allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dizzineness, status post fall major surgical or invasive procedure: 1. femoral temporary venous pacer 2. a line 3. ppm (ddd) placement history of present illness: 84 y/o f with severe as (0.8), chronic lymphoma, dvt on coumadin, asthma who p/w falls x 1 month. also had one episode of "fainting" one week ago. came to ed for fall. admitted to medicine floor. noted to have 8 sec run of non-conducted p's (assymptomatic). baseline ecg reveals bifasicular block with prolonged pr. came to ccu for chb. recieved 3u ffp. attempt at rij for temp wire unsuccessful. pt became hypotensive requiring max dose dopa and neo gtt's. intubated for airway protection. r fem temp wire placed successfully under flouro. pacing at 80 bpm's with threshold 0.4mamp set at 10. coming down on pressors. due to ventricular ectopy, weaning dopa first. past medical history: 1) aortic stenosis: last echo with ef > 55%, severe as (worse than prior echo) 2) rheumatoid arthritis (followed by dr. in rheum, on methotrexate) 3) asthma 4) htn 5) lle dvt 6) pneumonia 7) anemia of chronic disease 8) cad 9)h/o thrombocytopenia of unknown etiology (negative hit, and sra) 10) areflexive bladder (requiring chronic foley) social history: lives with daughter. etoh/tob/ivdu family history: non-contributory physical exam: vs: afebrile, 110/64, 86, 20, 100% 4l. gen: elderly female intubated with temporary pacer wire in place sedated with propofol drip. heent: perrl, mmm, jvp elevated ~11cm, firm hematom r neck. chest: cta anteriorly and laterally. cvr: rrr, iii/vi cresendo decresendo murmor at rusb radiating to carotids. s2 clearly heard. abdomen: soft, nt, obese with ?large area of distention. ext: 1+ edema. neuro: pt intubated, spontaneous movements even on sedation. pertinent results: 7.8/ 26.2/ 137 previous cbc: 6.7/29.2/137 140/4.1/104/26/22/1.1/139 ca: 8.5 mg: 1.9 p: 3.3 inr 2.5 . head ct no ich or mass . ct abdomen w/o contrast 10:49 am conclusion 1. moderate size hematoma in the subcutaneous tissues of the right groin. no pelvic or intra-abdominal hematoma. 2. large hernia containing two separate segments of colon. 3. mild circumferential thickening along part of the ascending colon partly located within the abdomen and within the right inferolateral abdominal wall hernia with mild adjacent stranding compared to previous ct. no sign of mechanical obstruction. possibilities would include an area of focal segmental congestion or even colitis depending on clinical correlation. 4. infrarenal abdominal aortic aneurysm measuring up to 3.9 cm transverse unchanged. 5. moderate right basal pleural effusion and minor associated right posterobasal atelectasis. 6. cholelithiasis. echo there is mild symmetric left ventricular hypertrophy. left ventricular chamber size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. left ventricular systolic function is probably borderline normal (ef~50-55%) but views are technically suboptimal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (estimated ~0.6 cm2 but lvot velocity estimation is technically limited) . there is no aortic regurgitation. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: a/p: this is a 84 year old female with severe as (0.8), chronic lymphoma, dvt on coumadin, asthma who p/w s/p fall and complete heart block. now s/p ddd pacer. . #cardiovascular - #ischemia - no previous history of ischemia. continued on asa 325. # pump - recieved 3u ffp. attempt at rij for temp wire unsuccessful. pt became hypotensive during attempt at rij temp wire requiring max dose dopamine and neosynephrine gtt's. hypotension was thought to be secondary to increased vagal tone with pressure and manipulation at the rij. patient was intubated for airway protection in setting of right neck hematoma. patient was subsequently weaned off pressors. repeat echo showed preserved ef 50-55%, tight as valve area 0.6 cm2. patient became hypotensive and required fluid boluses and resumed on dopamine ggt temporarily after removal of right femoral sheath and right groin hematoma was seen on ct. patient was resumed on diltiazem and was diuresed with iv lasix with goal of -500cc/day. # rhythm - noted to have 8 sec run of non-conducted p's (assymptomatic). baseline ecg reveals bifasicular block with prolonged pr. admitted to ccu for chb. received temp wire in r groin under fluoro. patient had ppm (ddd) placed on . . ##respiratory - s/p intubation for airway protection given hematoma in neck. initially