Inpatient Record - Paient 7 Discharge Summary Date of Admission 1/3 Date of Discharge 1/7 Discharge Diagnosis: Recurrent

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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