Preview
FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022
St. Joseph's Hospital AUSTIN,LARRY C
301 Prospect Ave MRN: 869385
Syracuse NY 13203-1807 DOB: , Sex: M
Hospital Health Center lnpatient Record Acet #: 101862849
Adm: 7/27/2016, D/C: 8/2/2016
A HIGHER LEVEL OF CARE
Admission Information - Patient Record Only
Arrival Date/Time 07/27/2016 1004 Admit Date/Time 07/27/2016 1004 IP Adm. Date/Time 07/27/2016 1331
Admission Type: Emergency Point of Origin Non-healthcare Facility Admit Category
Means of Amval: Rural Metro Primary Service Family Medicine Secondary Service N/A
Transfer Source: Service Area St. Joseph's Hospital Unit Progressive Care Unit
Health Center
Admit Provider Aran Laing, MD Attending Provider Kathryn L. Watson, MD Referring Provider
Discharge Information - Patient Record Only
Discharge DatelTime Discharge Disposition Discharge Destination Discharge Provider Unit
08/02/2016 0940 Skilled Nursing Facility Other None Progressive Care Unit
Events
DateITime Event Pt Class Unit RoomlEled Service
07/27/16 1004 ED Anival SJH EMERGENCY
07/27/16 1004 ED Roomed SJH EMERGENCY
07/27/16 1555 Admit from ED SJH EMERGENCY
07/28/16 1134 Patient Update Inpatient SJH D3 WEST MEDICAL ICU D-3132/D-3132 Critical Care
UNIT
07/28/16 1422 Transfer Out Inpatient SJH D3 WEST MEDICAL ICU D-3132/D-3132 Critical Care
UNIT
07/28/16 1422 Transfer In Inpatient SJH ENDOSCOPY UNIT Endo Pool/Endo Pool Critical Care
07/28/16 1550 Surgery Inpatient SJH ENDOSCOPY UNIT SJH EU 2 Gastroenterology
07/29/16 1519 Transfer Out Inpatient SJH ENDOSCOPY UNIT Endo Pool/Endo Pool Critical Care
07/29/16 1519 Transfer In Inpatient SJH MED SURG UNIT 1-4 1401/1401-W Critical Care
07/29/16 1522 Transfer Out Inpatient SJH MED SURG UNIT 1-4 1401/1401-W Critical Care
07/29/16 1522 Transfer In Inpatient SJH D3 WEST MEDICAL ICU D-3132/D-3132 Critical Care
UNIT
07/29/16 1940 Transfer Out Inpatient SJH D3 WEST MEDICAL ICU D-3132/D-3132 Critical Care
UNIT
07/29/16 1940 Transfer In Inpatient SJH 3-4 PROGRESSlVE CARE 3401/3401 Critical Care
UNIT
07/30/16 1216 Transfer Out Inpatient SJH 3-4 PROGRESSNE CARE 3401/3401 Critical Care
UNIT
07/30/16 1216 Transfer In Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care
IP/HEMODIALYSIS
07/30/16 1604 Transfer Out Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care
IP/HEMODIALYSIS
07/30/16 1604 Transfer In Inpatient SJH 3-4 PROGRESSNE CARE 3401/3401 Critical Care
UNIT
08/01/16 0702 Transfer Out Inpatient SJH 3-4 PROGRESSlVE CARE 3401/3401 Critical Care
UNIT
0801/16 0702 Transfer In Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care
IPMEMODIALYSIS
08/01/16 0801 Transfer Out Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care
IP/HEMODIALYSIS
08/01/16 0801 Transfer In Inpatient SJH 3-4 PROGRESSNE CARE 3401/3401 Critical Care
UNIT
08/01/16 1323 Transfer Out Inpatient SJH 3-4 PROGRESSNE CARE 3401/3401 Cittical Care
UNIT
08/01/16 1323 Transfer In Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care
IP/HEMODIALYSIS
08/01/16 1729 Transfer Out Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care
IP/HEMODIALYSIS
08/01/16 1729 Transfer In Inpatient SJH 3-4 PROGRESSIVE CARE 3401/3401 Critical Care
UNIT
08m2/16 0629 Patient Update Inpatient SJH 3-4 PROGRESSIVE CARE 3401/3401 Family Medicine
UNIT
08/02/16 0940 Discharge Inpatient SJH 3-4 PROGRESSlVE CARE 3401/3401 Family Medicine
UNIT
Final Diagnoses
Dx Code Diagnosis
A41.4 SeDsisdue to anaerobes (Primary)
R65.21 Severe sepsis with septic shock
L89.150 Pressure ulcer of sacral region. unstaceable
K26.4 Chronic or unspecified duodenal ulcer with hemorrhage
E87.2 Acidosis
E46 Unspecified protein-calorie malnutrition
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FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022
St. Joseph's Hospital AUSTIN,LARRY C
301 Prospect Ave MRN: 869385
Syracuse NY 13203-1807 DOB: , Sex: M
Hospital Health Center lnpatient Record Acet #: 101862849
Adm: 7/27/2016, D/C: 8/2/2016
A HIGHER LEVEL OF CARE
Final Diagnoses (continued)
_ Dx Code Diagnosis
R64 Cachexia
112.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
N18.6 End stage renal disease
D69.6 Thrombocytopenia. unspecified
M60.08 Infective myositis. other site
