week 4 assignemt To process a request for information, you need to access the correct patient for processing. A master patient index (MPI) is a database of

 

To process a request for information, you need to access the correct patient for processing. A master patient index (MPI) is a database of key information by patient, registered by a health care organization. If the MPI is used by a system, it is referred to as an enterprise master patient index (EMPI). Within the MPI/EMPI, sufficient information is retained to identify a patient, but it does not contain all information about a patient. The database uses algorithms to determine if a patient is already in the system and to avoid the creation of a duplicate. For each data element, there is a data dictionary with a definition, format for input, and system source of information.

Using the MPI/EMPI Data Dictionary, also listed below,

  • Review each patient record in your packet.
  • Complete and submit the Master Patient Index Template for your assigned packet, also listed below.

Note: You are only abstracting the information from one patient encounter.

 

Complete the data dictionary information for the patients in your packet. The patient files are from the V-Lab patient records, and you are only abstracting the information from one patient encounter.

IP Encounter Report

Admission Information – Hospital Account/Patient Record

Arrival Date/Time: None Admit Date/Time: 08/20/2013 6:00 AM IP Adm. Date/Time: 08/20/2013 6:00 AM
Admission Type: Elective Point of Origin: Clinic Or Physician Office Admit Category: None
Means of Arrival: Walk In Primary Service: Cardiology Secondary Service: None
Transfer Source: None Service Area: The Children’s Hospital

(Sa)
Unit: Cpcu

Admit Provider: Mitchell, Max B. Attending Provider: Truong, Uyen T. Referring Provider: None

Discharge Information – Hospital Account/Patient Record
Discharge Date/Time Discharge Disposition Discharge Destination Discharge Provider Unit
08/26/2013 12:34 PM Dc To Home Or Self Care

(Routine Disch)
Home Truong, Uyen T. Cpcu

ED Arrival Information

ED Disposition

None

Hospital Problems Reviewed: 6/28/2012 7:39 AM by Kaufholz, Charlotte D.

None

Non-Hospital Problems Reviewed: 6/28/2012 7:39 AM by Kaufholz, Charlotte D.

Codes Priority Class Noted – Resolved
Single Ventricle 745.3 Unknown – Present

Entered by Dumond, Alison
M.

severe pulmonary stenosis 746.9 1/20/2010 – Present
Entered by Dumond, Alison
M.

DOLV (Double Outlet Left Ventricle) 745.19 2/17/2010 – Present
Entered by Bartakian, Sergio

Bilateral SVC’s 747.49 3/3/2010 – Present
Entered by Ivy, D. Dunbar

MAPCA (major aortopulmonary collaterals) without PA-VSD 747.39,
747.29

3/9/2013 – Present

Entered by Villavicencio,
Karrie L.

RESOLVED: Double Outlet Right Ventricle/Mitral Atresia/Pulmonary
Stenosis/Left SVC

745.11 – 2/17/2010

Entered by Mackie, Sara M.
Resolved by Bartakian,
Sergio

RESOLVED: Chylothorax 457.8 4/13/2010 – 2/21/2012
Entered and resolved by
Dumond, Alison M.

Discharge Summaries – All Notes

Cardiology Inpatient Discharge Summary

Patient Name:
Admit: 8/20/2013
Discharge: 8/26/2013
Attending: Uyen Truong, MD
Primary Cardiologist:Karrie Villavicencio, MD
CT Surgeon: Dr. Max Mitchell
PCP: Jeremy D. Parker, M.D.

Diagnoses:
Principal/Final Diagnosis: Single ventricle (left) with tricuspid valve atresia, L-malposed great vessels,

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 1

Filed: 8/27/2013 11:38 AM Note Time: 8/26/2013 10:00 AM
Related Notes: Original Note by Tiernan, Kendra D. filed at 8/26/2013 2:41 PM

Discharge Summaries signed by Truong, Uyen T. at 8/27/2013 11:38 AM
Author: Truong, Uyen T. Service: Cardiology Author Type: Physician

Patient not seen in ED

First: Jerry
Middle:
Last: Lee
DOB: 4/8/10

Address: 538 Happy Malls Drive
Paramus, NJ 07653

Phone: 201-834-1313
MS:

MRN: 00-08-56-65-00
G: Male
R: Asian
SSN#: 234-55-6600
Adm:8/20/2013, D/C:8/26/2013

Site: Wilkes-Barre Hospital

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Discharge Summaries – All Notes (continued)

severe pulmonary valve stenosis, bilateral SVC.

