CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 17 0000. ref SDS 16 0000.
040502 -
040503 -
040504 -
040964 -
040966 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Last night before the 2nd antibiotics treatment about 0030, hiked 10
041302 - laps; this morning first thing about 0405 did another 6 or 7 laps,
041303 - making a total of about 1.3 miles, before the team arrives, and per
041304 - report on 091029 0700. ref SDS 13 01F9
041305 -
041306 -
041308 -  ..
0414 -
0415 -
0416 - 0620
0417 -
041701 - Meeting with Edwin.
041702 -
041703 - Blood draw for lab to evaluate WBC, INR, Pre-albumin and albumin for
041704 - rate of nourishment.
041706 -         ..
041707 -        [On 091214 1100 Edwin did blood draw again for pre-op on Heller
041708 -        Myotomy surgery to correct achalasia. ref SDS 21 5R5H
041709 -
041710 -
041711 -
041713 -  ..
0418 -
0419 -
0420 - 0641
0421 -
042101 - Coming around the corner while hiking the hallways, Neil and the
042102 - entire team were outside the room, including Joe, Melissa, and a new
042103 - member Erick, all comparing notes on other patients while making the
042104 - morning rounds.
042106 -  ..
042107 - Continued hiking.  On the next round only Neil and Paula were outide
042108 - the room.  Met in the hallway for a few minutes with Neal and Paula.
042110 -  ..
042111 - Neil asked how the patient is feeling.
042113 -  ..
042114 - Never better.  Already hiked 2 miles.  No signs of any problems.
042115 - Slight temperature 99.7 last night, was down this morning to normal
042116 - 97.6.
042118 -  ..
042119 - Neil checked edema in lower right leg at inner ankle where the
042120 - incision was made to harvest veins for the bypass surgery on 091022.
042121 - ref SDS 12 LO3G
042123 -  ..
042124 - Explained new pain the past 2 days when getting out of bed and placing
042125 - weight on the right foot.  Starting to walk, there is initial sharp
042126 - pain putting pressure on the right foot, causing a slight limp.  After
042127 - 100 steps or so, this subsides and can walk a mile or so without pain
042128 - or discomfort of any kind, such that the right leg and foot feels fine
042129 - like the left foot.  After stopping to rest and with the foot elevated
042130 - in bed for an hour or so, then getting up and putting weight on the
042131 - right foot yields the same initial painful experience.
042133 -  ..
042134 - Neil feels elevated WBC in the lab yesterday could be slight edema in
042135 - the lower right leg, where the incision is healing and causing pain,
042136 - reported today, and rather than establish aspiration pneumonia,
042137 - presented yesterday by Joe, reported on 091102 0642, ref SDS 17 PB6Y
042138 -
042139 -        [...below, Doctor Penn with Infectious Diseases makes
042140 -        examination and finds that cause of elevated WBC past 2 days is
042141 -        due to edema in lower right leg from the body recovery from a
042142 -        major incision for a major heart surgery. ref SDS 0 ER41
042144 -  ..
042145 - Neil indicated that the CT test shows pleural effusion and this occurs
042146 - often with heart surgery.  He clarified today that the radiology
042147 - report does not diagnose "aspiration pneumonia."
042149 -  ..
042150 - Neil feels that since the patient has had achalasia for years without
042151 - getting aspiration pneumonia, the liklihood that achalasia has
042152 - suddenly caused aspiration pneumonia is very slight.  Neil noted the
042153 - medical team has discussed going back to the feeding tube, placed on
042154 - 091030, ref SDS 14 T96K, and removed on 091101, ref SDS 16 EX5C, to
042155 - maintain sufficient nutrition for the heart surgery to heal, and to
042156 - prepare the patient for Heller Myotomy surgery in a few months to
042157 - correct achalasia.  Whether this is the best solution is an open
042158 - question based on patient history in this case, and considerations
042159 - presented by Doctor Ratcliffe on 091029, ref SDS 13 OH4J, again on
042160 - 091030, ref SDS 14 8J5J, and also Doctor Tseng reported on 091102.
042161 - ref SDS 17 WC77
042163 -  ..
042164 - This is a call by the patient on advice of the team.
042166 -  ..
042167 - Neil noted that since the patient has lived with achalasia since 2005,
042168 - and has shown a healthy lifestyle, including hiking 4 - 15 miles per
042169 - day 4 - 6 days per week for the past 4 years, this indicates an
042170 - adjustment in eating that has proven effective without a feeding tube,
042171 - and so should be effective for another few months pending surgery to
042172 - resolve achalasia.
