit of merit of Dr. ^ that you
.said you reviewed sad that yon agree with and
I want to look at 3 (s). It says the
standard of care required tLe physician to
evaluate the tease of the plaindlPa
hypotension on Stptember 29, 2002, in a
timely fashion, and you have tesdffed you
think Dr.
' breached that standard of
care, correct?
A. _ __Correct.
- Q. Tdlmewhatyoubelie4eDr.-_______.. did or did sot do that resulted.in...
thebreach of that standard of care ..
A. Okay. As I mentioned before, in
my handwritten Dotes that we have discussed I
indicated the failure to repeat the ab.c,
the blood count, to determine if tbere was
evidence of bleeding . There was as repeat
blood count until two hours later or almost
two hours Ister. Aad as far as the
evatuadon of the hypotension , a GT scan or
1
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4
$
6
7
8
9
10
S1
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Page 40
identify the source sad location of the
hemorrhage and to confirm thae so that
appropriate lntervendona could 6e undertaken.
Q. Aoytbing else under that 3(e)? We
talked about ao repeat blood count , CT, scan
wasn't ordered immediately at 2142.
A. And I also mentioned, maybe you
: didn 't hear nx say it, that as alternative sa
a way of diagaoaing the prYSeaee of a
retraperitoaeal óemorrhage would be ao
abdominal ultrasound.
Q. Io lieu of a CT scan?
A. In lieu of or in andcipadoo of a
CT scan. Ao abdominal ultrasound can be
performed a[ We bedside , CI'seaa obviously
1$
- can' t be done at the beds[de, you Lave to
]6
transport thepatient to radiology.
17
I8
Q. In your opinion would an abdominal
ultrasound performed st the bedside reflect
19
the existence of a retroperitoneal bleed?
20
^#. ^]es. -- - -21
22 ___ - ., . ¢ ._ u á retrnperítoneal bleed. had.beea
suspected at 2142 or de[ermlaed at 2142, what
23
treatrotoi should have been initlattd at that
24
time?
2$
Nationwide Scheduling
üL^MAL WOU^? / PRESSt^yRE
SORE FLOW SHEET
STAGES: ..
Locate and n ber dermai,woúnd!
pressure aór^on Tigures.'
Assess ánd dboument befoMr e$ch lesion
at least every] 7 days and ^ m.
Doownen! treálment •plan c^n Tr eatment
' Reoold. ^ ^ ^ i i
. Ootwmerd int^rventiorls orb Pat^eM Care
Fk>Mr Sheet
t,_ fitR ,?ye3^46 078 Q4/26/1447.
^.,^.: c. r arc
cc ^ MEU
fl At Risk - follow Stage I
preverRive measures
I Reddened area
11 Btiáter, skin break
111 Skin breák exposing
subcutaneous tissue
t111fStllé
trnrin
^onTlori
i
rye ^
R, I, II, III, N i
9P
pk. plMJred
s . aloiyft i
s = esehar ^
Slm In GYn ^
eero^+g^ uineous
P
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05/24/2005