D62 Acute posthemorrhaqic anemia
Z68.1 Body mass index (BMI) 19 or less. adult
K44.9 Diaphragmatic hernia without obstruction or qanq3ene
K20.8 Other esophaqitis
Z99.2 Dependence on renal dialysis
D63.1 Anemia in chronic kidney disease
E11.649 Type 2 diabetes mellitus with hypoolycemia without coma
L89.620 Pressure ulcer of left heel. unstaceable
L89.610 Pressure ulcer of right heel. unstaceable
169.391 Dysphaqia followina cerebral infarction
169.398 Other sequelae of cerebral infarction
R13.12 Dysphaqia. oropharynqeal phase
R53.1 Weakness
148.91 Unspecified atrial fibrillation
125.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
169.31 Coonitive deficits following cerebral infarction
FO1.50 Vascular dementia without behavioral disturbance
Z74.01 Bed confinement status
B37.2 Candidiasis of skin and nail
E78.5 Hyperlipidemia. unspecified
E83.39 Other disorders of phosphorus metabolism
173.9 Peripheral vascular disease. unspecified
187.2 Venous insufRciency(chronic) (peripheral)
Z66 Do not resuscitate
Z51.5 Encounter for palliative care
125.2 Old myocardial infarction
Z79.82 Long term (current) use of aspirin
Z79.899 Other lonq term (current) drug therapy
Z87.891 Personal history of nicotine dependence
Z88.1 Allergy status to other antibiotic aqents status
Z88.4 Allergy status to anesthetic agent status
Discharge Summary Notes
Discharge Summaries by Roslyn Chang, MD at 8/1/2016 10:56 PM
Author Rostyn Chang, MD Service Intemal Medicine Author Type: Physician
Date of Service 8/1/2016 10:56 PM Filed 8/1/2016 11:29 PM Status: Signed
Editor: Roslyn Chang, MD (Physician)
Patient Name: |Larry C Austin Medical Record No: 869385
Date of Birth: Age 61 years
Primary Physician: lan Trevor Daly, MD PCP Phone: 315-487-1573
Admission Date: 7/27/2016 Discharge Date: 8/1/2016
Reason for Admission: cc: Hematemesis UGI bleed with septic and hypovolemic shock
HPl: 61 y/o lives at James Square. Had episode of coffee ground emesis ~ and EMS was called.
male, 0900,
BP was low at that time, and he looked quite III. He had a recent Xray that was read as pneumonia, and was
given fluids at the SNF. He has HD T-T-S. In ED, he was hypotensive, and febrile, H/H was 6.0/19.2, WBC
13.2, temp 102, lactic acid 2.86. Consideration was given to doing an urgent EGD, but since no further emesis
was forthcoming, and he was hypotensive and possibly septic, it was deferred until he is more stabilized. 2
units PRBCs have been ordered.
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FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022
St. Joseph's Hospital AUSTIN,LARRY C
301 Prospect Ave MRN: 869385
Syracuse NY 13203-1807 DOB: , Sex: M
Hospital Health Center Inpatient Record Acct #: 101862849
Adm: 7/27/2016, D/C: 8/2/2016
A HIGHER LEVEL OF CARE
Discharge Summary Notes (continued)
Discharge Summaries by Roslyn Chang. MD at 8/1/2016 10:56 PM (continued)
He has been seen by GI-Dr. Laing, and Nephrology-Dr. Vimalendran.
Please see H&P and transfer summary for complete ICU course from 7/29/16.
Hospital Course:
1. Fever tachycardia likely sepsis secondary to Bacteroides ovatus bacteremia likely secondary to large sacral
decubitus ulcer - Patient was transferred down from the ICU to the progressive care unit on IV
worsening
Zosyn Cipro Vanco. Patient worsened and began developing fevers and blood cultures came out positive for
bacteroides ovatus Bacteremia with sensitivities pending. Patients vancomycin was discontinued and this
was changed over to IV Flagyl IV Zosyn IV Cipro. Infectious Disease was also consulted and it was thought
that his sacral wound was more fluctuant and worsening. General Surgery was also consulted again for which
upon discussion with family no surgical intervention was decided upon and patient and family agreed to take
patient home to his daughter's place for home with hospice. Recheck blood cultures otherwise showed no
growth however is likely slow-growing secondary to the anaerobic nature of Bacteroides. In regards to
patients wound care he is continued on Medihoney application to sacral wound with ABD covering to the
sacral wound with use of hypafix tape to secure the ABD pads and changing daily as well as p.r.n. Soiling.