042173 -
042174 -        [...below, Doctor Penn with Infectious Diseases makes
042175 -        examination and finds no evidence of pneumonia, nor aspiration
042176 -        pneumonia. ref SDS 0 ER52
042178 -         ..
042179 -        [...below Paula advises that doctor's order for feeding tube
042180 -        has been rescinded, based in part on findings for Doctor Penn
042181 -        that aspiration pneumonia has not occurred. ref SDS 0 HA6N
042183 -         ..
042184 -        [On 091214 1100 lab shows albumin 4.2, increased well above 3.6
042185 -        nutrition target criteria set by CT Surgery Team on 091030,
042186 -        ref SDS 14 MU5N, and was achieved without reliance on feeding
042187 -        tube, and by drinking 6 cans of Ensure per day, and minimal
042188 -        normal food digestion, pending resolution of achalasia.
042189 -        ref SDS 21 GI65
042190 -
042191 -
042193 -  ..
0422 -
0423 -
0424 - 0720
0425 -
042501 - Antibiotic treatment started by Pat.
042502 -
042504 -  ..
0426 -
0427 -
0428 - 0751
0429 -
042901 - Beep.
042902 -
042903 - Antibiotic treatment ends.
042904 -
042905 -
042907 -  ..
0430 -
0431 -
0432 - 0803
0433 -
043301 - Vitals...
043302 -
043303 - Stella arrives and performs tests...
043304 -
043305 -           Temp.................... 96.5
043306 -           Pulse................... 76
043307 -           BP...................... 109/55
043308 -           Oxygen.................. 95
043309 -
043310 -
043311 -
043313 -  ..
0434 -
0435 -
0436 - 1249
0437 -
043701 - Doctor Bennit Penn, Infectious Disease Department, visits...
043702 -
043703 - The doctor follows up initial diagnsis of aspiration pneumonia,
043704 - reported yesterday, on 091102 0642. ref SDS 17 PB6Y
043706 -  ..
043707 - Examination and patient history reviewed, including background on
043708 - achalasia, and that mother evidently had this condition.
043710 -  ..
043711 - Doctor Penn asked about symmptoms of coughing and sneezing?
043713 -  ..
043714 - Reported no incidence since the operation, and nothing prior with
043715 - respect to an actual disease, like a cold or the flue, for about 10
043716 - years.
043718 -  ..
043719 - Doctor asked about treatment of achalasia in this case?
043721 -  ..
043722 - Reviewed background beginning in 2005, and prior planning in 2006 to
043723 - perform pneumatic dilation, but was not performed due to glitch at VA
043724 - in paperwork, as shown in case study on 090908. ref SDS 4 FT6M
043726 -  ..
043727 - Stethoscope indicates lungs are clear, similar to Jan's examination
043728 - an hour ago.
043730 -  ..
043731 - Bennitt has looked at the CT test yesterday, which gave rise to
043732 - initial diagnosis of aspiration pneumonia.
043734 -  ..
043735 - The doctor indicated that while there is some pleural effusion, the
043736 - amount is more consistent with normal side effects of heart by-pass
043737 - surgery, than with pneumonia.  This aligns with Neal's analysis
043738 - earlier this morning, per above. ref SDS 0 4Z52
043740 -  ..
043741 - Doctor examined incision on left leg, and seemed to indicate there is
043742 - strong recovery, noting edema is expected, and the best treatment is
043743 - the hiking, about 4 miles so far today, as follows...
043744 -
043745 -                         15
043746 -                          5
043747 -                         10
043748 -                         20
043750 -                          ..
043751 -                         50 x 400  =  20000 feet
043753 -                     ..
043754 -                    About 4 miles so far today.
043755 -
043757 -  ..
043758 - Doctor Penn said to continue with vigorous walking, and assured that
043759 - this would aid recovery and would not compound edema in the right leg.
043761 -  ..
043762 - During this examination performed in part by pressing at various
043763 - points along the incision, several places where the incision was
043764 - pressed caused considerable pain, indicating variance in the rate of
043765 - recovery.
043766 -
043767 -        [...below Jan reports pulse spiked considerably when the doctor
043768 -        pressed the incision and caused pain. ref SDS 0 DQ4L
043770 -  ..
