Inpatient Record - Paient 7 Discharge Summary Date of Admission 1/3 Date of Discharge 1/7 D
Posted: Tue Mar 15, 2022 2:54 pm
Inpatient Record - Paient 7
Discharge Summary
Date of Admission 1/3
Date of Discharge 1/7
Discharge Diagnosis: Recurrent carcinoma, left
lung
This is a 63-year old female who is two years
status post left upper love resection for adenocarcinoma. Pathology
at that time revealed a positive bronchial margin of resection. She
was treated with post radiation and has done extremely well. She
has remained asymptomatic with no postoperative difficulty.
Follow-up serial CT scan have revealed a new lesion in the apical
portion of the left lung, which on needle biopsy was positive for
adenocarcinoma. She was admitted specifically for a left
thoracotomy and possible pneumonectomy.
Past Medical History: Positive for tobacco
abuse 2 PPDx30years in the past. Significant for a right and
also significant for hypertension, degenerative joint disease
of lumbar spine, and chronic pulmonary disease. The patient also
suffered a stroke in the left brain with resulting right
hemiparesis three years ago. Medications on discharge: Tenormin 25
mg once a day, Calan SR 240mg twice a day, Azacort MDI 12 puffs PO
t.i.d., Vioxx 25mg PO daily.
Physical Examination: Revealed a
well-healed right parotid incision. No supraclavicular adenopathy.
She has a healed left posterior lateral thoracotomy scar.
Impression is that of local recurrence, status post left upper
lobectomy. She is to undergo a left pneumonectomy.
Operative Findings and Hospital
Course: There was a large mass in the remaining lung,
extensive mediastinal fibrosis, bronchial margin free by frozen
section. Following surgery she was placed in the intensive care
unit postoperatively. The chest tube was removed on postoperative
day number two.
She experienced some EKG changes consistent with acute
nontransmural MI. Cardiology was consulted, and she was started on
nitroglycerin and IV heparin. She was eventually weaned from her
oxygen therapy.
She was started on regular diet and was discharged in good
condition. Her wound was clean and dry.
Instructions on Discharge: Discharged home
with instructions to follow up with cardiology next week. Also
follow up with me in the office.
History and Physical Examination - Patient
7
Admitted: 1/3
History of Present Illness: Patient
is a 63-year-old right-handed female with history of adenocarcinoma
of apical segment of left upper love of lung, now presenting with
mass of left lower love. She has received radiation therapy to her
chest. She weighs 123 pounds. She also has chronic obstructive
pulmonary disease.
Review of Systems: She can climb two
flights of steps with minimal difficulties. She has a significant
underbite. She has stiffness in lower spine, worse in the a.m. She
has hypertension and took her Tenormin 25mg, Calan SR 240mg this
a.m.
Past Surgical History: She had a
right parotidectomy seven years ago and was told they needed to use
a "very small" ETT. Two years ago she underwent a left upper lobe
resection at this facility. Previous medical records are being
requested.
Allergies: She is allergic to sulfa.
Postoperatively last time she received Demerol. She also had
hallucinations in the ICU for several days. She blames the
hallucinations on the Demerol. The only allergy sign was
hallucinations.
Physical Examination: Revealed a
well-healed right parotid incision. No supraclavicular adenopathy.
She has a healed left posterior lateral thoracotomy scar.
Impression is that of local recurrence, status post left upper
lobectomy. She is to undergo a left completion pneumonectomy,
muscle flap coverage of bronchial stump. The patient has
hemiparesis in the right extremities.
Impression: Carcinoma left lower
lobe of lung
Plan: Pneumonectomy of left lung.
The patient is agreeable to general anesthesia or us of epidural
narcotic. She is agreeable to postoperative ventilation if
necessary.
Progress Notes Patient 7
Date Note
1/3 Attending Physician: Admit for
recurrent lung carcinoma, s/p radiation therapy. Consent signed for
pneumonectomy. Epidural morphine usage postop explained to and
discussed with the patient. She is agreeable.
Anesthesia preop: Patient evaluated and examined. General
anesthesia chosen. Patient agrees. Will provide postoperative
epidural morphine for pain management s/p thoracotomy.