For patients bilateral heel wounds aquacel Ag application to bilateral heels and cover with Mepilex to bilateral
heels and change every 3 days as recommended. Otherwise for patients dry skin patient does get Hydrophor
oitnment to dry skin daily. Palliative care was also consulted while patient was in the ICU And at this point
family is agreeable to take patient home with hospice to his daughter's house. Patient is to be discharged on
8-16 at 0930 hr.
2. Acute blood loss anemia with UGI bleed s/p EGD 7/28/16 showing erosive esophagitis and ulcerated
ampulla of duodenum - Patients hematocrit did drift down once transferred to the progressive care
slowly
unit. He otherwise tolerated oral intake and was continued on protonix IV BID. Ceased language pathology
also did evaluate patient and patient was placed on a pureed solids nectar thick liquid diet with fluid restriction
however given that he is going home with hospice patient is changed to regular diet for comfort as tolerated.
3. HTN - Patient was taken off of multiple antihypertensive medications and placed on IV metoprolol with
only
hold parameters. Patients blood pressure did decrease with fevers as well from sepsis and at this point patient
is not discharged on any Antihypertensives as he is going home with hospice.
4. Malnutrition with dysphagia with hx of CVA Speech language pathology was consulted during hospital stay
for which patient was placed on Pureed solids and Nectar thick liquids. Patient has poor oral intake and
malnutrition likely contributing to his poor healing and at this point given that he is going home with hospice is
changed to a regular diet as tolerated.
5. ESRD on HD - Tues Thurs Sat. Nephrology was consulted during hospital stay and patient did undergo
HD. Palliative care consult was done and family finally decided to discontinue dialysis with his last dialysis
session on 8/1/2016 for which he did tolerate this. At this point he is being discharged home with hospice and
family as well as patient do not wish to continue dialysis at this time.
6. Hypoglycemia, hx dm
patient was placed on IV fluids d 10 given his hypoglycemia in the ICU. Patient did tolerate some oral intake
and is hypoglycemia resolved. He has discontinued off of IV fluids d 10 and is to be discharged home with
hospice for which she is on a regular diet.
7. Hx afib
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FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022
St. Joseph's Hospital AUSTIN,LARRY C
301 Prospect Ave MRN: 869385
Syracuse NY 13203-1807 DOB: , Sex: M
Hospital Health Center Inpatient Record Acet #: 101862849
Adm: 7/27/2016, D/C: 8/2/2016
A HIGHER LEVEL OF CARE
Discharge Summary Notes (continued)
Discharge Summaries by Roslyn Chang, MD at 8/1/2016 10:56 PM (continued)
Patient was taken off anticoagulation secondary to GI bleed. He is tachycardiac secondary to fever
secondary to sepsis. He was otherwise continued on IV metoprolol during hospital stay with hold parameters
however given that he is going home with hospice his metoprolol is discontinued upon discharge.
Primary Discharge Diagnosis:
Acute blood loss anemia with UGI bleed s/p EGD 7/28/16 showing erosive esophagitis and ulcerated ampulla
of duodenum as well as sepsis secondary to Bacteroides bacteremia from worsened sacral decubitus wound
Secondary Discharge Diagnosis:
Patient Active Problem List
Diagnosis
" Syncope
" End stage renal disease on dialysis
" Cellulitis of lower bilat
leg
" Anemia of renal disease
" Diabetes mellitus type 2, diet-controlled
" Inguinal hernia
" Peripheral vascular disease
" Myocardial infarction
" Venous
insufficiency
" Severe sepsis
" Testicular nodule
" Heel ulcer
" Hyponatremia
" Hypokalemia
" Perirectal abscess
" Fracture of greater trochanter of right femur
" Atrial fibrillation
" essential
Hypertension,
" disease
Coronary artery
" Pain of left thigh
" Femur left
fracture,
" Hyperphosphatemia
" Right knee pain
" Fall at home
" Weakness
" Fatigue
" Hyperkalemia
" Fluid overload
" Hypoglycemia
" Hypoxia
" Right sided weakness
" of atrial fibrillation
History
" Cerebrovascular accident due to thrombosis
(CVA)
" Acute radial nerve of right upper
palsy extremity
" Peripheral of upper limb due to metabolic disorder
neuropathy
" Hematemesis
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FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022
St. Joseph's Hospital AUSTIN,LARRY C
301 Prospect Ave MRN: 869385
Syracuse NY 13203-1807 DOB: 8/30/1954, Sex: M
Hospital Health Center Inpatient Record Acct #: 101862849
Adm: 7/27/2016, D/C: 8/2/2016
A HIGHER LEVEL OF CARE
Discharge Summary Notes (continued)
Discharge Summaries by Roslyn Chang, MD at 8/1/2016 10:56 PM (continued)
" Septic shock
" Acute blood loss anemia
" Decubitus ulcer of coccygeal unstageable
region,
" Leukocytosis
" Hypovolemic shock
" Severe protein-calorie malnutrition
" Bacteremia
" Pain
" Shortness of breath
" Physical debility
" Erosive esophagitis
" Sepsis due to bacteroides
" Decubitus ulcer of right unstageable
heel,
" Candida rash of groin
" Infective myositis
" Decubitus ulcer of sacral unstageable
region,
Condition at Discharge: Home with hospice.