043771 - Doctor Penn commented that examination today finds that edema in the
043772 - surgery incision on the right leg shows the body is still recovering
043773 - from a severe incision required for major surgery on 090122, in this
043774 - case quadruple heart bypass, and so aligns with elevated WBC in labs
043775 - the past few days, rather than aspiration pneumonia, as previously
043776 - noted by Neal this morning, per above. ref SDS 0 4Z40
043778 -         ..
043779 -        [...below Paula visits representing the CT team, and concurs in
043780 -        part with Doctor Penn that elevated WBC is caused in part by
043781 -        "angry" incision recoverying from heart surgery; though Paula
043782 -        reports the CT feels this is may not be the entire cause, and
043783 -        so further monitoring is needed. ref SDS 0 HA5O
043785 -         ..
043786 -        [On 091104 0718 after elevating right leg over night, it looks
043787 -        much better, ref SDS 18 I15I; blood test later shows WBC drops
043788 -        7 points to normal, ref SDS 18 PRPV; Doctor Tseng approves
043789 -        discharge based on significant drop in WBC. ref SDS 18 PR4V
043791 -  ..
043792 - Doctor Penn plans to consult with the radiologist who read the CT test
043793 - yesterday, and review the scans showing pleural effusion in order to
043794 - finalize his report to the CT team.
043796 -  ..
043797 - Asked for a copy of the radiology report.
043799 -  ..
043800 - The doctor based his understandings of the report on verbal
043801 - representations from members of the CT team.  He plans to view the
043802 - scans directly, as well as read the actual report, and then report his
043803 - findings and diagnosis to the CT team.
043805 -  ..
043806 - Thanked Bennitt for timely, thorough analysis.
043807 -
043809 -  ..
0439 -
0440 -
0441 - 1310
0442 -
044201 - Doctor Penn leaves.
044202 -
044203 - Jan rushes into the room and asks if everything is okay?  She said the
044204 - heart monitor showed a sudden spike of pulse to 170, which indicates
044205 - a-fibulation, a disaster for recovery from heart surgery.
044206 -
044207 -        [On 100305 1000 Kim remembers working with Jan 10 years ago,
044208 -        and now works with VA in Martinez; she assisted Doctor Lee
044209 -        performing endoscopy and colonoscopy tests. ref SDS 23 GO6W
044211 -  ..
044212 - Explained examination caused sudden pain on several places of incision
044213 - wound of right leg, per above. ref SDS 0 ER95
044215 -  ..
044216 - Jan notices the heart monitor in the room already shows pulse has
044217 - dropped back to normal 74.  She will report to the team that pain
044218 - accounts for spike in pulse, rather than fibulation.
044220 -  ..
044221 - This reflects several levels monitoring heart surgery patients.
044222 -
044223 -        1.  There is monitor in the room that constantly checks pulse
044224 -            using a wireless transmission of EKG signals connected
044225 -            to the patient.
044227 -             ..
044228 -        2.  The monitor in the room sends the same signals to the
044229 -            nurse's work station, across the hall, and about 20 feet
044230 -            from the patient.
044232 -             ..
044233 -        3.  Signals are also sent to the CT team control room
044234 -            monitoring all heart patients.
044236 -  ..
044237 - The main control is with the CT team, so they need timely notice of
044238 - false alarms to avoid launching immediate exigent recovery surgery.
044239 -
044240 -
044242 -  ..
0443 -
0444 -
0445 - 1314
0446 -
044601 - Antibiotic treatment started again to recover from diagnosis of
044602 - aspiration pneumonia, which Doctor Penn says is not supported by
044603 - evidence, per below. ref SDS 0 LE7J
044604 -
044605 -
044607 -  ..
0447 -
0448 -
0449 - 1439
0450 -
045001 - Paula visits.
045002 -
045003 - Good news.  Paula indicated the team plans to discharge the patient
045004 - tomorrow.
045006 -  ..
045007 - The CT team has consulted with Doctor Penn, Infectious Diseases.
045008 - There is now concensus that initial diagnosis yesterday of aspiration
045009 - pneumonia, has been rescinded, reported on 091102 0642. ref SDS 17
045010 - PB6Y
045011 -
045012 -        [...below Doctor Penn and his team from Infectious Disease
045013 -        Department visits and confirms that review of CT test does not
045014 -        support diagnosis of aspiration pneumonia, nor of any disease
045015 -        that requires treatment with antiobotics. ref SDS 0 LE7J
045017 -  ..
