allergies: penicillins / clinoril attending: chief complaint: abdominal pain, free air major surgical or invasive procedure: exploratory laparotomy, oversew and patch of perforated duodenal ulcer history of present illness: ms is a very pleasant woman transferred from with a diagnosis of free air on ct scan in the setting of abdominal pain. she states she has had off and on abdominal pain for the past week and was seen at 2 days prior to admisison where she was found to have mild cardiac enzyme elevation, and she was admitted there for the past few days. she was also having abdominal discomfort, all over but focused in the rlq, and had a ct scan that she states was normal. she was admitted for cardiac work-up, which was essentially negative and discharged home this morning feeling well. when she got home at 11am however, she noticed a severe increase in her rlq pain that became much more diffuse, , pain with any movement, nausea, no vomiting. no fevers, +chills. she returned to where at ct scan showed a significant amount of free air and extravasation of contrast in ther rlq. she currently is complaining of ongoing pain, although improved a bit with some morphine. no chest pain or shortness of breath, +nausea, no fevers/chills past medical history: peripheral vascular disease - non-healing l 3rd toe ulcer, 1 vessel runoff (peroneal) hypertension hypercholesterolemia bronchitis arthritis history of right lower extremity trauma glaucoma anxiety chronic back pain left superficial femoral artery pta on social history: quit smoking 30 years ago, no etoh, lives alone w son nearby family history: n/c physical exam: t99 83 120/68 16 95%ra gen: pleasant thin elderly woman laying in bed in nad, a+0x3 heent: dry mm, scerla anicteric cv: rrr lungs: ctab abd: distended, rigid, diffusely tender with rebound and guarding guaiac neg ext: well-perfused, no c/c/e pertinent results: 08:35pm wbc-11.1* rbc-4.02* hgb-12.6 hct-38.1 mcv-95 mch-31.4 mchc-33.1 rdw-13.4 08:35pm neuts-61 bands-28* lymphs-7* monos-1* eos-0 basos-0 atyps-3* metas-0 myelos-0 08:35pm plt count-387 08:35pm alt(sgpt)-19 ast(sgot)-55* ld(ldh)-646* ck(cpk)-138 alk phos-40 amylase-92 tot bili-0.3 08:35pm ck-mb-3 ctropnt-<0.01 08:35pm glucose-152* urea n-23* creat-0.9 sodium-134 potassium-6.0* chloride-102 total co2-23 anion gap-15 10:14pm pt-13.0 ptt-26.2 inr(pt)-1.1 brief hospital course: pt admitted to the surgical icu s/p ex-lap revealing perforated anterior duodenal ulcer repair with patch. she was kept intubated overnight, npo/ ivf, ngt to lws on protonix, and iv abx : transfer from the or intubated, extubated in am, wbc trending up, tranisent episdoe of afib resolved with lopressor : episodes of acute hypoxia with tachycardia and dyspnea, bronch done mucus plugging on rll, cta done to r/o pe, possibly flash pulmonary edema. b/l pleural effusions on cxr, afib overnight: rate controlled with lopressor : cta neg for pe, she had chf respiartorty distress abg respiratory acidosis, started on lasix drip, hydralzyne prn and lopressor increased, intubated due to respiratory failure. left tlc placed 2 units transfused, continued lasix gtt, hpylori ag sent. decreased fio2 to 40%, bedside echo wnl. dig started : ir for nj tube. tf started. tte ef>55%. ct showing bil pleural effusions. :diastolic hypotension 30's.map mid 50,s.started low dose neo infusion. : weaning vent to , dcd amlosipine due to diastolic hypotension. tachypneic and hypertnesive given hydral/ labetalol. : extubated. stable o/n. lasix gtt. contraction alkalsois from overdiuresis. still dnr/dni (if pt deteriorates, will be cmo) : extubated on nrb. cont with albumin and lasix gtt : made cmo by family per patient's request. transferred to private room on floor. : expired at 4:00 am medications on admission: alendronate 70 mg q week, amlodipine-atorvastatin 5 mg-20 mg'' atenolol 25''lumigan 0.03 % 1 gtt ou qpm, alphagan p 0.15 % 1 gtt ou twice a day, cosopt 0.5 %-2 % drops - 1 gtt ou twice a day folic acid 1, hctz 25, lidoderm 5 % (700 mg/patch) on in the am off in pm, aspirin 81, mvi, vitamin e 400 unit capsule q am discharge medications: none - patient expired discharge disposition: expired discharge diagnosis: perforated duodenal ulcer, respiratory failure, atrial fibrillation discharge condition: expired discharge instructions: none followup instructions: none md, Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other intubation of respiratory tract Suture of duodenal ulcer site Diagnoses: Acidosis Other chronic pain Subendocardial infarction, initial episode of care Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Unspecified glaucoma Candidiasis of mouth Ulcer of other part of foot Anxiety state, unspecified Alkalosis Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other postprocedural status Duodenitis, without mention of hemorrhage Backache, unspecified Other candidiasis of other specified sites Other abnormal blood chemistry Other specified peritonitis Atherosclerosis of native arteries of the extremities with ulceration Arthropathy, unspecified, site unspecified Leiomyoma of uterus, unspecified Other and unspecified ovarian cyst Foreign body in other specified parts bronchus and lung Acute duodenal ulcer with perforation, without mention of obstruction