History of Present Illness:
is a 3 year old male with complex cyanotic congenital heart disease consisting of a single ventricle, L-

malposition of the arteries, severe pulmonary valve stenosis, and bilateral SVC’s. had an atrial
septostomy during the first week of life. He under went a Bilateral Bi-directional Glenn procedure with atrial
septectomy, and ligation of the main pulmonary artery on 3/2/10 by Dr. Max Mitchell. His postoperative course
was complicated by Chylothorax necessitating 6 weeks of Enfaport formula.

underwent cardiac cath on 5/31/13 in anticipation of Fontan surgery. The cath demonstrated stable
hemodynamics. Glenn pressure was 12 mmHg with 1 mmHg between L-SVC and PA, LVED 9 mmHg, no
gradient across the bulboventricular foramen, and fully saturated pulmonary veins. Angiography revealed Mild
L-SVC and R-SVC anasotomosis stenosis. He underwent balloon angioplasty using 10 mm balloon with
angiographic improvement. No significant collaterals were noted. He tolerated the procedure well and was
discharged to home the next day. He has since been doing well, he has had no cyanosis, tachypnea or labored
breathing. He has a good appetite although he remains small for age. He has not had any apparent arrhythmia
or syncope. He is very active with no signs of fatigue. He has not had any recent fevers or intercurrent illness.

Problem List:

Patient Active Problem List
Diagnosis
•Single Ventricle
•severe pulmonary stenosis
•DOLV (Double Outlet Left Ventricle)
•Bilateral SVC’s
•MAPCA (major aortopulmonary collaterals) without PA-VSD

Evaluation & Management:
CV: was taken to the OR and underwent completion Fontan performed by Max Mitchell.
cardiopulmonary bypass time was 129 min, cross-clamp 0 min, and circulatory arrest time was 2 min.
tolerated the procedure well and was transferred to the CICU on the following infusions; Dopamine 5
mcg/kg/min
Milrinone 0.5 mcg/kg/min. Inotropes were weaned to off on POD#1 and he had no hemodynamic issues
throughout his post-operative cours. was started on Lasix IV Q6 for pulmonary edema and pleural
effusions. Diuretics were weaned to Lasix PO BID at time of discharge. No cardiac medications at time of
discharge. Will hae follow up on Thursday August 29th with Cardiac surgery for follow up visit.
Pulm: was intubated for surgery and extubated on POD#1. Diuretics were started for pulmonary edema
and were able to be weaned to Lasix PO Q6 at time of transfer. Mediastinal drain was removed on POD#1 and
bilateral pleural drains remained. Fluid analysis of the left pleural fluid revealed a triglyceride level of 243 and
cell count analysis with 4% lymphocytes. was placed on Low fat diet with plan to continue low fat diet
for 6 weeks. Final pleural tube removed on 8/25/13. CXR today 8/26/13 without evidence of reaccumulation of
pleural fluid (see film below). Discharged home on 1/2 lpm oxygen.
FENGI: was NPO for surgery and was able to eat on POD#1. With evolution of potential chylous
ascites form the left pleural chest tube analysis, was converted to a low-fat diet. was on
ranitidine for stress prophylaxis, which was eventually discontinued. will continue on low fat 10g/day
diet. Eating well and stooling at time of discharge. Diuretics were weaned to Lasix 13mg po bid at time of
discharge.
HEME: was transfused in the OR with 161 ml of packed red blood cells and 100 ml of fresh frozen

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 2

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Discharge Summaries – All Notes (continued)

plasma. HCT on 8/21 was 45. Home on Aspirin 81 mg Po q day
ID: received peri-op antibiotics with no further infection concerns.
Neuro: received IV pain control post operatively. He was weaned to Po pain control with Ibuprofen
and tylenol at time of discharge.