Discharge Exam:
Blood Pressure: BP: 153/75 Pulse: Heart Rate: 80
Temperature: Temp: 99.5 °F Respirations: Resp: 19
Admission Weight: Weight: 50 kg (110 Ib 3.7 O2 Saturation: SpO2: 96 % 2L NC
oz)
Discharge Weight: Weight: 53.1 kg (117 Ib 1
oz) (off weight at HD)
General - thin in bed,awake alert answers questions in 1-3 word
NAD, cachetic, lying slowly sentences,
fatigued
Cardiovascular - sis2
tachycardic,
Pulmonary/Chest - Coarse no rales
BS, rhonchi, wheezing,
Abdominal - no rebound no guarding.
Soft, ND, NT, BS+,
Extremities - No peripheral edema bilaterally
Skin - skin now moisturized.
Dry flaking
Significant Procedures/Tests:
EGD on 7/28/16
Study Information:
CT ABD AND PELVIS NO CONTRAST Accession # 2605910
Study Date: 07/27/2016 11:56
Comparison: CT scan of the pelvis 10/09/2014.
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FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022
St. Joseph's Hospital AUSTIN,LARRY C
301 Prospect Ave MRN: 869385
Syracuse NY 13203-1807 DOB: , Sex: M
Hospital Health Center Inpatient Record Acct #: 101862849
Adm: 7/27/2016, D/C: 8/2/2016
A HIGHER LEVEL OF CARE
Discharge Summary Notes (continued)
Discharge Summaries by Roslyn Chang. MD at 8/1/2016 10:56 PM (continued)
Indication:
sepsis, AMS, vomiting, sacral ulcer
Technique: Axial images were obtained without iv contrast and with
multi-planar reconstruction.
Findings: Lower Chest: Small dependent right lower pleural effusion with
mild right lower lobe compressive atelectasis. Small to moderate
incompletely visualized left pleural effusion . Mild left lower lobe
compressive atelectasis. Cardiomegaly. Density blood is less than
myocardium suggestive of underlying anemia.
Hyperdense spleen measuring 77 HU can be seen with sickle cell disease,
secondary to iron deposition or Thorotrast accumulation. Liver is of
normal density measuring 50-60 Hounsfield density units. punctate
benign-appearing hepatic calcification. Cholelithiasis. No biliary
dilatation identified. The pancreas is grossly unremarkable in appearance.
There is symmetric bilateral renal atrophy. 4.6 cm exophytic left upper
pole renal cyst measures 14 HU. Diffuse arterial sclerosis involving the
small renal arteries. Adrenal glands unremarkable. Urinary bladder not
distended. Mild bladder wall thickening.
There is diffuse arteriosclerosis most prominent within a small arteries.
Is the patient diabetic? No abdominal aortic aneurysm.
There is no significant ascites. However, there is moderate diffuse
subcutaneous body wall edema.
There is soft tissue thickening and abnormal density along the posterior
aspect of the sacrum and coccyx with subcutaneous air bubbles identified
along the right posterior aspect of the coccyx and in the left gluteal
soft tissue structures extending into the left gluteal musculature. The
left gluteal musculature is enlarged. There is no focal localized fluid
collection identified suggestive of abscess. Findings are compatible with
known sacral decubitus ulcer and underlying cellulitis and left gluteal
myositis. No focal destructive bony changes identified. No suspicious
periostitis. The soft tissue fullness and stranding extends to the
posterior aspect of the anus. There is no focal intrapelvic fluid
collection. There is increased stool within the rectum with moderate
distension and resultant rectal wall thickening.
There is mild generalized stranding within the peritoneal and mesenteric
fat. There are a few mildly dilated loops of proximal mid small bowel,
nonspecific.. No bowel wall thickening.