045018 - There will be one more treatment with antibiotics, and then this
045019 - treatment will be ended.
045020 -
045021 -        [On 091104 0718 patient given Ciprofloxacin HCL 500 MG
045022 -        antibiotic to take at home every 12 hours. ref SDS 18 415P
045024 -  ..
045025 - Paula examines the long incison on the right leg.  She applies a
045026 - treatment ointment of some kind with a spreading pad.
045028 -  ..
045029 - Paula seems to agree with Bennitt that the "angry" appearance of the
045030 - incision wound, most notably near the ankle, likely accounts for
045031 - elevated WBC, per meeting above. ref SDS 0 ER41  Paula adds that in
045032 - her experience performing similar incisions, and providing follow up
045033 - care for hundreds of heart surgery patients, what she observes on the
045034 - right leg today would not be exected to cause 70% rise in WBC.
045036 -  ..
045037 - Paula notes the leg actually lookw pretty good.
045039 -  ..
045040 - As a result, the CT team feels there may be a compound problem to
045041 - solve, which requires further analysis with respect to treatment.
045043 -  ..
045044 - Better news.
045046 -  ..
045047 - Paula reports that Doctor Stewart has scheduled surgery to correct
045048 - achalasia on 091217, with a meeting for pre-surgery examination and
045049 - consultation, a week earlier on 091208.
045051 -  ..
045052 - This implements planning in the meeting with Doctor Stewart on 091030
045053 - 0810 at 1406 for performing Heller Myotomy surgery to correct
045054 - achalasia problem. ref SDS 14 KE3B  Aligns with Doctor Ratcliffe's
045055 - planning on 091029 for surgery to correct achalasia from 2 - 3 months
045056 - following heart surgery, and in order for the patient to get adequate
045057 - nuturtion that enables heart surgery to fully heal. ref SDS 13 RE7I
045058 -
045059 -        [On 091104 0718 Medical Chart discharge guidance lists meeting
045060 -        with Doctor Stewart 091117 1300, which conflicts with patient
045061 -        history today. ref SDS 18 Q03J
045063 -         ..
045064 -        [On 091119 1000 Erick confirmed visit with Doctor Stewart on
045065 -        091208, and is reviewing date of surgery scheduled for 091217.
045066 -        ref SDS 19 935H
045068 -         ..
045069 -        [On 091208 1300 Doctor Stewart advances schedule for surgery to
045070 -        resolve achalasia one day to 091216. ref SDS 20 6E41
045072 -  ..
045073 - The team has rescinded the order for a feeding tube.  This eliminates
045074 - conflict with the patient refusing to perform doctor's order, which
045075 - was looming, per meeting with Paula and Neal this morning, see above.
045076 - ref SDS 0 4Z52
045077 -
045079 -  ..
0451 -
0452 -
0453 - 1451
0454 -
045401 - Jan visits after Paula leaves.
045402 -
045403 - Jan noted that heart surgery incision on the right leg to harvest
045404 - tissue for the by-pass work can heal more quickly by elevating the leg
045405 - when laying down, so it is even to slightly above the heart.  This
045406 - allows blood to flow more easily that expedites healing.
045408 -  ..
045409 - The nurse's aid brought 3 pillows, so the right leg can be elevated
045410 - while working after doing the hikes.
045411 -
045412 -     [...below good results; seems like fast improvement recovering
045413 -     from "angry" and painful leg incision. ref SDS 0 G73I
045414 -
045415 -     [On 091104 0718 after elevating right leg over night, it looks
045416 -     much better, ref SDS 18 I15I; blood test later shows WBC drops 7
045417 -     points to normal, ref SDS 18 PRPV; Doctor Tseng approves discharge
045418 -     based on significant drop in WBC. ref SDS 18 PR4V
045419 -
045420 -
045421 -
045422 -
045424 -  ..
0455 -
0456 -
0457 - 1538
0458 -
045801 - Meeting Infectious Disease team, including representative from
045802 - Pharmacy...
045803 -
045804 -            Doctor Bennitt Penn
045805 -            Doctor Phylis Tien
045806 -            Don Maddox, Pharmacy
045807 -            Mr Chonde, Senior Student, observing
045809 -  ..
045810 - Doctor Penn met with the radiologist and examined the scans for the CT
045811 - test from yesterday, as planned in the prior meeting at 1300, per
045812 - above at 1249. ref SDS 0 ER92
045814 -  ..
