CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 15 0000. ref SDS 14 0000.
040502 -
040503 -
040504 -
040981 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Before the team arrived, did 15 laps, about 1.25 miles.
041302 -
041303 - Neil and the entire team visited, including Joe, Melissa, and a new
041304 - member, Erick.
041306 - ..
041307 - Neil examined the chest and leg incisions. He reported healing is
041308 - ahead of schedule, and cited benefits of exercise evident in patient
041309 - history, per above. ref SDS 0 I15I
041311 - ..
041312 - Neil advised that another xray is ordered to check on fluid in the
041313 - chest. He explained to the team that excess fluid around the heart
041314 - can cause problems that require patients to return for immediate
041315 - treatment of the heart surgery. He seemed to say there was a little
041316 - fluid in the xray yesterday. This is expected to dissipate by today,
041317 - so the xray evaluates for trends. Did fluid go down, or start coming
041318 - up again for some reason?
041319 -
041320 - [...below xray performed. ref SDS 0 02G6
041322 - ..
041323 - Neil asked for the story on removing the feeding tube?
041325 - ..
041326 - Reviewed the record yesterday on 091101 0910. ref SDS 15 PR4Q
041328 - ..
041329 - Neil advised that there is a meeting with the full surgery team later
041330 - today. He will present the record on removing the feeding tube.
041331 - Sounds like a major issue.
041333 - ..
041334 - Asked Neal to include albumin and pre-albumin in the lab this morning
041335 - to correlate nutrition without using feeding tube, compared to using
041336 - Ensure.
041338 - ..
041339 - Neil said he will add albumin and pre-albumin to the lab order.
041341 - ..
041342 - Neil indicated that Doctor Tseng feels the patient has shown
041343 - sufficient recovery from surgery and complications to go home. Neil
041344 - will write the discharge order for today.
041345 -
041346 - [...below on 091102 0642 at 0940 meeting with Paula discloses
041347 - findings of elevated WBC in the lab this morning; CT surgery
041348 - team wants to delay discharge 2 days for evaluating this new
041349 - condition. ref SDS 0 PQ5P
041351 - ..
041352 - [On 091103 0347 at 1439 Paula advises CT team plans discharge
041353 - next day on 091104. ref SDS 16 HA6K
041354 -
041355 -
041356 -
041357 -
041359 - ..
0414 -
0415 -
0416 - 0702
0417 -
041701 - Had a blood draw to evaluate impact of not using feeding tube last
041702 - night.
041704 - ..
041705 - The lab technician who drew blood, is a real nice guy, verified that
041706 - the order includes albumin and pre-albumin.
041707 -
041709 - ..
0418 -
0419 -
0420 - 0719
0421 -
042101 - Xray to evaluate lungs again for pneumonia, and check cavity for
042102 - fluid. ref SDS 0 NB81
042103 -
042105 - ..
0422 -
0423 -
0424 - 0739
0425 -
042501 - EKG test to evaluate for discharge.
042502 -
042504 - ..
0426 -
0427 -
0428 - 0744
0429 -
042901 - Pat arrives. She will arrange for discharge. She will call Hellen
042902 - in Nutrition and order enough Ensure for 2 weeks. When we meet
042903 - with Neal in 2 weeks to evaluate heart surgery recovery, can get more
042904 - Ensure at that time based on date of surgery for achalasia which will
042905 - be scheduled by Doctor Stewart in General Surgery.
042906 -
042907 - [...below on 091102 0642 at 0940 meeting with Paula discloses
042908 - findings of elevated WBC in the lab this morning; CT surgery
042909 - team wants to delay discharge 2 days for evaluating this new
042910 - condition. ref SDS 0 PQ5P
042912 - ..
042913 - [On 160816, purchase Ensure to maintain nutrition with minimal
042914 - diet of solid food, while LESV heals from severe ulceration,
042915 - following Hellen's guidance taking 7 cans of Ensure for
042916 - nutrition until medical remedy, shown in case study on 140101
042917 - 0600 followed up, ref SDS 20 NQ4I
042918 -
042919 -
042920 -
042922 - ..
0430 -
0431 -
0432 - 0752
0433 -
043301 - Vitals taken. Everything good.
043302 -
043303 -
043305 - ..
0434 -
0435 -
0436 - 0800
0437 -
043701 - Breakfast with 1 can of Ensure.
043702 -
043703 -
043704 -
043706 - ..
0438 -
0439 -
0440 - 0807
0441 -
044101 - Called for Neil to ask...
