Secondary malignant neoplasm of lung Chronic kidney disease unspecified Other and unspecified hyperlipidemia Personal history of malignant melanoma of skin Personal history of tobacco use Retention of urine unspecified Other premature beats
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: CARDIOTHORACIC
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
RLL nodule
 
Major Surgical or Invasive Procedure:
Video-assisted Right lower lobe wedge resection on ___

 
History of Present Illness:
Mr ___ is a ___ year old man with a
RLL pulmonary nodule noted as incidental finding on T spine CT
___. It was measured at 11x15mm at that time.  A follow-up
Chest CT ___ noted that the nodule was 22x14mm.  There were
other smaller indeterminate nodules. His Pet-CT ___ showed
FDG avidity of the nodule with SUV 15.2.

He denies any respiratory or infectious symptoms such as 
dyspnea,
cough, hemoptysis, purulent sputum, fevers, chills, or sweats. 
He is quite active and has not noticed any changes in energy
level.  He denies new aches or pains, new neurologic symptoms, 
or
weight loss. He presents today for wedge resection and possible 
lobectomy if the nodule turns out to be a primary lung cancer. 
 
Past Medical History:
Carotid stenosis: right ICA near 40% stenosis and a left ICA 60%
to 69% stenosis (followed by Dr ___
CRI
HLD
depression
s/p RIH repair x ___
s/p LIH repair
Benign prostatic hypertrophy.
Increased prostate-specific antigen.
Perforated diverticulitis with temporary colostomy s/p reversal
___
s/p appendectomy.
s/p Back surgeries x4, most recently anterior-posterior fusion 
of
___
s/p bilat RCR
s/p foot surg
s/p pilonidal cystectomy
s/p melanoma excision L shoulder ___
 
Social History:
___
Family History:
non-contributory
 
Physical Exam:
BP: 138/92. Heart Rate: 96. Weight: 200. Height: 73. BMI: 26.4.
Temperature: 98.3. O2 Saturation%: 96.

GENERAL        
[x] WN/WD  [x] NAD  [x] AAO  [ ] abnormal findings:

HEENT          
[x] NC/AT   [x] EOMI   [x] PERRL/A   [x] Anicteric
[x] OP/NP mucosa normal     [x] Tongue midline
[x] Palate symmetric  [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:

RESPIRATORY    
[x] CTA/P     [x] Excursion normal     [x] No fremitus
[x] No egophony    [x] No spine/CVAT
[ ] Abnormal findings:

CARDIOVASCULAR 
[x] RRR    [x] No m/r/g    [x] No JVD   [x] PMI nl  [x] No edema
[x] Peripheral pulses nl    [x] No abd/carotid bruit
[ ] Abnormal findings:

GI             
[x] Soft    [x] NT   [x] ND  [x] No mass/HSM   [x] No hernia
[ ] Abnormal findings:

GU             [x] Deferred  
[ ] Nl genitalia    [ ] Nl pelvic/testicular exam    [ ] Nl DRE
[ ] Abnormal findings:

NEURO          
[x] Strength intact/symmetric    [x] Sensation intact/ symmetric
[x] Reflexes nl     [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact   [ ] Abnormal findings:

MS      
[x] No clubbing   [x] No cyanosis   [x] No edema   [x] Gait nl
[x] No tenderness  [x] Tone/align/ROM nl   [x] Palpation nl
[x] Nails nl   [ ] Abnormal findings:

LYMPH NODES   
[x] Cervical nl      [x] Supraclavicular nl     [x] Axillary nl
[x] Inguinal nl   [ ] Abnormal findings:

SKIN           
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening     [ ] Abnormal findings:

PSYCHIATRIC    
[x] Nl judgment/insight    [x] Nl memory   [x] Nl mood/affect
[ ] Abnormal findings:
 
Pertinent Results:
___ 07:50AM BLOOD WBC-12.8* RBC-5.05 Hgb-13.2* Hct-42.4 
MCV-84 MCH-26.2* MCHC-31.2 RDW-14.5 Plt ___
___ 07:50AM BLOOD UreaN-19 Creat-1.3* Na-135 K-4.5 Cl-100
___ 07:50AM BLOOD Mg-1.7

___ CXR
The right chest tube has been removed.  No pneumothorax is 
present.  
Atelectasis at the right lower lobe is present. 
Subcutaneous emphysema is seen on the right. 