propofol used for sedation, however was changed to fentanyl and versed with better effect. patient was extubated sat'ing well on room air. continued advair, ipratropium and albuterol neb prn. . ##hematomas - patient developed multiple hematomas at access sites including rij, left forearm, right groin and left chest (pacer site). bleeds stopped with pressure bandages, ffp and vit k. abdominal ct showed right groin bleed and no rp/intrapelvic bleed. anticoagulation was held and patient was transfused as needed. . ## as: severe with area of 0.8, mean gradient 50's. ct surgery was consulted and spoke with patient who said that she does not wish to go to surgery at this time. . ## uti: enterococcus 100k, providencia rettgeri 10-100k on ucx. was on vanco 1g for 48 hours perioperatively. completed 1 week of ampicillin for entercoccus uti and levoquin 4 days,for gn coverage. . ## anemia: labs consistent with iron def anemia. started po iron repletion. in an elderly with iron def. anemia concerning for gi origin and should have outpt workup. patient received blood after decreased hct after rij attempt, r femoral groin cordis removal and left chest hematoma at pacer site. hct now stable and patient off coumadin. . ## - pt with h/o dvt (dx' ) and anticogulated with coumadin on admission, inr was 2.5. coumadin was held and patient was put on heparin gtt. patient received ffp prior to central line placement and after right groin bleed. patient also received vit k prior to ppm placement and s/p right groin bleed and heparin ggt was held. initially patient was started on coumadin with heparin bridge however had pacer bleed and so coumadin and heparin were held given bleeding risks. . ## falls: likely chb. head scan negative. pt consult, will need to go to rehab. . ## ppx: colace/senna prn . ## code: full code medications on admission: diltiazem 120 mg er methotrexate sodium 2.5 mg--8 tablet(s) by mouth q week on thursday warfarin 7.5 mg-10 mg po daily folate albuterol flovent servevent discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 5. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed: not to exceed 4g/day. 7. albuterol sulfate 0.083 % solution sig: one (1) inhalation q2h (every 2 hours) as needed for shortness of breath or wheezing. 8. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 9. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 10. diltiazem hcl 120 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 11. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po tid (3 times a day). 12. furosemide 80 mg tablet sig: one (1) tablet po once a day. 13. methotrexate 2.5 mg tablet sig: eight (8) tablet po qthursday. discharge disposition: extended care facility: center - discharge diagnosis: primary diagnosis: high-degree heart block secondary diagnosis: chronic lymphoma aortic stenosis hx of dvt lymphoma rheumatoid arthritis iron deficiency anemia discharge condition: good discharge instructions: please take medications as prescribed. we have started you on lasix 80mg po qd. since you have aortic stenosis, please have your primary care physician adjust your lasix does accordingly. we did not resume you coumadin because you developed multiple hematomas while on it. please get your labs drawn on and have the your primary care physician the results. check daily weights. you have iron deficiency anemia and have been started on iron repletion. you have have a gi outpatient follow-up to exclude other causes of your anemia. you have a permanent pacemaker which you need to follow-up at device clinic regularly for maintenance. if you have any chest pain, fevers/chills, loss of consciousness or any worrying symptoms please call your primary care physician or come to the emergency room. followup instructions: provider: clinic phone: date/time: 11:00 provider: ,md phone: date/time: 12:30 please follow-up with you primary care physician weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Arterial catheterization Transfusion of packed cells Transfusion of other serum Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Hematoma complicating a procedure Asthma, unspecified type, unspecified Aortic valve disorders Other malignant lymphomas, unspecified site, extranodal and solid organ sites Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Atrioventricular block, complete Long-term (current) use of anticoagulants Iron deficiency anemia, unspecified Rheumatoid arthritis Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, unspecified