045815 - He feels there is no evidence of aspiration pneumonia, pneumonia, nor
045816 - of any infectious disease, per Paula's report above. ref SDS 0 HA6K
045818 -  ..
045819 - Doctor Penn explained the CT scan yesterday does not show fluid in the
045820 - lung, which was cited yesterday for initial diagnosis of aspiration
045821 - pneumonia, reported on 091102 0642. ref SDS 17 PB6Y
045823 -  ..
045824 - The doctor thinks the CT test scan yesterday shows liquid pumped into
045825 - the area during heart surgery on 091022 has not yet fully dissipated,
045826 - and so has pooled or collected outside the lower left lobe of the
045827 - lungs.  This liquid buildup is slightly squeezing the lower left lobe,
045828 - and this gives a false impression of plureal effusion from aspirated
045829 - liquid and food inside the lung, leading to an incorrect diagnosis of
045830 - aspiration pneumonia.
045832 -  ..
045833 - Antibiotics drip treatment is therefore ended, because there is no
045834 - evidence for plureal effusion nor aspiration pneumonia.
045836 -  ..
045837 - The doctor and the team expects this fluid outside the lungs, which is
045838 - a side effect of heart bypass surgery, and which is "squeezing" the
045839 - lower left lung, will dissipate through natural daily living, and the
045840 - lungs will naturally return to normal shape within a few weeks,
045841 - particularly with the level of exercise demonstrated by the patient,
045842 - per above. ref SDS 0 HR7N
045843 -
045844 -            [...below Doctor Tseng confirms that drip treatment with
045845 -            antibiotic is ended. ref SDS 0 N336
045847 -             ..
045848 -            [...below medical chart not posted correctly, causes
045849 -            confusion for nurse attempting to give antibiotic treatment
045850 -            already canceled by the doctor. ref SDS 0 A346
045852 -  ..
045853 - The team does not propose tapping to withdraw fluid, as Neal did last
045854 - Tuesday or Wednesday.  At that time, Neal drew much more fluid than
045855 - even the team expected based on xrays.
045856 -
045857 -
045858 -
045860 -  ..
0459 -
0460 -
0461 - 1611
0462 -
046201 - Jan says the CT team ordered another lab, because the draw this
046202 - morning did not test for INR, which checks for recovery from blood
046203 - clot that occurred in the Cordis IV.
046205 -         ..
046206 -        [...below lab reports INR 2.5, so within target range to treat
046207 -        blood clot with only Coumadin. ref SDS 0 A239
046209 -  ..
046210 - Millie called about this time, and so the discusson occurred while Jan
046211 - was doing the blood draw.
046213 -  ..
046214 - Jan had difficulty finding a vein.  "Fishing around in the arm" to
046215 - find a vein with good blood flow caused considerable pain; sudden
046216 - expression of agony startled Millie during the call; she proposed
046217 - calling back.  Jan finally got a blood flow, the pain subsided, and we
046218 - completed the call.
046219 -
046220 -
046222 -  ..
0463 -
0464 -
0465 - 1615
0466 -
046601 - Vitals again.
046602 -
046603 - Stella arrives and performs tests...
046604 -
046605 -           Temp.................... 96.5
046606 -           Pulse................... 74
046607 -           BP...................... 110/58
046608 -           Oxygen.................. 94
046610 -  ..
046611 - Lack of fever conflicts with diagnosis of aspration pneumonia.
046612 -
046613 -
046614 -
046616 -  ..
0467 -
0468 -
0469 - 1625
0470 -
047001 - Minda visited.
047002 -
047003 - Checked O2, and breathing.
047005 -  ..
047006 - While Minda was in the room...
047007 -
047009 -  ..
0471 -
0472 -
0473 - 1627
0474 -
047401 - Doctor Tseng visited.  Paula, Erick, and Mellisa attended.  Neil
047402 - peaked in but only waved and did not participate in the meeting.
047404 -  ..
047405 - Doctor Tseng confirms understanding from earlier meeting with Doctor
047406 - Penn, per above, ref SDS 0 N283, that antibiotics are ended tonight,
047407 - although she seemed to go on to say that some medication will be
047408 - provided for home care going forward.  Not sure about this point.