Six lumbar-type vertebral bodies. Mild compression fracture superior
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FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022
St. Joseph's Hospital AUSTIN,LARRY C
301 Prospect Ave MRN: 869385
Syracuse NY 13203-1807 DOB: , Sex: M
Hospital Health Center Inpatient Record Acet #: 101862849
Adm: 7/27/2016, D/C: 8/2/2016
A HIGHER LEVEL OF CARE
Discharge Summary Notes (continued)
Discharge
Preview
FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022 St. Joseph's Hospital AUSTIN,LARRY C 301 Prospect Ave MRN: 869385 Syracuse NY 13203-1807 DOB: , Sex: M Hospital Health Center lnpatient Record Acet #: 101862849 Adm: 7/27/2016, D/C: 8/2/2016 A HIGHER LEVEL OF CARE Admission Information - Patient Record Only Arrival Date/Time 07/27/2016 1004 Admit Date/Time 07/27/2016 1004 IP Adm. Date/Time 07/27/2016 1331 Admission Type: Emergency Point of Origin Non-healthcare Facility Admit Category Means of Amval: Rural Metro Primary Service Family Medicine Secondary Service N/A Transfer Source: Service Area St. Joseph's Hospital Unit Progressive Care Unit Health Center Admit Provider Aran Laing, MD Attending Provider Kathryn L. Watson, MD Referring Provider Discharge Information - Patient Record Only Discharge DatelTime Discharge Disposition Discharge Destination Discharge Provider Unit 08/02/2016 0940 Skilled Nursing Facility Other None Progressive Care Unit Events DateITime Event Pt Class Unit RoomlEled Service 07/27/16 1004 ED Anival SJH EMERGENCY 07/27/16 1004 ED Roomed SJH EMERGENCY 07/27/16 1555 Admit from ED SJH EMERGENCY 07/28/16 1134 Patient Update Inpatient SJH D3 WEST MEDICAL ICU D-3132/D-3132 Critical Care UNIT 07/28/16 1422 Transfer Out Inpatient SJH D3 WEST MEDICAL ICU D-3132/D-3132 Critical Care UNIT 07/28/16 1422 Transfer In Inpatient SJH ENDOSCOPY UNIT Endo Pool/Endo Pool Critical Care 07/28/16 1550 Surgery Inpatient SJH ENDOSCOPY UNIT SJH EU 2 Gastroenterology 07/29/16 1519 Transfer Out Inpatient SJH ENDOSCOPY UNIT Endo Pool/Endo Pool Critical Care 07/29/16 1519 Transfer In Inpatient SJH MED SURG UNIT 1-4 1401/1401-W Critical Care 07/29/16 1522 Transfer Out Inpatient SJH MED SURG UNIT 1-4 1401/1401-W Critical Care 07/29/16 1522 Transfer In Inpatient SJH D3 WEST MEDICAL ICU D-3132/D-3132 Critical Care UNIT 07/29/16 1940 Transfer Out Inpatient SJH D3 WEST MEDICAL ICU D-3132/D-3132 Critical Care UNIT 07/29/16 1940 Transfer In Inpatient SJH 3-4 PROGRESSlVE CARE 3401/3401 Critical Care UNIT 07/30/16 1216 Transfer Out Inpatient SJH 3-4 PROGRESSNE CARE 3401/3401 Critical Care UNIT 07/30/16 1216 Transfer In Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care IP/HEMODIALYSIS 07/30/16 1604 Transfer Out Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care IP/HEMODIALYSIS 07/30/16 1604 Transfer In Inpatient SJH 3-4 PROGRESSNE CARE 3401/3401 Critical Care UNIT 08/01/16 0702 Transfer Out Inpatient SJH 3-4 PROGRESSlVE CARE 3401/3401 Critical Care UNIT 0801/16 0702 Transfer In Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care IPMEMODIALYSIS 08/01/16 0801 Transfer Out Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care IP/HEMODIALYSIS 08/01/16 0801 Transfer In Inpatient SJH 3-4 PROGRESSNE CARE 3401/3401 Critical Care UNIT 08/01/16 1323 Transfer Out Inpatient SJH 3-4 PROGRESSNE CARE 3401/3401 Cittical Care UNIT 08/01/16 1323 Transfer In Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care IP/HEMODIALYSIS 08/01/16 1729 Transfer Out Inpatient SJH HEMODIALYSIS IP HEMODIALYSIS Critical Care IP/HEMODIALYSIS 08/01/16 1729 Transfer In Inpatient SJH 3-4 PROGRESSIVE CARE 3401/3401 Critical Care UNIT 08m2/16 0629 Patient Update Inpatient SJH 3-4 PROGRESSIVE CARE 3401/3401 Family Medicine UNIT 08/02/16 0940 Discharge Inpatient SJH 3-4 PROGRESSlVE CARE 3401/3401 Family Medicine UNIT Final Diagnoses Dx Code Diagnosis A41.4 SeDsisdue to anaerobes (Primary) R65.21 Severe sepsis with septic shock L89.150 Pressure ulcer of sacral region. unstaceable K26.4 Chronic or unspecified duodenal ulcer with hemorrhage E87.2 Acidosis E46 Unspecified protein-calorie malnutrition Generated by GAR08789 at 8/15/17 11:45 AM Page 4611 FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022 St. Joseph's Hospital AUSTIN,LARRY C 301 Prospect Ave MRN: 869385 Syracuse NY 13203-1807 DOB: , Sex: M Hospital Health Center lnpatient Record Acet #: 101862849 Adm: 7/27/2016, D/C: 8/2/2016 A HIGHER LEVEL OF CARE Final Diagnoses (continued) _ Dx Code Diagnosis R64 Cachexia 112.