Discharge Physical Exam:
Exam: BP 86/67 | Pulse 85 | Temp 36.2 (Tympanic) | Resp 23 | Ht 97 cm | Wt 12.4 kg | SpO2 89%
Temp Avg: 36.5 °C (97.7 °F) Min: 35.7 °C (96.3 °F) Max: 37 °C (98.6 °F)
Pulse Avg: 84.8 Min: 66 Max: 105
Rhythm: Normal sinus rhythm
Resp Avg: 24.3 Min: 21 Max: 28
Cuff BP: Systolic (24hrs), Avg:90 mmHg, Min:83 mmHg, Max:103 mmHg
Diastolic (24hrs), Avg:60 mmHg, Min:50 mmHg, Max:70 mmHg
BP Mean Avg: 65.6 Min: 56 Max: 75
SpO2 Avg: 89.3 % Min: 88 % Max: 94 %
Oxygen:O2 Flow Rate – LPM: 0.5 LITERS/MIN

Weight: Admit/Med Weight: Weight: 12.4 kg
Daily Weight: Wt. (Current): 12.4 kg
Gen: awake, alert, and interactive and no acute distress
HEENT: Normocephalic and atraumatic, pupils equal, round, and reactive to light, extraocular movements
intact, OP clear with moist mucous membranes
Neck: there is full active range of motion
Cardiovascular: Precordium: quiet, Rhythm: RRR, Sounds: negative for: rub, gallop, murmur or systolic
click, Pulses: +2 bilaterally throughout
Resp: breath sounds clear to auscultation bilaterally
Abdomen: liver span is 2 cm and abdomen is soft and non tender
Extremities: warm, well-perfused without cyanosis, clubbing or edema
Skin: incision clean, dry, and intact pink, warm, well perfused, no rashes
Neurological: grossly nonfocal

General Discharge Information:
Operative Procedures:
Date of Surgery: 8/20/2013
Title of Procedure: Completion Fontan (16 mm GoreTex extracardiac Fontan with 4.0 mm fenestration)
Preoperative Diagnosis: Single Ventricle s/p Bilateral Bi-directional Glenn Shunts
Postoperative Diagnosis: Same
Surgeon(s): Max Mitchell
Assistant(s): Fisher and Handfland
Anesthesia: GETA
Findings: L-TGA -t ype great vessel relationship, Small left SVC, MPA stump very adherent to the heart
Estimated Blood Loss: N/A
Fluid Replacement: N/A
Drains: blt 16F Chest tubes, 15F Blake pericardial drain
Specimens: none
Complications: None known
CBP: 129 min
XCI: none
Condition: To CICU in critical condition

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 3

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Discharge Summaries – All Notes (continued)

CXR:

Post-Op Echo: 8/26/13 Technically study secondary to uncooperative, agitated and active patient.
Fontan with laminar flow and a mean gradient of 6.8 mmHg through the fenestration. Bilateral Glenn
anastomoses with unobstructed, phasic low velocity antegrade flow in right and left Glenn shunts. The proximal
branch pulmonary arteries are well visualized with low velocity, phasic flow from their respective Glenns.
Collaterals are not visualized secondary to patient agitation on this study. Wide open atrial communication
Unobstructed bulboventricular foramen. Trivial atrioventricular valve regurgitation. Trace insufficiency through
the native pulmonary valve. Stump of native MPA seen No aortic valve stenosis, trace aortic insufficiency.
Unobstructed aortic arch. Subjectively normal right-sided, morphologic left ventricular systolic function. No
appreciable pericardial effusion or pleural effusions.