047409 -
047410 -            [...below medical chart not posted correctly, causes
047411 -            confusion for nurse attempting to give antibiotic treatment
047412 -            already canceled by the doctor. ref SDS 0 A346
047414 -             ..
047415 -            [On 091104 medical records list medications that include
047416 -            antibiotic to recover from aspiration pneumonia, which has
047417 -            not been diagnosed. ref SDS 18 415P
047419 -  ..
047420 - No feeding tube was ordered.
047422 -  ..
047423 - Doctor Tseng wants to hold the decision on discharge until at least
047424 - tomorrow to see if WBC drops from current 19.  She feels there may be
047425 - something not yet diagnosed causing such an elevated count.  There was
047426 - discussion about the target level.  She initially proposed 13 - 14 is
047427 - a good criteria.  After reviewing patient history showing WBC for past
047428 - 5 years at 12, the criteria that signals danger in this patient is
047429 - more like 15 - 16.
047431 -  ..
047432 - At this point, the cause of elevated WBC is unknown.  Doctor Tseng
047433 - wants to hold off initiating discharge until WBC shows downward trend
047434 - toward normal for the patient, which is 12.  So this may take a few
047435 - days.
047437 -  ..
047438 - The doctor further ordered treatment for the lungs to bring up phlem
047439 - or otherwise relieve liquid on the lungs.
047441 -  ..
047442 - The doctor did not seem to be aware of Doctor Penn, and the Infectious
047443 - Disease team, who expect the liquid will dissipate from daily living,
047444 - and so do not prescribe treatment.  Doctor Tseng orders conservative
047445 - care with proactive treatment to expand the lungs.  Minda, observing
047446 - during the meeting, will perform the work immediately.  Paula will
047447 - enter the doctor's order in the computer.
047449 -  ..
047450 - Doctor Tseng was not aware that Doctor Stewart has scheduled the next
047451 - surgery to correct achalasia.  She seemed pleased to hear this work
047452 - is now coordinated between her team and Doctor Stewart in General
047453 - Surgery.
047455 -  ..
047456 - So, tomorrow is more blood work, and possibly xrays to evaluate fluid
047457 - issue for the lower left lung.
047459 -  ..
047460 - After the doctor and the CT team left, Paula stayed behind for a few
047461 - minutes and gave instructions to Minda for physical therapy treatment
047462 - to jostle the lower left lung from the "squeezed" condition reported
047463 - by Doctor Penn, ref SDS 0 N277, and on the chance this pleural
047464 - effusion fluid be a factor causing elevated WBC.
047465 -
047466 -
047468 -  ..
0475 -
0476 -
0477 - 1643
0478 -
047801 - Minda performs CPT (or similar sounding therapy), which consists of
047802 - pounding on the patients back, primarily on the left side of the lung,
047803 - which seems problematic.  The goal is to loosen that lung from the
047804 - "squished" mode explained by Doctor Penn, per above. ref SDS 0 N277
047806 -  ..
047807 - She slaps or hits the back with moderate to strong blows using the
047808 - heal of the hand.  Since Minda is a relatively small person, maybe
047809 - weighs 120 pounds, while these are strong blows for her, they are
047810 - easily tolerated for the few mintues of the treatment.  Concerned she
047811 - would wear herself out.
047813 -  ..
047814 - This will occur several more times tonight.
047815 -
047817 -  ..
0479 -
0480 -
0481 - 1655
0482 -
048201 - Minda returns with an instrument...
048203 -             ..
048204 -            Percussor vibrating instrument.
048206 -  ..
048207 - This is similar to a vibrator, except there is more a sensation of
048208 - slight pounding, rather than mere lateral movement.
048210 -  ..
048211 - Minda concentrates again on the lower left lung, attempting to the the
048212 - lung to expand into the fluid, again as noted by Doctor Penn, per
048213 - above. ref SDS 0 N286
048215 -  ..
048216 - Minda also used the vibrator to treat a new problem, of an evident
048217 - tear or strain in the left shoulder at the neck line.  Evidently
048218 - stretching to press the nurse call bu
048219 -
048220 -
048222 -  ..
0483 -
0484 -
0485 - 1738
0486 -
048601 - Dinner delivered.
048602 -
048603 - This aligns with Doctor Tseng's notice that patient is off NPO
048604 - (nothing by mouth), and does not require feeding tube, and so can have
048605 - a regular meal.
048607 -  ..
048608 - Jan stopped in and said INR 2.5 was reported for the lab at 1538, per
048609 - above. ref SDS 0 0Z6E
048611 -  ..
