1 Patient Name - Nestor J. Date of Visit Check-In Time 9:45 am. Date of Birth Insurance - Medicare Sex - Male Medical Record Number Physician Robert A. M.D. Reason for Visit Elective Pacemaker Replacement. Patient is pacemaker dependent. Diagnoses: Pacemaker Dependent Hypertension Hyperlipidemia
2 HISTORY HPI - The patient is a very pleasant 88-year-old gentleman status post initial single-chamber ventricular pacemaker insertion 01/10/02, and status post pacemaker generator replacement 02/12/10. Recent testing found that the pacemaker was at elective replacement interval. He is pacemaker dependent. He was referred for pacemaker generator replacement. The indications, risks, benefits of procedure were explained to the patient as well as to his wife and niece. He understood and consented for the operation Past Medical History - Patient also has a history of hypertension, hyperlipemia and past tobacco use. FAMILY HISTORY: Patient s father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54. SOCIAL HISTORY: Patient has smoked tobacco in the past. There is no abuse of alcohol, no use of illicit drugs. ALLERGIES: No allergies to medications. REVIEW OF SYSTEMS: Patient denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Electronically signed by Robert A. M.D. on at 9:45 am.
3 PHYSICAL EXAMINATION: GENERAL: Patient is in no acute distress. VITAL SIGNS: Height 5 feet 11 inches, weight 188 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 67, respiratory rate 16, and O2 saturation 95% HEENT: Cranium is normocephalic and atraumatic. Patient has moist mucosal membranes. Patient wears a hearing aid. NECK: Veins are not distended. There are no carotid bruits. LUNGS: Clear to auscultation and percussion without wheezes. HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced. Patient is pacemaker dependent. ABDOMEN: Soft and non-distended. Bowel sounds present. EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI. There is no evidence of hematoma or bruit and intact distal pulses. LABORATORY DATA: EKG reviewed which shows the rate of 65 beats per minute and no acute disease. Current Medications Glucosamine 500/400 mg once a day Multivitamin p.o. daily. Nitroglycerin sublingual Toprol-XL 25 mg once a day Aspirin 325 mg once a day. Plavix 75 mg once a day. Diovan 160 mg once a day.
4 Norvasc 5 mg once a day. Lipitor 5 mg once a day. Diagnoses: Pacemaker Dependent Hypertension Hyperlipidemia Electronically signed by Robert A. M.D. on at 9:45 am.
5 OPERATIVE REPORT PROCEDURE: Pacemaker generator replacement PREOPERATIVE DIAGNOSIS: 1. End-of-service with pacemaker generator. 2. Pacemaker dependent. POSTOPERATIVE DIAGNOSIS: 1. End-of-service with pacemaker generator. 2. Pacemaker dependent. PROCEDURE: ANESTHESIA: Pacemaker generator replacement. MAC plus local. ESTIMATED BLOOD LOSS: None. FINDINGS: The explanted pacemaker is a St. Jude Medical model #5136, serial # The chronic right ventricular lead is a St. Jude Medical model # 1246, T/58, serial #CB The implanted pacemaker is a St. Jude Medical Zephyr XL SR, single chamber rate responsive pacemaker, model #5626, serial # Pacing parameters for the right ventricular lead, R-waves were not measured as he is pacemaker dependent, impedance 648 ohms, and pacing threshold 0.4 volts. PROCEDURE IN DETAIL: A time-out was performed prior to start of the operation. The patient was correctly identified as well as the procedure. With the patient under monitored anesthesia care, the patient's left upper chest and neck were prepped with DuraPrep and draped sterilely. A 1% Xylocaine was infiltrated locally over the more superior of the two
6 pacemaker scars. The pacemaker scar was incised. The subcutaneous tissues were divided with electrocautery. The fibrous capsule surrounding the pacemaker generator was opened and the pacemaker explanted. The lead was loosened and removed from the pacemaker generator and quickly attached to the pacemaker cable for pacing and testing, as the patient is pacemaker dependent. Pacing parameters were excellent. The lead was then inserted into the receptacle of the pacemaker generator and tightened down. The pocket was irrigated with antibiotic solution. Hemostasis was good. The generator was inserted into the pocket. The incision was closed in layers with continuous Vicryl sutures including the subcuticular layer. Dermabond and a Coverlet were applied. The patient tolerated the procedure well and there were no complications. Sponge, instruments, and needle counts were correct. The patient was transported to the post-care unit in stable condition. POSTOPERATIVE DIAGNOSIS: 1. End-of-service with pacemaker generator. 2. Pacemaker dependent. Electronically signed by Robert A. M.D. on at 11:45 am.