MRSA: Negative
Cultures: none
Pending Studies: None
Condition on Discharge: Good
Discharge Disposition: Discharged to: Home

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 4

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Discharge Summaries – All Notes (continued)

Discharge Medications and Treatment:

Current Discharge Medication List

START taking these medications
Details

furosemide (LASIX) 10 MG/ML
Solution

13 mg (1.3 mL) by mouth twice a day for 31 days

CONTINUE these medications which have CHANGED
Details

aspirin (ST. JOSEPH ASPIRIN) 81
MG Chew Tab

81 mg (1 tab) by mouth every day

Follow Up/Information Provided to Family:

Home Oxygen
Diagnosis (required) SV s/p fontan
For renewal, please contact: Other (See Comments) cardiologist
Room air saturation (include
date and result)

85%

PCP Name Dr. Villavicencio
PCP Phone Number 720.777.6820
Oxygen Flow Rate at
Discharge (Lpm)

1/2L

Oxygen Usage CONTINUOUSLY
Estimated length of need
(maximum 6 months)

6 months

Discharge Follow-up Appointment

Follow-up appointment(s)

CV surgery post operative
appointment Thursday August
29th: 1:00 chest xray and 1:45
with Faith Fisher NP

Follow-up appointment(s)
Please f/u with primary
cardiologist in 3-4 weeks. Please
call to schedule appointment.

Discharge Activity
Sternal precautions
Discharge activity AS TOLERATED

Discharge Diet
Low FAT diet
Discharge diet REGULAR FOR AGE

Discharge Instructions
Please call for concerns with fever greater than 100.4, increased work of breathing, cyanosis,

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 5

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Discharge Summaries – All Notes (continued)

chest pain, palpitations, fainting, redness or drainage from incision, nausea/vomiting, or with other
concerns. 720.777.6820

Clean incision with warm soap and water. Do not rub. No submersion. Pat dry.

Discharge instructions including: follow-up appointments, return precautions, activity restrictions, and safe use
of medications were discussed with parents and grandmother.

I have spent >30 minutes in planning discharge of patient including final exam, follow-up, reason to call, and
homecare.

Kendra D. Tiernan, CPNP-PC
8/26/2013

.I saw and evaluated the patient. I discussed the case with the CPNP, Kendra Tiernan, and agree with the
findings and plan as documented. is doing well. Echo shows unobstructed Fontan circuit with good SV
systolic function. His wound looks c/d/i and he has good activity and appetite. Will plan for discharge with
follow-up with CVS.

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 6

Electronically signed by Tiernan, Kendra D. at 8/26/2013 2:41 PM
Electronically signed by Truong, Uyen T. at 8/27/2013 11:38 AM

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

H&P – All Notes

CARDIOLOGY PRE-OP HISTORY & PHYSICAL

PCP: Jeremy D. Parker, M.D.
Cardiologist: Karrie Villavicencio, MD
Surgeon: Dr. Max Mitchell

Diagnosis: Malposed great vessels great vessels,

HPI
is a 3 year old male

Review of Systems:
Constitutional: Negative
HEENT: Negative
Eyes: Negative
Respiratory: Positive for desaturation related to single ventricle physiology, home sats 80%
Cardiovascular: See history of present illness.
Gastrointestinal: Negative
Genitourinary: Negative
Reproductive/Endocrine: Negative
Musculoskeletal: Negative
Hematology/Lymphatic: Negative
Immune/Allergy/Rheumatologic: Negative
Skin: Negative
Neuro: Negative

Birth/Medical/Surgical/Family History:
I have reviewed, verified and personally updated the past medical, surgical, birth, family and social history.

PAST MEDICAL HISTORY:
Past Medical History
Diagnosis Date
•single ventricle

L TGA, Pulmonary stenosis, Bilateral SVCs
•Chylothorax

PAST SURGICAL HISTORY:
Past Surgical History
Procedure Laterality Date
•Atrial septostomy,xvenous,balloon 9/25/09
•Circumcision 9/28/09
•Shunt svc to pa, both lungs 3/2/10

Glenn, bidirectional (bilateral), Atrial septectomy, division of MPA

MEDICATIONS:
40.5 mg daily ASA
IMMUNIZATIONS:
up to date

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 7

8/19/2013 11:41 AM

H&P signed by Fisher, Faith A. at 8/20/2013 5:34 AM
Author: Fisher, Faith A. Service: Cardiology Author Type: Nurse Practitioner
Filed: 8/20/2013 5:34 AM Note Time:

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

H&P – All Notes (continued)

ALLERGIES:
Review of patient’s allergies indicates no known allergies.
Family History
Problem Relation Age of Onset
•Negative Family History

History

Social History Narrative
Parents live in Cheyanne on a military base

DIET:
regular diet
DEVELOPMENTAL HISTORY:
appropriate for age
FAMILY HISTORY:
No Sudden Cardiac Death, No Congenital Heart Disease
PSYCH/SOCIAL HISTORY:
Patient has 1 siblings.
Patient is in pre school grade in school.