044102 -
044103 - 1. Want to leave today with schedule not only to see Neil in 2
044104 - weeks, but to perform the surgery correcting achalasia problem
044105 - the same day in order to save a trip, and per Joe's planning in
044106 - the meeting yesterday on 091031 0730. ref SDS 14 I15I
044107 -
044108 - [On 091103 0347 at 1439 Paula advises CT team plans
044109 - discharge next day on 091104, ref SDS 16 HA6K, and
044110 - schedules surgery to correct achalasia on 091217
044111 - ref SDS 16 LP7L
044113 - ..
044114 - 2. Has CT team signed off at this time for Doctor Stewart to
044115 - perform achalasia surgery as soon as possible? In that case,
044116 - the schedule is entirely in Doctor Stewart's hands.
044118 - ..
044119 - 3. If not what CT team criteria has to be met in order for Stewart
044120 - to schedule the work?
044121 -
044122 -
044123 -
044125 - ..
0442 -
0443 -
0444 - 0903
0445 -
044501 - Vitals again.
044502 -
044504 - ..
044505 - Medicines
044506 -
044508 - ..
044509 - Levonox and Coumidin.
044510 -
044511 -
044513 - ..
0446 -
0447 -
0448 - 0916
0449 -
044901 - Blood draw for culture testing for infection.
044902 -
044904 - ..
0450 -
0451 -
0452 - 0940
0453 -
045301 - Paula visited.
045302 -
045303 - She said that Neil got the message this morning, per above,
045304 - ref SDS 0 PR6R, and asked her to meet and explain status.
045306 - ..
045307 - Paula advised the CT surgery team concurs that past difficulties
045308 - following through on care to recover from achalasia, shown in case
045309 - study on 090908 1130, ref SDS 4 FT6M, justify the medical team
045310 - scheduling surgery for achalasia as part of the discharge process for
045311 - recovering from CABG, and in order to avoid further delays recovering
045312 - from achalasia.
045314 - ..
045315 - She understands I want to walk out of the hospital with date scheduled
045316 - to return in December for Heller Myotomy surgery, as discussed with
045317 - Doctor Stewart on 091030 0810. ref SDS 13 KE3B
045318 -
045319 - [On 091103 0347 Paula reports VA has scheduled Heller Myotomy
045320 - surgery on 091217, by Doctor Stewart to recover from achalasia.
045321 - ref SDS 16 BN6F
045323 - ..
045324 - Paula advised there has been a delay in discharge, because the lab
045325 - this morning shows WBC increased from 16 to 18. The team is looking
045326 - for a decline.
045328 - ..
045329 - The team wants to delay discharge at least 2 days to diagnose cause
045330 - of rise in WBC, which is often an infection, e.g., pneumonia.
045331 -
045332 - [On 091103 0347 at 1439 Paula advises CT team plans discharge
045333 - next day on 091104. ref SDS 16 HA6K
045335 - ..
045336 - CT test ordered today to further evaluate for infection driving
045337 - elevated WBC today.
045338 -
045339 - [...below Paula, ref SDS 16 PS60, says CT team getting "wet
045340 - read" from Radiology for CT test, and to assess elevated WBC.
045341 - ref SDS 0 WB68
045343 - ..
045344 - Reviewed issues on scheduling surgery to correct achalasia, per above.
045345 - ref SDS 0 PR6R
045346 -
045347 - 1. Paula said the CT team cannot sign off on Doctor Stewart doing
045348 - the surgery, until the problem with WBC increase this morning
045349 - is diagnosed and treated if necessary.
045351 - ..
045352 - 2. Sign off by CT team will occur with examination 2 weeks after
045353 - discharge. Criteria will be no new complications, assuming
045354 - solution to elevated WBC has occurred.
045356 - ..
045357 - 3. Paula gave a ballpark estimate of surgery for achalasia in
045358 - early December, 4 - 6 weeks away.
045359 -
045360 -
045361 -
045362 -
045364 - ..
0454 -
0455 -
0456 - 1035
0457 -
045701 - Astrid visits from Hellen's Nutrition Department.
045702 -
045703 - She brought 3 cans of Ensure, which Hellen wants the customer to
045704 - drink before 1400.
045705 -
045706 - [...below completed 3 cans Ensure before 1400.
045707 - ref SDS 0 0R4A
045709 - ..
045710 - Discussed future diet.
045712 - ..
045713 - Soups, like clam chowder, tomato, beef broth.
045714 -
045715 -
045717 - ..