 
Brief Hospital Course:
Mr. ___ was taken to the operating room on ___ for a VATS 
RLL wedge resection vs lobectomy. The frozen section pathology 
of the nodule showed spindle cell proliferation, consistent with 
melanoma (given his history), and therefore only a wedge and not 
formal lobectomy was performed. He tolerated the procedure well 
and was extubated to the PACU. He was noted to have some PVCs 
and so electrolytes and hemoglobin were obtained. Electrolytes 
were repleted as needed. He was transferred to the surgical 
floor hemodynamically stable. His diet was advanced as 
tolerated. His chest tube was kept to water seal overnight. 
On POD1 his chest tube was removed, and a post-pull film showed 
no evidence of pneumothorax. His foley catheter was also 
discontinued on POD1 however he failed to void spontaneously. 
Foley was replaced and discontinued again at midnight on POD2, 
after which he did void spontaneously. He remained 
hemodynamically stable and afebrile throughout his hospital 
stay, and his pain was well controlled on an oral regimen. He 
was discharged home on POD2 with instructions to arrange 
follow-up with Dr. ___ 2 weeks from discharge.

TRANSITIONAL ISSUES:
- Patient to follow-up in Thoracic Surgery Clinic 2 weeks from 
discharge with CXR.
- Final pathology report unavailable at time of discharge.
 
Medications on Admission:
butran transdermal 10 mcg/hr patch, cymbalta ___ 90 mg ___, nexium 
40 mg ___ ___ 5 mg ___, gabapentin 400 mg TID, 
lorazepam 0.5-1 mg qhs, oxycodone ___ mg TID PRN pain, 
oxycontin 10 mg bid, simvastatin 20 mg, terazosin 5 mg ___ 
81, Ca-Vit D, glucosamine, senna
 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H 
RX *acetaminophen 650 mg 1 tablet(s) by mouth Q ___ hours Disp 
#*40 Tablet Refills:*0
2. Gabapentin 400 mg PO Q8H 
3. Oxycodone SR (OxyconTIN) 10 mg PO BID pain 
4. Simvastatin 20 mg PO DAILY 
5. Pantoprazole 40 mg PO Q24H 
6. Terazosin 5 mg PO HS 
7. Lorazepam 0.5 mg PO HS:PRN insomnia 
8. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
RX *oxycodone 10 mg ___ tablet(s) by mouth q ___ hours Disp #*30 
Tablet Refills:*0
9. Duloxetine 90 mg PO DAILY 
10. Finasteride 5 mg PO DAILY 
11. Aspirin 81 mg PO DAILY 
12. Docusate Sodium 100 mg PO BID 
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp 
#*60 Tablet Refills:*0
13. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 
RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet 
Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
right lower lobe lung nodule

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
___, 

* You were admitted to the hospital for lung surgery and you've 
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour 
while awake.
* Check your incisions daily and report any increased redness or 
drainage.   Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours.  If it 
starts to drain, cover it with a clean dry dressing and change 
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home 
but you can wean it over a few weeks as the discomfort resolves. 
 Make sure that you have regular bowel movements while on 
narcotic pain medications as they are constipating which can 
cause more problems.  Use a stool softener or gentle laxative to 
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.  
* Continue to stay well hydrated and eat well to heal your 
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat 
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as 
you can tolerate.

Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms 
that concern you.
 
Followup Instructions:
___

{'RLL pulmonary nodule': ['Secondary malignant neoplasm of lung'], 'Carotid stenosis': ['Chronic kidney disease', 'unspecified'], 'HLD': ['Other and unspecified hyperlipidemia'], 'depression': [], 's/p RIH repair': [], 's/p LIH repair': [], 'Benign prostatic hypertrophy': [], 'Increased prostate-specific antigen': [], 'Perforated diverticulitis with temporary colostomy s/p reversal': [], 's/p appendectomy': [], 's/p Back surgeries': [], 's/p bilat RCR': [], 's/p foot surg': [], 's/p pilonidal cystectomy': [], 's/p melanoma excision L shoulder': ['Personal history of malignant melanoma of skin'], 'Dyspnea': [], 'cough': [], 'hemoptysis': [], 'purulent sputum': [], 'fevers': [], 'chills': [], 'sweats': [], 'energy level': [], 'aches or pains': [], 'neurologic symptoms': [], 'weight loss': []}