RESULTS:
LABS:
CBC w/ diff
Recent Labs

08/19/13
0946

WBC 5.1
RBC 6.20*
HGB 17.1*
HCT 50.2*
MCV 81.1
MCH 27.6
MCHC 34.0
RDW 13.1
PLTCT 269
MPV 7.8
SEGS 52.9
LYMPHS 29.2
MONOS 10.3*
EOS 6.8
BASOS 0.8

BMP plus (Chem 10)
Recent Labs

08/19/13
0946

NA 139
K 3.8
CL 103
BIC 24
BUN 13
CRE 0.37
GLU 62
CA 9.4

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 8

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

H&P – All Notes (continued)

CHEST X-RAY: comparison is made with the most recent previous CXR dated June 1 FINDINGS: Stable
appearance of sternotomy wires mediastinal clips and embolization coils. Stable lung volumes with stable
interstitial prominence. There is no evidence of consolidation or pleural effusion. No bony abnormalities
identified.

ECG: 79 bpm, sinus bradycardia
ECHOCARDIOGRAM:
Bilateral Glenn anastomoses with unobstructed, phasic low velocity antegrade flow in right and left Glenn
shunts. The branch pulmonary arteries are well visualized with low velocity, phasic flow from their respective
Glenns. Multiple small aortopulmonary collaterals; most prominent one arises from descending aorta entering
region of left pulmonary artery. Wide open atrial communication Unobstructed bulboventricular foramen. Trivial
atrioventricular valve regurgitation. Trace infufficiency through the native pulmonary valve. Stump of native
MPA seen No aortic valve stenosis, trace aortic insufficiency. Unobstructed aortic arch. Subjectively normal
right-sided, morphologic left ventricular systolic function.

PHYSICAL EXAM:
Weight: Weight: 12.4 kg (0.75%)
Height: 94.00cm (12.12%)
OFC: (Normalized head circumference data available only for age 0 to 36 months.)
BMI: Body mass index is 13.26 kg/(m^2). 0.37%
BP 88/53 | Pulse 112 | Temp 97.5 (Tympanic) | Ht 97 cm | Wt 12.4 kg
Pulse oximetry on room air is 82%
GENERAL: alert, no acute distress, acyanotic, well developed, well nourished
HEAD: normocephalic, atraumatic
EYES: PERRL, EOMI
EARS: TM’s clear bilaterally
NOSE: septum midline, pink mucosa, no discharge
MOUTH/THROAT: moist mucosa, no oral lesions
TEETH: normal
NECK: supple, full range of motion, no JVD, no lymphadenopathy
CHEST: Sternum: medial sternotomy, healed
LUNGS: clear to auscultation bilaterally and normal work of breathing without intercostal retractions, or
accessory muscle use
CARDIOVASCULAR: Precordium: quiet, Rhythm: RRR, Sounds: 1/6 systolic murmur LSB, Pulses: +2
bilaterally throughout
ABDOMEN: soft, non-tender, non-distended, no organomegaly or masses
EXTREMITIES: warm and well-perfused, without edema, moves extremities well and cyanosis
SKIN: no rashes
NEUROLOGIC: grossly intact, strength normal

ASSESSMENT
3 year old male with history of malposed great vessels and single ventricle with bilateral SVCs. He under went
stage 1 and 2 palliation and is here for Fontan completion. He is well appearing today with no evidence of
acute CV or Respiratory compromise. He remains afebrile with no s/s of systemic or localized infection. He is
active and well to proceed to surgeryl. POC report no concerns.

PLAN
Scheduled for Fontan Completion on 8/20/2013 with Dr. Max Mitchell.