0458 -
0459 -
0460 - 1041
0461 -
046101 - Nurse arrives and advises need to drink a liter of water to prepare
046102 - for CT test, ordered per Paula above. ref SDS 0 4Q6S
046103 -
046104 -
046106 - ..
0462 -
0463 -
0464 - 1051
0465 -
046501 - Anne loaned cell phone, and called Millie to notify not coming home
046502 - today.
046504 - ..
046505 - Mil was disappointed. She has been shopping to get things to eat, per
046506 - meeting with Astrid, above, ref SDS 0 4R4V,
046507 -
046509 - ..
0466 -
0467 -
0468 - 1113
0469 -
046901 - CT test.
046902 -
046903 - [On 151019 0930 Radiology Department report compares CCTA
046904 - test finding bypassed arteries show increased calcification
046905 - compared with prior test performed on 151102. ref SDS 21
046906 - J14N
046908 - ..
046909 - Later on 151218, CT scan file was received from VAMCSF Radiology
046910 - Department. ref SDS 22 YD5G
046912 - ..
046913 - Stored Radiology Imaging Fiies in directory...
046914 -
046915 - F:\05\00003\SM\CC\GMPF\GFJ\20091102-121821\
046916 -
046917 - F:\05\00003\SM\CC\AGMJ\20091102-121821\
046919 - ..
046920 - The file that launches radiology imaging is...
046921 -
046922 - F:\05\00003\SM\CC\GMPF\GFJ\20091102-121821\GEARView.exe
046923 -
046924 - F:\05\00003\SM\CC\AGMJ\20091102-121821\GEARView.exe
046926 - ..
046927 - Following report was received 6 years later on 151207, at Radiology
046928 - Department 2nd Floor VAMCSF...
046930 - ..
046931 - 1. VAMC Department of Radiology
046932 - 4150 Clement Street
046933 - San Francisco, CA 94121
046934 -
046945 - ..
046946 - 2. Read................ 2009 11 02
046947 - Typed............... 2009 11 02 1911
046948 - Case Number......... 246
046949 - Examination date.... 2009 11 02 1208
046951 - ..
046952 - 3. Procedure...................... CT Chest W/C DESCENDT+
046953 -
046954 - (Case 246 Complete)............ CT Chest W/C-DESCENDANT (CT detailed) CPT: 71260
046955 - Contrast Media................. Non-ionic Iodinated
046957 - ..
046958 - Reason for Study............... elevated WBC today-source of infection
046959 -
046960 - (Case 247 complete)............ CT Abdomen w/cont (CT detailed) CPT: 74160
046961 - Contrast Media................. Non-ionic Iodinated
046962 -
046963 - (Case 248 complete)............ CT Pelvis w/cont (CT detailed) CPT: 72193
046964 - Contrast Media................. Non-ionic Iodinated
046965 -
046966 - (Case 249 complete)............ CT Reconstruction, Multiplanar, A(CT detailed) CPT: 76376
046968 - ..
046969 - Clinical History
046970 - Status......................... Verified
046972 - ..
046973 - CT Chest, Abdomen, Pelvis
046975 - ..
046976 - Comparison...................... none
046978 - ..
046979 - 4. History
046980 -
046981 - Elevated white blood cell (WBC) cound today. Question source
046982 - of infection.
046984 - ..
046985 - History
046987 - ..
046988 - 5. Technique
046989 -
046990 - Multiple contiguous axial images were obtained helically from
046991 - the lung apices
046993 - ..
046994 - 6. Findings
046995 -
046996 - 1. Small left pleural effusion. Consolidated lung left base
046997 - most likely represents atelectasis. Volume loss left
046998 - hemithorax.
047000 - ..
047001 - Research shows...
047002 -
047003 - Mayo Clinic
047004 -
047005 - http://www.mayoclinic.org/diseases-conditions/atelectasis/basics/definition/con-20034847
047006 -
047007 - Atelectasis (at-uh-LEK-tuh-sis) a complete or partial
047008 - collapse of a lung or lobe of a lung develops when the
047009 - tiny air sacs (alveoli) within the lung become deflated.
047010 - It's a breathing (respiratory) complication after surgery.
047012 - ..
047013 - This finding aligns with CABG +4 surgery on 091022. 091022 0700,
047014 - ref SDS 12 F58J
047016 - ..
047017 - VAMCSF Radiology Department Report CT on 091102 continues...
047018 -
047019 - 2. The right lung is clear.
047021 - ..
047022 - 3. The heart appears mildly enlarged.