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease N18.6 End stage renal disease D69.6 Thrombocytopenia. unspecified M60.08 Infective myositis. other site D62 Acute posthemorrhaqic anemia Z68.1 Body mass index (BMI) 19 or less. adult K44.9 Diaphragmatic hernia without obstruction or qanq3ene K20.8 Other esophaqitis Z99.2 Dependence on renal dialysis D63.1 Anemia in chronic kidney disease E11.649 Type 2 diabetes mellitus with hypoolycemia without coma L89.620 Pressure ulcer of left heel. unstaceable L89.610 Pressure ulcer of right heel. unstaceable 169.391 Dysphaqia followina cerebral infarction 169.398 Other sequelae of cerebral infarction R13.12 Dysphaqia. oropharynqeal phase R53.1 Weakness 148.91 Unspecified atrial fibrillation 125.10 Atherosclerotic heart disease of native coronary artery without angina pectoris 169.31 Coonitive deficits following cerebral infarction FO1.50 Vascular dementia without behavioral disturbance Z74.01 Bed confinement status B37.2 Candidiasis of skin and nail E78.5 Hyperlipidemia. unspecified E83.39 Other disorders of phosphorus metabolism 173.9 Peripheral vascular disease. unspecified 187.2 Venous insufRciency(chronic) (peripheral) Z66 Do not resuscitate Z51.5 Encounter for palliative care 125.2 Old myocardial infarction Z79.82 Long term (current) use of aspirin Z79.899 Other lonq term (current) drug therapy Z87.891 Personal history of nicotine dependence Z88.1 Allergy status to other antibiotic aqents status Z88.4 Allergy status to anesthetic agent status Discharge Summary Notes Discharge Summaries by Roslyn Chang, MD at 8/1/2016 10:56 PM Author Rostyn Chang, MD Service Intemal Medicine Author Type: Physician Date of Service 8/1/2016 10:56 PM Filed 8/1/2016 11:29 PM Status: Signed Editor: Roslyn Chang, MD (Physician) Patient Name: |Larry C Austin Medical Record No: 869385 Date of Birth: Age 61 years Primary Physician: lan Trevor Daly, MD PCP Phone: 315-487-1573 Admission Date: 7/27/2016 Discharge Date: 8/1/2016 Reason for Admission: cc: Hematemesis UGI bleed with septic and hypovolemic shock HPl: 61 y/o lives at James Square. Had episode of coffee ground emesis ~ and EMS was called. male, 0900, BP was low at that time, and he looked quite III. He had a recent Xray that was read as pneumonia, and was given fluids at the SNF. He has HD T-T-S. In ED, he was hypotensive, and febrile, H/H was 6.0/19.2, WBC 13.2, temp 102, lactic acid 2.86. Consideration was given to doing an urgent EGD, but since no further emesis was forthcoming, and he was hypotensive and possibly septic, it was deferred until he is more stabilized. 2 units PRBCs have been ordered. Generated by GAR08789 at 8/15/17 11:45 AM Page 4612 FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022 St. Joseph's Hospital AUSTIN,LARRY C 301 Prospect Ave MRN: 869385 Syracuse NY 13203-1807 DOB: , Sex: M Hospital Health Center Inpatient Record Acct #: 101862849 Adm: 7/27/2016, D/C: 8/2/2016 A HIGHER LEVEL OF CARE Discharge Summary Notes (continued) Discharge Summaries by Roslyn Chang. MD at 8/1/2016 10:56 PM (continued) He has been seen by GI-Dr. Laing, and Nephrology-Dr. Vimalendran. Please see H&P and transfer summary for complete ICU course from 7/29/16. Hospital Course: 1. Fever tachycardia likely sepsis secondary to Bacteroides ovatus bacteremia likely secondary to large sacral decubitus ulcer - Patient was transferred down from the ICU to the progressive care unit on IV worsening Zosyn Cipro Vanco. Patient worsened and began developing fevers and blood cultures came out positive for bacteroides ovatus Bacteremia with sensitivities pending. Patients vancomycin was discontinued and this was changed over to IV Flagyl IV Zosyn IV Cipro. Infectious Disease was also consulted and it was thought that his sacral wound was more fluctuant and worsening. General Surgery was also consulted again for which upon discussion with family no surgical intervention was decided upon and patient and family agreed to take patient home to his daughter's place for home with hospice. Recheck blood cultures otherwise showed no growth however is likely slow-growing secondary to the anaerobic nature of Bacteroides. In regards to patients wound care he is continued on Medihoney application to sacral wound with ABD covering to the sacral wound with use of hypafix tape to secure the ABD pads and changing daily as well as p.r.n. Soiling. For patients bilateral heel wounds aquacel Ag application to bilateral heels and cover with Mepilex to bilateral heels and change every 3 days as recommended. Otherwise for patients