Faith A. Fisher, CPNP-AC
Time Spent:

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 9

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

H&P – All Notes (continued)

Outpt: I spent 30 minutes of a total visit of 30 minutes in counseling/ direct
management/discussion/coordination of care. Please review the impression/plan/recommendations
in my clinic note regarding what was discussed during this visit.

Cardiothoracic Surgery History and Physical Update

Date of Service: 8/20/2013
Cardiologist: Villavicencio
PCP: Jeremy D. Parker, M.D.

H&P Review Statement:
I have reviewed the previously documented H&P completed on 8/19/20132, assessed the patient, and
confirmed the information and findings previously documented as current.

Assessment/Plan:
is a 3 year old male with single ventricle who will undergo completion Fontan. The risks,

benefits, and alternatives for the procedure have been described to the parents/patient and have agreed to
proceed and consent signed.

Max B. Mitchell, M.D.

(MR # Printed by [103311] at 10/11/13 9:47 AM Page 10

Author Type: Physician
Filed: 8/20/2013 6:43 AM Note Time: 8/20/2013 6:42 AM

Electronically signed by Fisher, Faith A. at 8/20/2013 5:34 AM

Electronically signed by Mitchell, Max B. at 8/20/2013 6:43 AM

H&P signed by Mitchell, Max B. at 8/20/2013 6:43 AM
Author: Mitchell, Max B. Service: Surgery-Cardio/Thoracic

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Consults – All Notes

Occupational Therapy and Speech Pathology Note:

Feeding and swallowing consult received. Chart reviewed and met with family. No identified concerns for
dysphagia or progression of oral feeds at this time. No therapies are recommended at this time. Please re-
consult if concerns or change in medical status occurs. Thank you.

Kaitlyn R. Goure, M.A. CCC-SLP
Speech Language Pathologist
Children’s Hospital Colorado
Desk: 720-777-6075
Monday-Friday

Jen Rodgers, OTR
Occupational Therapist
Childrens Hospital Colorado
Aurora, CO
720-777-7442
PCD: 73851
Weds-Fri

8/21/2013

has been up and walking with parents and nursing by report. No Physical Therapy needs at this time.
Please reconsult if needs arise.

Char S. Jacobs PT
Physical Therapy Department
Children’s Hospital Colorado
Voicemail (720) 777-7428
PCD X78505

(MR # Printed by [103311] at 10/11/13 9:48 AM Page 11

Electronically signed by Rodgers, Jennifer F. at 8/21/2013 2:13 PM

Rodgers, Jennifer F. Service: (none) Author Type: Occupational Therapist

Consults signed by Jacobs, Charle’ S. at 8/21/2013 9:41 PM
Author: Jacobs, Charle’ S. Service: (none) Author Type: Physical Therapist
Filed: 8/21/2013 9:41 PM Note Time: 8/21/2013 9:40 PM

Filed: 8/21/2013 2:13 PM Note Time:

Electronically signed by Jacobs, Charle’ S. at 8/21/2013 9:41 PM

8/21/2013 2:12 PM

Consults signed by Rodgers, Jennifer F. at 8/21/2013 2:13 PM
Author:

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Procedures – All Notes

PROCEDURE NOTE

Title of Procedure: PICC Line Placement

Date Performed: 8/23/2013

Performed by: Wayne J. Blalock
Assistants: Jason Justice RT (R)
Supervised by: None

Indications: Difficult venous access, Extended period of IV therapy, Frequent blood sampling and
Hyperosmolar drug, TPN, PPN, irritating drug, chemotherapy
Consent: Written consent obtained from caregiver after procedure discussed

Procedure Technique:
A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if
applicable. The left arm was prepped and draped in a sterile fashion.
Using ultrasound for visualization, the brachial vein was identified and accessed with a 22G BD Insyte
Autoguard needle x1 attempt(s). A single static image was captured and saved. A guidewire was placed into
the vein and advanced 10 cm.
Using the Modified Seldinger Technique, the catheter was advanced to the desired distance. The catheter was
flushed with normal saline and attached to the skin with Tegaderm IV Advanced and Cavilon. A single image
of the chest was obtained to document PICC position.
Patient tolerated the procedure well with general anesthesia in Cardiac Pre/Post.