047024 - ..
047025 - 4. No mediastinal lymphadenopathy appreciated.
047027 - ..
047028 - 5. The esophagus is distended throught its course measuring up
047029 - to 5.2 cm in width and contains a moderate amount of fluid
047030 - in its distal half. The patient has known achalasia.
047032 - ..
047033 - 6. The patient is status post recenbt CABG. Poststernotomy
047034 - osseous changes and sternal wires are noted.
047036 - ..
047037 - 7. There is a 3.0 x 2.2 cm high density collection just to the
047038 - left of the sternum at the level of the main pulmonary
047039 - artery consistent with hematoma/post surgical change.
047041 - ..
047042 - 8. Similar-appearing high density material is noted in a
047043 - horizontal orientation behnd the sternum at the
047044 - postsurgical levels. No rim enhancing collection to
047045 - suggest abscess is noted. There is a small amount of high
047046 - density pericardial fluid.
047048 - ..
047049 - 9. No free intraperitoneal air or fluid are evident.
047051 - ..
047052 - 10. Evaluation of the liver is limited due to streak artifact.
047054 - ..
047055 - 11. The gallbaldder, biliary tree, pancreas, spleen, right
047056 - kidney and adrenals are unremarkable.
047058 - ..
047059 - 12. Too small to characterize lateral mid to lower pole left
047060 - renal lesion.
047062 - ..
047063 - 13. No hydronephrosis in either kidney.
047065 - ..
047066 - 14. Retroacritic left renal vein.
047068 - ..
047069 - 15. The abdominal aorta measures up to 2 cm maximum AP
047070 - dimension.
047072 - ..
047073 - 16. There is no abdominal or pelvic lymphadenopathy.
047075 - ..
047076 - 17. The stomach, small bowel and colon are markable.
047078 - ..
047079 - Was this intended to say "unremarkable". Research finds no
047080 - instances using "markable" in connection with CT tests.
047081 -
047082 - 18. The bladder contains a small air buble but is otherwise
047083 - unremarkable.
047084 -
047085 - 19. The prostate does not appear enlarged.
047087 - ..
047088 - 20. No suspicious osseous abnormalities.
047090 - ..
047091 - 21. Slight retrolisthesis of L5 and S1.
047093 - ..
047094 - 22. Small fat containing right inguinal hernia.
047096 - ..
047097 - 23. A few air bubles are noted in teh left lower abdominal
047098 - wall.
047100 - ..
047101 - 7. Impressions
047102 -
047103 - 1. Expected postsurgical changes in the chest from the
047104 - patient's recent CABG.
047105 -
047106 - No definite evidence of abscess.
047108 - ..
047109 - 2. Left basilar consolidation, likely atelectasis, and small
047110 - left pleural effusion.
047112 - ..
047113 - 3. Achalasia
047115 - ..
047116 - 4. No acute process appreciated within the abdomen or pelvis.
047118 - ..
047119 - The images were personally reviewed by the attending
047120 - radiologist, who agrees with the above interpretation.
047122 - ..
047123 - Primary diagnostic code:
047125 - ..
047126 - Primary Interpretting Staff:
047127 - Benjamin M Yeh, MD, Staff Radiology (verifier)
047129 - ..
047130 - Primary Interpretting Resident:
047131 - Robin Olander, MD, Fellow-Radiology
047132 -
047133 -
047134 -
047135 -
047136 -
047137 -
047139 - ..
0472 -
0473 -
0474 - 1217
0475 -
047501 - CT test complete. Pushed wheel chair back to Telemetry Unit in order
047502 - to save labor cost for the hospital, and to exercise.
047504 - ..
047505 - Instructions from Micheal in the CT Department - drink another pitcher
047506 - of water to flush contrast medium from system.
047507 -
047508 -
047510 - ..
0476 -
0477 -
0478 - 1238
0479 -
047901 - Lunch arrives with 2 more cans of Ensure, making a total of 5, since
047902 - this morning after breakfast, which included 1 can, making a total of
047903 - 6 so far for the day.
047905 - ..
047906 - Main menu pea or Lima bean soup which was not consumable.
047908 - ..
047909 - Went hiking instead.
047911 - ..
047912 - Saw Astrid in the hallway while hiking.
047914 - ..
047915 - Astrid will try to get clam chowder or tomato, celerary, beef broth
047916 - soup.
047918 - ..
047919 - Also while hiking, saw Paula and Joe. Paula said results of the CT
047920 - test are not yet posted.
047921 -
047922 -
047923 -
047925 - ..