dry skin patient does get Hydrophor oitnment to dry skin daily. Palliative care was also consulted while patient was in the ICU And at this point family is agreeable to take patient home with hospice to his daughter's house. Patient is to be discharged on 8-16 at 0930 hr. 2. Acute blood loss anemia with UGI bleed s/p EGD 7/28/16 showing erosive esophagitis and ulcerated ampulla of duodenum - Patients hematocrit did drift down once transferred to the progressive care slowly unit. He otherwise tolerated oral intake and was continued on protonix IV BID. Ceased language pathology also did evaluate patient and patient was placed on a pureed solids nectar thick liquid diet with fluid restriction however given that he is going home with hospice patient is changed to regular diet for comfort as tolerated. 3. HTN - Patient was taken off of multiple antihypertensive medications and placed on IV metoprolol with only hold parameters. Patients blood pressure did decrease with fevers as well from sepsis and at this point patient is not discharged on any Antihypertensives as he is going home with hospice. 4. Malnutrition with dysphagia with hx of CVA Speech language pathology was consulted during hospital stay for which patient was placed on Pureed solids and Nectar thick liquids. Patient has poor oral intake and malnutrition likely contributing to his poor healing and at this point given that he is going home with hospice is changed to a regular diet as tolerated. 5. ESRD on HD - Tues Thurs Sat. Nephrology was consulted during hospital stay and patient did undergo HD. Palliative care consult was done and family finally decided to discontinue dialysis with his last dialysis session on 8/1/2016 for which he did tolerate this. At this point he is being discharged home with hospice and family as well as patient do not wish to continue dialysis at this time. 6. Hypoglycemia, hx dm patient was placed on IV fluids d 10 given his hypoglycemia in the ICU. Patient did tolerate some oral intake and is hypoglycemia resolved. He has discontinued off of IV fluids d 10 and is to be discharged home with hospice for which she is on a regular diet. 7. Hx afib Generated by GAR08789 at 8/15/17 11:45 AM Page 4613 FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022 St. Joseph's Hospital AUSTIN,LARRY C 301 Prospect Ave MRN: 869385 Syracuse NY 13203-1807 DOB: , Sex: M Hospital Health Center Inpatient Record Acet #: 101862849 Adm: 7/27/2016, D/C: 8/2/2016 A HIGHER LEVEL OF CARE Discharge Summary Notes (continued) Discharge Summaries by Roslyn Chang, MD at 8/1/2016 10:56 PM (continued) Patient was taken off anticoagulation secondary to GI bleed. He is tachycardiac secondary to fever secondary to sepsis. He was otherwise continued on IV metoprolol during hospital stay with hold parameters however given that he is going home with hospice his metoprolol is discontinued upon discharge. Primary Discharge Diagnosis: Acute blood loss anemia with UGI bleed s/p EGD 7/28/16 showing erosive esophagitis and ulcerated ampulla of duodenum as well as sepsis secondary to Bacteroides bacteremia from worsened sacral decubitus wound Secondary Discharge Diagnosis: Patient Active Problem List Diagnosis " Syncope " End stage renal disease on dialysis " Cellulitis of lower bilat leg " Anemia of renal disease " Diabetes mellitus type 2, diet-controlled " Inguinal hernia " Peripheral vascular disease " Myocardial infarction " Venous insufficiency " Severe sepsis " Testicular nodule " Heel ulcer " Hyponatremia " Hypokalemia " Perirectal abscess " Fracture of greater trochanter of right femur " Atrial fibrillation " essential Hypertension, " disease Coronary artery " Pain of left thigh " Femur left fracture, " Hyperphosphatemia " Right knee pain " Fall at home " Weakness " Fatigue " Hyperkalemia " Fluid overload " Hypoglycemia " Hypoxia " Right sided weakness " of atrial fibrillation History " Cerebrovascular accident due to thrombosis (CVA) " Acute radial nerve of right upper palsy extremity " Peripheral of upper limb due to metabolic disorder neuropathy " Hematemesis Generated by GAR08789 at 8/15/17 11:45 AM Page 4614 FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022 St. Joseph's Hospital AUSTIN,LARRY C 301 Prospect Ave MRN: 869385 Syracuse NY 13203-1807 DOB: 8/30/1954, Sex: M Hospital Health Center Inpatient Record Acct #: 101862849 Adm: 7/27/2016, D/C: 8/2/2016 A HIGHER LEVEL OF CARE Discharge Summary Notes (continued) Discharge Summaries by Roslyn Chang, MD at 8/1/2016 10:56 PM (continued) " Septic shock " Acute blood loss anemia " Decubitus ulcer of coccygeal unstageable region, " Leukocytosis " Hypovolemic shock " Severe protein-calorie malnutrition " Bacteremia " Pain " Shortness of breath " Physical debility " Erosive esophagitis " Sepsis due to bacteroides " Decubitus ulcer of right unstageable heel, " Candida rash of groin " Infective myositis " Decubitus ulcer of sacral unstageable region, Condition at Discharge: Home with hospice. Discharge Exam: Blood Pressure: BP: 153/75 Pulse: Heart Rate: 80 Temperature: Temp: 99.5 °F Respirations: Resp: 19 Admission Weight: Weight: 50 kg (110 Ib 3.7 O2 Saturation: SpO2: 96 % 2L NC oz) Discharge Weight: Weight: 53.1 kg (117 Ib 1 oz) (off weight at HD) General - thin in bed,awake alert answers questions in 1-3 word NAD, cachetic, lying slowly sentences, fatigued Cardiovascular - sis2 tachycardic, Pulmonary/Chest - Coarse no rales BS, rhonchi, wheezing, Abdominal - no rebound no guarding. Soft, ND, NT, BS+, Extremities - No peripheral edema bilaterally Skin - skin now moisturized. Dry flaking Significant Procedures/Tests: EGD on 7/28/16 Study Information: CT ABD AND PELVIS NO CONTRAST Accession # 2605910 Study Date: 07/27/2016 11:56 Comparison: CT scan of the pelvis 10/09/2014. Generated by GAR08789 at 8/15/17 11:45 AM Page 4615 FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022 St. Joseph's Hospital AUSTIN,LARRY C 301 Prospect Ave MRN: 869385 Syracuse NY 13203-1807 DOB: , Sex: M Hospital Health Center Inpatient Record Acct #: 101862849 Adm: 7/27/2016, D/C: 8/2/2016 A HIGHER LEVEL OF CARE Discharge Summary Notes (continued) Discharge Summaries by Roslyn Chang. MD at 8/1/2016 10:56 PM (continued) Indication: sepsis, AMS, vomiting, sacral ulcer Technique: Axial images were obtained without iv contrast and with multi-planar reconstruction. Findings: Lower Chest: Small dependent right lower pleural effusion with mild right lower lobe compressive atelectasis. Small to moderate incompletely visualized left pleural effusion . Mild left lower lobe compressive atelectasis. Cardiomegaly. Density blood is less than myocardium suggestive of underlying anemia. Hyperdense spleen measuring 77 HU can be seen with sickle cell disease, secondary to iron deposition or Thorotrast accumulation. Liver is of normal density measuring 50-60 Hounsfield density units. punctate benign-appearing hepatic calcification. Cholelithiasis. No biliary dilatation identified. The pancreas is grossly unremarkable in appearance. There is symmetric bilateral renal atrophy. 4.6 cm exophytic left upper pole renal cyst measures 14 HU. Diffuse arterial sclerosis involving the small renal arteries. Adrenal glands unremarkable. Urinary bladder not distended. Mild bladder wall thickening. There is diffuse arteriosclerosis most prominent within a small arteries. Is the patient diabetic? No abdominal aortic aneurysm. There is no significant ascites. However, there is moderate diffuse subcutaneous body wall edema. There is soft tissue thickening and abnormal density along the posterior aspect of the sacrum and coccyx with subcutaneous air bubbles identified along the right posterior aspect of the coccyx and in the left gluteal soft tissue structures extending into the left gluteal musculature. The left gluteal musculature is enlarged. There is no focal localized fluid collection identified suggestive of abscess. Findings are compatible with known sacral decubitus ulcer and underlying cellulitis and left gluteal myositis. No focal destructive bony changes identified. No suspicious periostitis. The soft tissue fullness and stranding extends to the posterior aspect of the anus. There is no focal intrapelvic fluid collection. There is increased stool within the rectum with moderate distension and resultant rectal wall thickening. There is mild generalized stranding within the peritoneal and mesenteric fat. There are a few mildly dilated loops of proximal mid small bowel, nonspecific.. No bowel wall thickening. Six lumbar-type vertebral bodies. Mild compression fracture superior Generated by GAR08789 at 8/15/17 11:45 AM Page 4616 FILED: ONONDAGA COUNTY CLERK 08/11/2022 03:29 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 197 RECEIVED NYSCEF: 08/11/2022 St. Joseph's Hospital AUSTIN,LARRY C 301 Prospect Ave MRN: 869385 Syracuse NY 13203-1807 DOB: , Sex: M Hospital Health Center Inpatient Record Acet #: 101862849 Adm: 7/27/2016, D/C: 8/2/2016 A HIGHER LEVEL OF CARE Discharge Summary Notes (continued) Discharge