Size: 3 French Single Lumen

Catheter Type: BioFlo

Catheter Length: 14 cm

Tip Position: SVC

Complications: None

Follow up: Report given to Cardiology Service.
Wayne Blalock MS, RN, VA-BC Interventional Radiology – PICC Service 720-777-9772

(MR # Printed by [103311] at 10/11/13 9:48 AM Page 12

Procedure Orders:
1. IR-PICC PLACED BY RN IN OR/PC UNDER 5 YEARS OLD [39610304] ordered by Blalock, Wayne J. at 08/23/13 1012

Author: Blalock, Wayne J. Service: Interventional Radiology Author Type:

Procedures
1. IR-PICC PLACED BY RN IN OR/PC UNDER 5 YEARS OLD [X10164]

Registered Nurse
Filed: 8/23/2013 10:12 AM

Electronically signed by Blalock, Wayne J. at 8/23/2013 10:12 AM

Note Time: 8/23/2013 10:10 AM

Procedures signed by Blalock, Wayne J. at 8/23/2013 10:12 AM

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Progress Notes – All Notes

CICU POST OP NOTE

Patient Name:
MRN:
DOB:
Attending: Jon Kaufman, MD
Primary Cardiologist: Karrie Villavicencio, MD

Date of Surgery: 8/20/2013
Title of Procedure: Completion Fontan (16 mm GoreTex extracardiac Fontan with 4.0 mm fenestration)

Diagnosis: Single left ventricle, malposed great arteries, TV atresia, B/L SVC
Surgeon(s): Max Mitchell
Procedure Details:
Findings: L-TGA -type great vessel relationship, Small left SVC, MPA stump very adherent to the heart
Bypass time: 129 min
Cross clamp time: 0 min
Circulatory arrest time: 2 min
Infusions:
Dopamine 5 mcg/kg/min
Milrinone (mcg/kg/min): 0.5
Precedex 0.7 mcg/kg/hr
Foreign bodies: Chest tube Mediastinal x1, Pleural Bilateral, ET Tube, Foley, NG Tube, Pacing Wires, PIV
Central lines: Art line Lt Rad, CVP RIJ, RFV
Estimated Blood Loss: N/A
Fluid Replacement: PRBC, FFP, Cryo, PLTs

Temp Avg: 36.2 °C (97.2 °F) Min: 36 °C (96.8 °F) Max: 36.5 °C (97.7 °F)
Pulse Avg: 96.7 Min: 91 Max: 104
Resp Avg: 16.3 Min: 0 Max: 47
Systolic (24hrs), Avg:85 mmHg, Min:85 mmHg, Max:85 mmHg

Diastolic (24hrs), Avg:42 mmHg, Min:42 mmHg, Max:42 mmHg
CVP 14-18
SpO2 Avg: 88.7 % Min: 79 % Max: 100 %
Resp/Oxygen: CONVENTIONAL VENT: Vent Mode: SIMV;Pressure Regulated Volume Control;Press
Support
Set Tidal Vol (ml): 110 ML
Vent Rate: 20
Peak Pressure (measured): 19 CM/H2O
PEEP/CPAP: 5
Pressure Support: 6

PE:
General: No acute distress, Intubated, Sedated

(MR # Printed by [103311] at 10/11/13 9:48 AM Page 13

Physician
Filed: 8/22/2013 12:59 PM Note Time: 8/20/2013 2:22 PM
Related Notes: Original Note by Farina, Mark A. filed at 8/20/2013 5:39 PM

Progress Notes signed by Kaufman, Jonathan M. at 8/22/2013 12:59 PM
Author: Kaufman, Jonathan M. Service: Cardiology Author Type:

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Progress Notes – All Notes (continued)