0480 -
0481 -
0482 - 1349
0483 -
048301 - Completed drinking 3 cans of Enusre before 1400, per Astrid above.
048302 - ref SDS 0 4R4V
048303 -
048305 - ..
0484 -
0485 -
0486 - 1414
0487 -
048701 - Joe arrives with update on diagnosis of elevated WBC, following CT
048702 - test, and urinalysis this morning. Joe says that the blood culture
048703 - report will not be available until tomorrow.
048705 - ..
048706 - He asked for the chart.
048708 - ..
048709 - Advised it is has been hanging on a rail in the hallway outside the
048710 - door.
048712 - ..
048713 - Joe left.
048714 -
048716 - ..
0488 -
0489 -
0490 - 1414
0491 -
049101 - Saw Paula again in the hallway.
049102 -
049103 - She said Joe is making a presention on Welch case to the full CT team
049104 - in a few minutes.
049106 - ..
049107 - Radiology has not posted results of the CT test. The CT team will get
049108 - a "wet read" from Radiology to assess cause of elevated WBC, per
049109 - above. ref SDS 0 PQ5P
049110 -
049111 - [...below Joe had not received "wet read" results on the CT
049112 - test. ref SDS 0 WC33
049113 -
049115 - ..
0492 -
0493 -
0494 - 1507
0495 -
049501 - Enusure completed last 2 of 5 cans delivered so far since this
049502 - morning. ref SDS 0 4R4V
049503 -
049504 -
049506 - ..
0496 -
0497 -
0498 - 1523
0499 -
049901 - Wanita arrives. Lasix treatment to draw fluid. This is an IV,
049902 - rather than oral medication.
049904 - ..
049905 - Orders to start measuring fluid draw down again, which was stopped
049906 - yesterday when discharge was underway.
049907 -
049908 - [On 111121 1727 taking Rosuvastatin to reduce cholesterol
049909 - has side effect increase frequency urination, similar to
049910 - lasix. ref SDS 19 MX9G
049911 -
049913 - ..
0500 -
0501 -
0502 - 1529
0503 -
050301 - Joe arrives.
050302 -
050303 - He explains the team wants to drop a liter of fluid above what is
050304 - taken in, which is the purpose of Lasix, per above. ref SDS 0 WB8Q
050306 - ..
050307 - Start the new project.
050309 - ..
050310 - Asked about results of CT test, per above? ref SDS 0 4R8H
050312 - ..
050313 - Joe asked if results have been posted?
050315 - ..
050316 - Explained understandings from Paula, that Joe got the results from a
050317 - "wet read" to make a presentation to the CT team, per above.
050318 - ref SDS 0 PB5Y
050320 - ..
050321 - Joe said this is news to him. He will call Radiology for the "wet
050322 - read."
050323 -
050324 -
050325 -
050327 - ..
0504 -
0505 -
0506 - 1559
0507 -
050701 - Joe arrives.
050702 -
050703 - Aspiration pneumonia has been diagnosed by the cardiothoracic (CT)
050704 - team from the CT test that found pleural effusion in the left lung.
050705 - ref SDS 0 FR6G For reference Joe cited death of Bernie Mac,
050706 - television personality and comic.
050708 - ..
050709 - Joe advises that the CT test today shows a lump in the lower lobe of
050710 - the left lung.
050711 -
050712 - [On 091103 0347 at 1249 Doctor Penn visits from Infectious
050713 - Disease Department to assess diagnosis, and inidicates that
050714 - further review of tests and patient history may not support
050715 - diagnosis of aspiration pneumonia. ref SDS 16 ER3K
050717 - ..
050718 - [On 091103 0347 1439 Paula reports diagnosis of aspiration
050719 - pneumonia has been withdrawn. ref SDS 16 HA5L
050721 - ..
050722 - [On 091103 0347 at 1538 Penn and his team from Infectious
050723 - Disease Department visits and confirms that review of CT test
050724 - does not support diagnosis of aspiration pneumonia, nor of any
050725 - disease that requires treatment with antiobotics. ref SDS 16
050726 - LE7J
050728 - ..
050729 - Asked to see the radiology report for the CT test that diagnoses
050730 - aspiration pneumonia.
050731 -
050732 - [On 151019 0930 2 months after, and 6 years later, received
050733 - report on CT test done today on 091102, and based on report for
050734 - CT test on 151019, citing comparison with prior CT on 091102.
050735 - 151019 0930, ref SDS 21 074J
050737 - ..