Attending Physician:
Procedure Note:
Preop DX: Local recurrence of carcinoma of the lung
Postoperative Dx: Same
Procedure: Pneumonectomy with muscle flap coverage of bronchial
stump
Complications: R/O Intraop MI
Anesthesia Postoperative: Patient in stable condition following
GEA with possible intraoperative MI due to hypotension. CPK to be
evaluated as available. Patient comfortable with epidural morphine.
No adverse effects of anesthesia experienced.
1/4 Attending Physician:
Path report confirms recurrent adenocarcinoma. Patient stable but
with persistent hypotension resolving slowly - will consult
cardiology. CPK MB positive. Incision clean and dry. COPD stable,
arthritis stable.
Cardiology Consult: The patient has resolving intraoperative
myocardial infarction fue to demand ischemia caused by the
hypotension.Will continue to monitor.
1/5 Attending Physician: Looks
and feels well, weaning off morphine. Blood pressure stable. Left
pleural space expanding and filling space. Chest tube removed,
epidural Cath removed.
Cardiology Consult: The patient looking and feeling better.
1/6 Attending Physician: Patient
stable for discharge in a.m. Cardiology to follow.
Operative Report Patient 7
Date 1/4
Operation: Pneumonectomy
Preoperative Diagnosis: Recurrent
carcinoma of left lung
Postoperative Diagnosis: Same
Anesthesia: General endotracheal
anesthesia
Operative Findings: There was a large mass
in the left lower lobe.
The patient was prepped and draped in the usual fashion.
Following thoractomy the left lung was completely removed. A muscle
flap coverage was used for the bronchial stump. During the
procedure the patient experienced and episode fo hypotension, watch
for resulting MI. The patient was fluid resuscitated and sent to
the record room in good condition.
Pathology Report Patient 7
Date 1/3
Specimen: Left lung, resected
Clinical Data: This is a 63 year old
female with recurrent disease on CT scan
Diagnosis: Adenocarcinoma of the lower
lobe of the left lung, bronchial margin is free of
disease.
Physician's Orders Patient 7
Date Order
1/3 Admit to surgical
floor
Standard
order for thoracotomy
Tenormin
25mg q.d.
Calan SR
240mg twice a day
Moduretic one tab q.d.
K-Dur
10meq q.d. in a.m.
Vioxx
25mg PO daily in a.m.
Proventil
(albuterol) MDI 2 puffs PO q.i.d.
Azacort
MDI 2 puffs PO q.i.d.
CBC
Postoperative
Orders:
Admit to
ICU
Serial CPK
stat
CBC
SMA 12
Anesthesia:
Morphine pump
ad lib
D5NSS 100
cc/hr
Strict input
and output documentation
1/4. Attending MD: Consult Cardiology
Cardiology:
Lasix 20mg b.i.d. PO
D/C IV
1/5 Transfer to floor
Continue meds
1/6. Discharge patient in a.m.
Laboratory Reports Patient 7
Hematology
Date: 1/3
WBC
Hematology
Date: 1/4
WBC
Chemistry
Date: 1/3
24-32
Date: 1/3
Chest X-Ray: Reveals mass in the
left lower love. There are surgical clips in the thorax from
apparent previous surgery. The thoracic organs are midline and the
vasculature is normal.
Impression: Carcinoma LLL, no congestive
heart failure.
Date: 1/4
Chest X-Ray: Reveals absence of left
lung. Other architecture is normal other than postoperative
changes.The thoracic organs are midline and the sculpture is
normal
Impression: Postoperative changes
constant with lobectomy; no no congestive heart failure.
EKG Report Patient 7
Date: 1/3
Normal sinus rhythm
Date: 1/4
There are nonspecific ST changes consistent with possible
evolving myocardial infarction due to demand ischemia as a result
of the intraoperative hypotension.
Date: 1/5
Possible acute myocardial infarction, please correlate with
other clinical findings.
1. Choose the correct principal Diagnosis code.
a. C34.32
b. C34.82
c. I95.89
d. I97.791
e. J44.9
2. Choose the correct secondary diagnosis code(s).
a. C34.32
b. I10
c. I21.A1
d. I69.351
e. I95.89
f. I97.791
g. J44.9
h. M47.816
i. Z87.891
j. Z92.3
3. Choose the correct procedure code(s) that apply.
a. 0BBF0ZZ
b. 0BBJ0ZZ
c. 0BCF3ZZ
d. 0BCB8ZZ
e. 0BCJ0ZZ
f. 0BDB8ZX
g. 0BDL4ZX
h. 0BTB0ZZ
i. 0BTL0ZZ
j. none apply
Discharge Summary
Date of Admission 1/3
Date of Discharge 1/7
Discharge Diagnosis: Recurrent carcinoma, left
lung
This is a 63-year old female who is two years
status post left upper love resection for adenocarcinoma. Pathology
at that time revealed a positive bronchial margin of resection. She
was treated with post radiation and has done extremely well. She
has remained asymptomatic with no postoperative difficulty.