048612 - This is great news, because it ends self-injection with Levonox.
048614 -  ..
048615 - Ed called at dinner time.  There was a long discussion about baseball
048616 - and football.
048617 -
048618 -
048619 -
048621 -  ..
0487 -
0488 -
0489 - 1814
0490 -
049001 - Finally ate some dinner, for the first time in 2 days.
049002 -
049003 - Had to get up from bed in order to eat from the tray a few feet away,
049004 - because c16 is on a tray across the bed.
049006 -  ..
049007 - Noticed a big change from the past few days.
049009 -  ..
049010 - The incision on the right leg now looks less "agnry" after being
049011 - elevated for a few hours, per Jan's recommendation above. ref SDS 0
049012 - G46G
049014 -  ..
049015 - Additionally, there was no pain placing the right foot on the ground,
049016 - and with weight.  Walked a few steps and did not feel pain, as
049017 - occurred previously.
049019 -  ..
049020 - Menu was some kind of soup, which didn't taste good, so took a few
049021 - spoon fulls,
049023 -  ..
049024 - There were 2 cans of Ensure.  Drank a third or so of one with the few
049025 - spoonfuls of soup.
049027 -  ..
049028 - Since the soup was kind of thick, hiked a lap after a few spoonfuls of
049029 - soup and swallows of Ensure, in order to avoid clogging that prevents
049030 - swallowing Ensure.
049032 -  ..
049033 - After the first lap, drank the rest of the 1st can of Ensure.  Seemed
049034 - to go down okay. with no sensation of backup.
049036 -  ..
049037 - Hiked another lap, then drank half the second can, and did another
049038 - lap, then finished the 2nd of 2 cans of Ensure.
049040 -  ..
049041 - Hiked another lap.
049043 -  ..
049044 - On returning, Jan advised the doctor ordered a move to the 2nd floor
049045 - ward, which is for less acute patients.  The team feels that
049046 - evaluation of WBC ordered by Doctor Tseng as a predicate to discharge
049047 - can be done with less support.
049048 -
049049 -
049051 -  ..
0491 -
0492 -
0493 - 1935
0494 -
049401 - Moved to 2nd floor.  Share with another customer, since cleared of
049402 - infectious disease, per Doctor Penn above.
049404 -  ..
049405 - Phone:     415 221 4810 ex 5165
049407 -  ..
049408 - Excellent facilities, like on 3rd floor Telemetry.
049410 -  ..
049411 - Met the new team.  They change shifts in 30 minutes at 2000.
049412 -
049413 -
049415 -  ..
0495 -
0496 -
0497 - 2051
0498 -
049801 - Nurse Dionne arrives with medication, including antibiotic drip
049802 - treatment.
049804 -  ..
049805 - Reviewed the record showing that antibiotic drip treatment was
049806 - canceled by Doctor Tseng earlier today, ref SDS 0 P26X, confirming
049807 - prescription by Doctor Penn. ref SDS 0 N283
049809 -  ..
049810 - Dionne explained that nurses have to follow the doctor's order, and
049811 - there is nothing in the medical chart eliminating antibiotic
049812 - treatments.
049814 -  ..
049815 - Asked Dionne to notify the medical team about updating the medical
049816 - chart.  In the meantime, will defer antibiotic medication until the
049817 - prescription is confirmed.
049818 -
049820 -  ..
0499 -
0500 -
0501 - 2137
0502 -
050201 - Dionne returns.
050202 -
050203 - She had called the on-call doctor for the 2nd floor hosptial ward, and
050204 - explained the possible error in the orders for patient medication.
050206 -  ..
050207 - The on-call doctor called the on-call doctor for the CT team.  This
050208 - inquiry discovered that nobody had logged the treatment change ordered
050209 - by Doctor Penn, and confirmed by Doctor Tseng, per above. ref SDS 0
050210 - P26X
050212 -  ..
050213 - Dionne said the doctor's order ending antibiotic treatment has now
050214 - been entered in the medical chart.
050215 -
050216 -        [On 091217 0600 excellent coordination and support through
050217 -        doctor/patient partnership corrected error in medical chart to
050218 -        provide medication in time to be effective. ref SDS 22 OG9L
050219 -
050220 -
050221 -
050222 -
050223 -
050224 -
050225 -
050226 -
050227 -
050228 -
0503 -