050738 - Joe said he would submit the report.
050740 - ..
050741 - Need to compare the test today, with the test last Thursday or
050742 - Friday.
050743 -
050744 - [...below follow up visit Joe indicates the prior CT test did
050745 - not show aspiration pneumonia; the CT team diagnosed aspiration
050746 - pneumonia based on evident fluid in the lungs. ref SDS 0 PC8R
050748 - ..
050749 - Treatment will start with drip antibiotics.
050751 - ..
050752 - Joe said the team wants to put the feeding tube back to prevent making
050753 - aspiration pneumonia worse relative to the achalasia problem, and to
050754 - maintain nutrition for recovering from heart surgery, and to be
050755 - prepared for surgery later to correct achalasia problem.
050757 - ..
050758 - Joe emphasized the patient is asymptomatic, i.e., there are no actual
050759 - symptoms of aspiration pneumonia, except elevated WBC. He expects
050760 - however that WBC will rise significantly in the days ahead, based on
050761 - findings of pleural effusion in the left lung.
050762 -
050763 - [On 091103 0347 Jan, the nurse in TCU, recommends elevating
050764 - right leg after hiking in order to reduce infection from
050765 - incision for heart surgery on 091022, which is healing slowly
050766 - near the ankle. ref SDS 16 G46G
050768 - ..
050769 - [On 091104 0718 after elevating right leg over night, it looks
050770 - much better, ref SDS 17 I15I; blood test later shows WBC drops
050771 - 7 points to normal, ref SDS 17 PRPV; Doctor Tseng approves
050772 - discharge based on significant drop in WBC. ref SDS 17 PR4V
050774 - ..
050775 - Joe said Doctor Tseng was disappointed that Doctor Nguyen approved
050776 - removing the feeding tube yesterday on 091101 0910. ref SDS 15 HS56
050778 - ..
050779 - Joe indicated that Doctor Tseng has prescribed placing the feeding
050780 - tube again in order to maintain nutrition for recovery from heart
050781 - surgery, as discussed by Doctor Ratcliffe on 091030. ref SDS 13 8J5J
050783 - ..
050784 - Joe advised that there is a delay scheduling installation of the
050785 - feeding tube again, because the Neuclear Medicine Department has a big
050786 - backlog. As well the CT team is still in a long surgery, and so
050787 - getting the doctor's order and everything lined up to restore the
050788 - feeding tube will not occur until later tonight, or possibly tomorrow.
050789 -
050790 - [...below, on 091102 analysis does not support finding of
050791 - aspiration pneumonia nor prescribing feeding tube. ref SDS 0
050792 - RR4L
050794 - ..
050795 - [On 091214 1100 lab shows albumin 4.2, increased well above
050796 - 3.6 nutrition target criteria set by CT Surgery Team on
050797 - 091030, ref SDS 13 MU5N, and was achieved with 6 cans of
050798 - Ensure per day, and minimal normal food digestion, pending
050799 - resolution of achalasia. ref SDS 18 GI65
050801 - ..
050802 - In the meantime, Doctor Tseng has ordered NPO status, which means the
050803 - patient gets...
050804 -
050805 - Nothing by mouth.
050807 - ..
050808 - No water, no food.
050810 - ..
050811 - This prevents getting even Ensure, which has enabled the pre-albumin
050812 - and albumin blood counts to rise demonstrating adequate nutrition for
050813 - recovering from heart surgery, and to be prepared for surgery to fix
050814 - the achalasia problem.
050816 - ..
050817 - NPO presents a "self-fullfilling prophecy" scenario that necessarily
050818 - drops pre-albumin and albimin nitrition blood counts, and so the team
050819 - will cite this as evidece to show a feeding tube is essential.
050821 - ..
050822 - Joe will present the patient position to support NPO status that gives
050823 - the CT team more time to develop sufficient evidence to justify
050824 - treatment of aspiration pneumonia with feeding tube and withholding
050825 - Ensure previously prescribed to provide nutrition.
050827 - ..
050828 - For example, the medical team should submit the radiology report for
050829 - the CT test today that shows precisely what findings are made, rather
050830 - than conclusions drawn from the findings of aspiration pneumonia.
050832 - ..
050833 - Joe will present the customer's position to the CT team. He feels
050834 - nothing will be done on the feeding tube until tomorrow.
050835 -
050836 -
050837 -
050839 - ..
0509 -
0510 -
0511 - 1639
0512 -
051201 - Gloria visited.
051202 -
051203 - She is posting NPO on the door, which notifies the team that the
051204 - patient can have...