Follow-up serial CT scan have revealed a new lesion in the apical
portion of the left lung, which on needle biopsy was positive for
adenocarcinoma. She was admitted specifically for a left
thoracotomy and possible pneumonectomy.
Past Medical History: Positive for tobacco
abuse 2 PPDx30years in the past. Significant for a right and
also significant for hypertension, degenerative joint disease
of lumbar spine, and chronic pulmonary disease. The patient also
suffered a stroke in the left brain with resulting right
hemiparesis three years ago. Medications on discharge: Tenormin 25
mg once a day, Calan SR 240mg twice a day, Azacort MDI 12 puffs PO
t.i.d., Vioxx 25mg PO daily.
Physical Examination: Revealed a
well-healed right parotid incision. No supraclavicular adenopathy.
She has a healed left posterior lateral thoracotomy scar.
Impression is that of local recurrence, status post left upper
lobectomy. She is to undergo a left pneumonectomy.
Operative Findings and Hospital
Course: There was a large mass in the remaining lung,
extensive mediastinal fibrosis, bronchial margin free by frozen
section. Following surgery she was placed in the intensive care
unit postoperatively. The chest tube was removed on postoperative
day number two.
She experienced some EKG changes consistent with acute
nontransmural MI. Cardiology was consulted, and she was started on
nitroglycerin and IV heparin. She was eventually weaned from her
oxygen therapy.
She was started on regular diet and was discharged in good
condition. Her wound was clean and dry.
Instructions on Discharge: Discharged home
with instructions to follow up with cardiology next week. Also
follow up with me in the office.
History and Physical Examination - Patient
7
Admitted: 1/3
History of Present Illness: Patient
is a 63-year-old right-handed female with history of adenocarcinoma
of apical segment of left upper love of lung, now presenting with
mass of left lower love. She has received radiation therapy to her
chest. She weighs 123 pounds. She also has chronic obstructive
pulmonary disease.
Review of Systems: She can climb two
flights of steps with minimal difficulties. She has a significant
underbite. She has stiffness in lower spine, worse in the a.m. She
has hypertension and took her Tenormin 25mg, Calan SR 240mg this
a.m.
Past Surgical History: She had a
right parotidectomy seven years ago and was told they needed to use
a "very small" ETT. Two years ago she underwent a left upper lobe
resection at this facility. Previous medical records are being
requested.
Allergies: She is allergic to sulfa.
Postoperatively last time she received Demerol. She also had
hallucinations in the ICU for several days. She blames the
hallucinations on the Demerol. The only allergy sign was
hallucinations.
Physical Examination: Revealed a
well-healed right parotid incision. No supraclavicular adenopathy.
She has a healed left posterior lateral thoracotomy scar.
Impression is that of local recurrence, status post left upper
lobectomy. She is to undergo a left completion pneumonectomy,
muscle flap coverage of bronchial stump. The patient has
hemiparesis in the right extremities.
Impression: Carcinoma left lower
lobe of lung
Plan: Pneumonectomy of left lung.
The patient is agreeable to general anesthesia or us of epidural
narcotic. She is agreeable to postoperative ventilation if
necessary.
Progress Notes Patient 7
Date Note
1/3 Attending Physician: Admit for
recurrent lung carcinoma, s/p radiation therapy. Consent signed for
pneumonectomy. Epidural morphine usage postop explained to and
discussed with the patient. She is agreeable.
Anesthesia preop: Patient evaluated and examined. General
anesthesia chosen. Patient agrees. Will provide postoperative
epidural morphine for pain management s/p thoracotomy.
Attending Physician:
Procedure Note:
Preop DX: Local recurrence of carcinoma of the lung
Postoperative Dx: Same
Procedure: Pneumonectomy with muscle flap coverage of bronchial
stump
Complications: R/O Intraop MI
Anesthesia Postoperative: Patient in stable condition following
GEA with possible intraoperative MI due to hypotension. CPK to be
evaluated as available. Patient comfortable with epidural morphine.