HEENT: Pupils 2
Neuro: Grossly non-focal
CVS: Precordium: dynamic, Rhythm: RRR, Sounds: systolic ejection murmur grade 2/6 low pitched blowing
murmur at the at LLSB, Pulses: radial 2+, femoral 2+ and pedal 2+
Resp: breath sounds clear to auscultation bilaterally
GI: bowel sounds Absent, abdomen soft, nondistended, nontender, liver edge 1 cm below costal margin
Ext: warm and cap refill 3 sec
Skin: incision clean, dry, and intact and dressing in place over incision

Labs:
CBC w/diff
Recent Labs

08/20/13
1440

WBC 7.9
RBC 5.38*
HGB 14.9*
HCT 43.8*
MCV 81.4
MCH 27.6
MCHC 33.9
RDW 13.3
PLTCT 128*
MPV 7.0
SEGS 85.1*
LYMPHS 6.6*
MONOS 7.3
EOS 1.0
PLTEST DECREASED 50-130,000

BMP (Chem 10)
Recent Labs

08/20/13
1440

NA 144*
K 3.5
CL 109
BIC 21
BUN 12
CRE 0.33
GLU 117*
CA 9.4
MG 2.6*
PHOS 5.7

CARDS
Recent Labs

08/20/13
1313

LACWB 1.86

COAGS:
Recent Labs

08/20/13
1440

PT 17.2*
INR 1.39
PTT 35

(MR # Printed by [103311] at 10/11/13 9:48 AM Page 14

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Progress Notes – All Notes (continued)
FIB 208

ABG
Recent Labs

08/20/13
1434

PHART 7.30*
PCO2ART 45*
PO2ART 74
HCO3ART 22
TCO2ART 23
BEART -5.0*
O2SATART 94

Studies:
CHEST X-RAY:

EKG: SR
ECHO: TEE Post; CONCLUSIONS Fontan baffle is well seen with unobstructed flow. There is a fenestration
with phasic forward flow (unable to calculate a mean gradient due to poor Doppler angle). Bilateral Glenn

(MR # Printed by [103311] at 10/11/13 9:48 AM Page 15

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Progress Notes – All Notes (continued)

anastomoses with unobstructed, phasic low velocity antegrade flow in right Glenn shunt. The left Glenn could
not be optimally visualized. The branch pulmonary arteries are well visualized with low velocity, phasic flow.
Unobstructed inferior vena cava. Multiple small aortopulmonary collaterals. Wide open atrial communication
Trivial-to-mild atrioventricular valve regurgitation. Normal right-sided, morphologic left ventricular systolic
function.

CATH: 5/31/2013; Hemodynamics: Glenn pressure 12 mmHg with 1 mmHg between L-SVC and PA. LVED 9
mmHg, no
gradient across the bulboventricular foramen. Fully saturated pulmonary veins.
Angiography: Mild L-SVC and R-SVC anastomosis stenosis, underwent balloon angioplasty using 10 mm
balloon with angiographic improvement. No significant collaterals.

IMPRESSION: is a 3 year old male in critical condition s/p Fontan completion with a 16mm
extracardiac, fenestrated conduit

PLAN:
CV:

(MR # Printed by [103311] at 10/11/13 9:48 AM Page 16

IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013

Progress Notes – All Notes (continued)

– continue inotropic support through extubation
– moniotr HR and rhythm
– no gradient between PAP and Fem line

Pulm:
– wean to extubation
– goal sats >80

FEN:
– ADAT after extubation
– replace electrolytes as needed
– pt has h/o chylothorax. Needs to have established good PO intake prior to removing CT’s

ID:
– peri-op ancef

Heme:
– monitor CT output and correct COAGs as needed
– start ASA tonight if extubated
– keep Hct >40

Neuro:
– Precedex through extubation
– toradol and PRN morphine, tylenol

GI:
– stress prophylaxis with zantac

GU: Foley in place

Mark A. Farina, PA-C
8/20/2013

Cardiology CICU Attending Note For Children < 6 Years Old

Date of Service: 8/20/2013
At 1600, I examined who remains critically ill. I agree with the note by the the provider PA
Farina, with the findings and recommendations as documented.

Patient Active Problem List
Diagnosis
•Single Ventricle
•severe pulmonary stenosis
•DOLV (Double Outlet Left Ventricle)
•Bilateral SVC’s
•MAPCA (major aortop

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