051205 -
051206 - "Nothing by Mouth"
051208 - ..
051209 - Gloria checked the medical chart on the computer.
051211 - ..
051212 - The most recent note diagnoses aspiration pneumonia based on the CT
051213 - test, elevated WBC this morning, and that the patient has had
051214 - achalasia for 5 years.
051215 -
051216 -
051218 - ..
0513 -
0514 -
0515 - 1725
0516 -
051601 - Joe visits again.
051602 -
051603 - He indicated that the prior CT test did not show aspiration pneumonia
051604 - in the left lung, per question qbove. ref SDS 0 5159
051606 - ..
051607 - Asked Joe again for a copy of the radiology report finding aspiraton
051608 - pneumonia, and the report for the prior test 2 days ago, for
051609 - comparison, since the prior test did not show this new problem.
051611 - ..
051612 - Joe explained that aspiration pneumonia problem has only occurred in
051613 - the past few days. There is nothing in the radiology report for the
051614 - prior CT test that diagnoses aspiration pneumonia. The team concludes
051615 - that after 5 years having achalasia, suddenly in the past 2 days the
051616 - patient has somehow sucked food and liquid into the lungs, when that
051617 - has never before occurred, and this has occurred without the patient
051618 - having any physicial symptoms, like gaging when food goes down the
051619 - "wrong way."
051621 - ..
051622 - Joe advised that he does not have the radiologist's actual report.
051623 - Analysis is based on verbal discussions, and the CT team looking at
051624 - the actual scans.
051626 - ..
051627 - Joe indicated again that Doctor Elaine Tseng is disappointed that
051628 - Doctor Nguyen ordered removal of the feeding tube yesterday on 091101
051629 - 0910. ref SDS 15 PSSR
051631 - ..
051632 - Reviewed the record showing no aspiration events in patient history.
051634 - ..
051635 - Joe advised that not feeling sensations of aspirating food and liquid
051636 - into the lungs, i.e. "drowning," can now occur more easily because the
051637 - esophogus was moved around, i.e., jostled, during heart bypass surgery
051638 - on 090122. The team feels changes to esophagul configuration now
051639 - enable food and liquid to get into the lungs, i.e., aspirate, without
051640 - the patient being aware, from coughing or drowning sensation and which
051641 - can be relieved by throwing up to prevent aspiration, as occurred the
051642 - past 5 years, and as discussed with Doctor Shunk during the angiogram
051643 - test on 091021. At that time, Doctor Shunk seemed to report finding
051644 - no evidence of aspiration nor injury of any kind to the lungs, nor the
051645 - throat, reported on 091021 0716. ref SDS 11 8U8H
051646 -
051647 - [On 091103 0347 Paula reports diagnosis of aspiration pneumonia
051648 - has been withdrawn. ref SDS 16 HA5L
051650 - ..
051651 - CT team diagnosis of aspiration seems conflicting with experience
051652 - today consuming over 2 liters of water, and an equal amount of Ensure.
051653 - If this is going into the lungs, rather than into the stomach through
051654 - the partially closed esophugus sphincter valve, then the lungs would
051655 - be would significantly bloated, and the patient would die.
051657 - ..
051658 - This might explain why the past few days there has been no evidence of
051659 - symptoms, and there is no food eaten at all. Everything has been
051660 - consumed as liquid, with all indications that everything was
051661 - swallowed.
051663 - ..
051664 - Additionally, why would this only be occurring in the left lung?
051665 - Aspirating is an "equal opportunity" process. Should be affecting
051666 - both lungs equally.
051668 - ..
051669 - Joe advised that Doctor Tseng wants to put the feeding tube back, but
051670 - the IR department is still backed up this afternoon.
051672 - ..
051673 - Doctor Tseng is still in the OR, and so meeting with the full team has
051674 - been delayed.
051675 -
051677 - ..
0517 -
0518 -
0519 - 1749
0520 -
052001 - Joe returns.
052002 -
052003 - He asks about urinating to remove fluids. He will check the record to
052004 - get quantities.
052006 - ..
052007 - Joe examined the lower right leg with incision for the surgery on
052008 - 091022.
052010 - ..
052011 - Joe pressed on the right leg next to the incision and reported
052012 - finding edema, which means continued swelling.
052013 -
052014 -
052015 -
052016 -
052017 -
052019 - ..
0521 -
0522 -
0523 - 1904
0524 -
052401 - Gloria gives antibiotics with drip treatment.