No adverse effects of anesthesia experienced.
1/4 Attending Physician:
Path report confirms recurrent adenocarcinoma. Patient stable but
with persistent hypotension resolving slowly - will consult
cardiology. CPK MB positive. Incision clean and dry. COPD stable,
arthritis stable.
Cardiology Consult: The patient has resolving intraoperative
myocardial infarction fue to demand ischemia caused by the
hypotension.Will continue to monitor.
1/5 Attending Physician: Looks
and feels well, weaning off morphine. Blood pressure stable. Left
pleural space expanding and filling space. Chest tube removed,
epidural Cath removed.
Cardiology Consult: The patient looking and feeling better.
1/6 Attending Physician: Patient
stable for discharge in a.m. Cardiology to follow.
Operative Report Patient 7
Date 1/4
Operation: Pneumonectomy
Preoperative Diagnosis: Recurrent
carcinoma of left lung
Postoperative Diagnosis: Same
Anesthesia: General endotracheal
anesthesia
Operative Findings: There was a large mass
in the left lower lobe.
The patient was prepped and draped in the usual fashion.
Following thoractomy the left lung was completely removed. A muscle
flap coverage was used for the bronchial stump. During the
procedure the patient experienced and episode fo hypotension, watch
for resulting MI. The patient was fluid resuscitated and sent to
the record room in good condition.
Pathology Report Patient 7
Date 1/3
Specimen: Left lung, resected
Clinical Data: This is a 63 year old
female with recurrent disease on CT scan
Diagnosis: Adenocarcinoma of the lower
lobe of the left lung, bronchial margin is free of
disease.
Physician's Orders Patient 7
Date Order
1/3 Admit to surgical
floor
Standard
order for thoracotomy
Tenormin
25mg q.d.
Calan SR
240mg twice a day
Moduretic one tab q.d.
K-Dur
10meq q.d. in a.m.
Vioxx
25mg PO daily in a.m.
Proventil
(albuterol) MDI 2 puffs PO q.i.d.
Azacort
MDI 2 puffs PO q.i.d.
CBC
Postoperative
Orders:
Admit to
ICU
Serial CPK
stat
CBC
SMA 12
Anesthesia:
Morphine pump
ad lib
D5NSS 100
cc/hr
Strict input
and output documentation
1/4. Attending MD: Consult Cardiology
Cardiology:
Lasix 20mg b.i.d. PO
D/C IV
1/5 Transfer to floor
Continue meds
1/6. Discharge patient in a.m.
Laboratory Reports Patient 7
Hematology
Date: 1/3
WBC
Hematology
Date: 1/4
WBC
Chemistry
Date: 1/3
24-32
Date: 1/3
Chest X-Ray: Reveals mass in the
left lower love. There are surgical clips in the thorax from
apparent previous surgery. The thoracic organs are midline and the
vasculature is normal.
Impression: Carcinoma LLL, no congestive
heart failure.
Date: 1/4
Chest X-Ray: Reveals absence of left
lung. Other architecture is normal other than postoperative
changes.The thoracic organs are midline and the sculpture is
normal
Impression: Postoperative changes
constant with lobectomy; no no congestive heart failure.
EKG Report Patient 7
Date: 1/3
Normal sinus rhythm
Date: 1/4
There are nonspecific ST changes consistent with possible
evolving myocardial infarction due to demand ischemia as a result
of the intraoperative hypotension.
Date: 1/5
Possible acute myocardial infarction, please correlate with
other clinical findings.
1. Choose the correct principal Diagnosis code.
a. C34.32
b. C34.82
c. I95.89
d. I97.791
e. J44.9
2. Choose the correct secondary diagnosis code(s).
a. C34.32
b. I10
c. I21.A1
d. I69.351
e. I95.89
f. I97.791
g. J44.9
h. M47.816
i. Z87.891
j. Z92.3
3. Choose the correct procedure code(s) that apply.
a. 0BBF0ZZ
b. 0BBJ0ZZ
c. 0BCF3ZZ
d. 0BCB8ZZ
e. 0BCJ0ZZ
f. 0BDB8ZX
g. 0BDL4ZX
h. 0BTB0ZZ
i. 0BTL0ZZ
j. none apply