052402 -
052403 - 1. Zosyn (Piperazillin)............ 30 min drip
052405 - ..
052406 - 2. Bancomycin...................... 60 min drip
052408 - ..
052409 - Given for pneumonia.
052411 - ..
052412 - Gloria asked if the line was flushed after the CT test today?
052414 - ..
052415 - Gloria feels changes made to the IV in the CT Department make follow
052416 - on work in the Telemetry Department more difficult. She says this
052417 - occurs too frequently, and noted that if CT Department needs to
052418 - modify the IV catheter in order to inject contrast medium, they
052419 - should at least restore safety caps to prevent backflow from the
052420 - patient.
052421 -
052422 -
052423 -
052424 -
052426 - ..
0525 -
0526 -
0527 - 1943
0528 -
052801 - Beep.
052802 -
052803 - First drip treatment ends. ref SDS 0 P94P
052805 - ..
052806 - Start second drip treatment. ref SDS 0 CE4O
052807 -
052809 - ..
0529 -
0530 -
0531 - 2122
0532 -
053201 - Beep.
053202 -
053203 - Second drip treatment completes.
053205 - ..
053206 - Pat flushes the port with saline.
053207 -
053209 - ..
0533 -
0534 -
0535 - 2124
0536 -
053601 - Hiking 12 laps, about 1.1 miles.
053602 -
053604 - ..
0537 -
0538 -
0539 - 2210
0540 -
054001 - Pat brings nightly medications, standard for heart bypass surgery, and
054002 - to treat blood clot in the neck from the Cordis needle...
054004 - ..
054005 - 1. Enoxoparin (Levonox)............... 8.0 mg/0.8 ml route: subcutaneous
054006 -
054007 - Increase INR to resolve blood clot problem, and taken by
054008 - injection, complements Warfarin. ref SDS 0 5X44
054010 - ..
054011 - 2. Metroprolol........................ 12.5 mg route: oral
054012 -
054013 - Controls blood pressure following heart
054014 - bypass surgery
054016 - ..
054017 - 3. Warfarin (Coumadin)................ 5.0 mg route: oral
054018 -
054019 - Increase INR to resolve blood clot problem; taken with
054020 - Enoxoparin (Levonox), per above. ref SDS 0 PVYV
054022 - ..
054023 - 4. simvastatin....................... 20.0 mg route: oral
054024 -
054025 - Cholesterol medication to prevent future circulatory
054026 - failures, as occurred on 091021 0716. ref SDS 11 7L47
054027 -
054029 - ..
054030 - Oral medications were crushed and mixed with small amount of water and
054031 - with orange juice. Diluting orange juice with water increased
054032 - liquidity of mixture, reducing risk of aspiration, cited by Joe this
054033 - afternoon, per above. ref SDS 0 PB6Y
054034 -
054035 -
054037 - ..
0541 -
0542 -
0543 - 0000
0544 -
054401 - CT team Doctor Tseng, Neal, Joe, planned to visit, but did not have
054402 - time due to long surgery this afternoon...
054404 - ..
054405 - Need to discuss...
054406 -
054407 - 1. What went wrong in the face of no evident aspiration,
054408 - minimal throwing up, e.g., tuna fish sandwich Friday night
054409 - when the feeding tube was inserted and experimeneted with
054410 - KC to see how this would effect eating, reported on 091030
054411 - 0810. ref SDS 13 0K5C
054413 - ..
054414 - Joe says esophugus got jumbled during surgery and this
054415 - prevents usual symptoms of aspiration.
054417 - ..
054418 - Lessons learned...
054420 - ..
054421 - 2. Expert opinion (infectious disease doctor) on how severe
054422 - the problem is relative to other patients who have
054423 - expired.
054425 - ..
054426 - 3. Besides elevated white blood cell count, what symptoms will
054427 - occur that correlate to the lump in the lungs?
054429 - ..
054430 - 4. What explains increase in bowel movements? Seems to
054431 - indicate food is getting through, as occurred previously
054432 - the past 5 years.
054434 - ..
054435 - 5. How many aspiration pneumonia patients have been treated by
054436 - the doctor?
054438 - ..
054439 - 6. How many have died of this condition?
054441 - ..
054442 - 7. How long is typical recovery?
054444 - ..
054445 - 8. Should treatment with antibiotics draw down WBC tomorrow,
054446 - and if not then does this require change in course of
054447 - treatment?
054448 -
054449 -
054450 -
054451 -
054452 -
054453 -
054454 -
054455 -
0545 -