7 Date Patient Nestor J. Sex M Medical Record Number GENERAL CHEMISTRY TEST RESULT L=Low H = High NORMAL RANGE Sodium 120 L Potassium Chloride 89 L CO2 34 H Glucose 139 H Random BUN 49 H 8-20 Creatinine 1.7 H Calcium 8.4 L Total Protein 4.8 L Albumin 2.1 L Bilirubin Total AST ALT ALK Phos BUN / Creat 29.1 H Ratio Calaculated Osmo KEY - L=Abnormal Low H=Abnormal High UNITS
8 COMPLETE BLOOD COUNT REPORT Patient Name Nestor J. Report Date Medical Record Number Ordering Physician Robert A. COMPLETE BLOOD COUNT TEST NORMAL ABNORMAL FLAG UNITS REFERENCE RANGE WBC RBC HB/Hgb HCT MCV 79 L MCH MCHC R Platelet Count 451 H Mean Platelet Volume WBC DIFFERENTIAL TEST NORMAL ABNORMAL FLAG UNITS REFERENCE RANGE Neutrophil 62 % Lymphocyte 31 % Monocyte 8 % 0-10 Esoinophil 4 % 0-5 Basophil 1 % 0-2 Neutrophil 4.0 K/mcL Absolute Lymphocyte 4.4 K/mcL Absolute Monocyte 0.6 K/mcL Absolute Esosinophil 0.32 K/mcL Absolute Asophil Absolute 0.1 K/mcL KEY - L=Abnormal Low H=Abnormal High ** = Critical Value Contact Physician Immediately
9 RADIOLOGY / NUCLEAR MEDICINE REPORTING INTERPRETATION PROVIDED BY: HITNOTS HEALTH RADIOLOGY GROUP CHEST- ONE VIEW: Patient Nestor J. Sex M Medical Record Number INDICATION: Patient is here for evaluation of possible pneumothorax. Patient had a pacemaker inserted this a.m. Cardiac pacing unit is positioned at the tip of the left axilla with leads extending into the right atrium as well as in the right ventricle. No pneumothorax is visualized. There is a small, unilateral pleural effusion on the left side. Broad pulmonary function is seen bilaterally which may reflect chronic changes or congestive heart failure. No cardiomegaly. IMPRESSION: No pneumothorax status post cardiac pacemaker. No cardiomegaly.
10 Measurments Heart Rate 61 bpm P Duration 77 ms ECG Report PR Interval 155 ms QRS Duration 92 ms QT Interval 386 ms QTc Interval 386 ms P,QRS T Axia 67, 68, 69 Interpretation 004 Normal rhythm 244 Ischemic ST T changes in anterior leads 279 Poor R. Progression in right precordial leads Date Time 10:14 am.
11 OPERATIVE CHECKLIST Patient Nestor J. Sex M Medical Record Number Date Time 10:16am Items to Check Yes No N/A Explain No Answer Initials Pre-op Teaching Seen by Anesthesia ID Band Fall Precaution Band Allergy List / Band N/A Operative Consent H&P EKG CBC Previous Record, if ordered Dentures Removed N/A Eye glasses/ Contacts Removed Hearing Aid Removed Jewelry Removed Hairpieces / Pins Removed Body Piercing Removed Electronically signed by Diane W., RN at 10:02 am on N/A N/A
12 INFORMED CONSENT FOR SURGICAL PROCEDURE It is your doctor s obligation to provide you with the information you need in order to decide whether to consent to the surgery or special procedure that your doctors have recommended. The purpose of this form is to verify that you have received this information and have given your consent to the surgery or special procedure recommended to you. You should be involved in any and all decisions concerning the surgical procedure. Sign this form only after you understand the procedure, the risks, the alternatives, the risks associated with the alternatives, and all of your questions have been answered. Please initial and date directly below this paragraph indicating your understanding of this paragraph. NJ Patient's Initials or Authorized Representative Date Your doctors have recommended the following operation or procedure- Pacemaker Replacement. I, Nestor J. hereby authorize Robert A., MD and any associates or assistants the doctor deems appropriate, to perform a Pacemaker Replacement The risks and benefits associated with the procedure have been explained to me. However, I understand there is no certainty that I will achieve these benefits and no guarantee has been made to me regarding the outcome of the procedure(s). I also authorize the administration of sedation and/or anesthesia as may be deemed advisable or necessary for my comfort, well being and safety. The risks and possible undesirable consequences associated with the procedure have been explained to me including, but not limited to, blood loss, transfusion reactions, infection, heart complications, blood clots, loss of or loss of use of body part or other neurological injury or death. If your doctor determines that there is a reasonable possibility that you may need a blood transfusion as a result of the surgery or procedure to which you are consenting, your doctor will inform you of this and will provide you with information concerning the benefits and risks of the various options for blood transfusion, including pre-donation by yourself or others. You also have the right to have adequate time before your procedure to arrange for pre-donation, but you can waive this right if you do not wish to wait. Transfusion of blood or blood products involves certain risks, including the transmission of disease such as hepatitis or Human Immunodeficiency Virus (HIV), and you have a right to consent or refuse consent to any transfusion. You should discuss any questions that you may have about transfusions with your doctor.
13 INFORMED CONSENT FOR SURGICAL PROCEDURE Page 2. - In permitting my doctor to perform the procedure(s), I understand that unforeseen conditions may be revealed that may necessitate change or extension of the original procedure(s) or a different procedure(s) than those already explained to me. I therefore authorize and request that the abovenamed physician, his assistants, or his designees perform such procedure(s) as necessary and desirable in the exercise of his/her professional judgment. The reasonable alternative(s) to the procedure(s) have been explained to me. I hereby authorize my doctor to utilize or dispose of removed tissues, parts or organs resulting from the procedure(s) authorized above. I consent to any photographing or videotaping of the procedure(s) that may be performed, provided my identity is not revealed by the pictures or by descriptive texts accompanying them. I also consent to the admittance of students or authorized equipment representatives to the procedure room for purposes of advancing medical education or obtaining important product information. As required by the Safe Medical Device Act, I consent to the release of my name, address, and social security number to the manufacturer of any medical device I receive. By signing below, I am indicating that I have had an opportunity to ask the doctor all questions concerning risks, alternatives, and risks of those alternatives. Date_ Signature Nestor J. AUTHORIZED REPRESENTATIVE: The Patient/Authorized Representative states that he/she understands this information and has no further questions. Electronically signed on 6/2/2016 at 5:03 pm CERTIFICATION OF PHYSICIAN: I hereby certify that the facts, risks, the risks associated with the alternatives of the procedure(s) described in this form have been discussed with the individual granting consent. In addition, I have answered any questions asked of me.
14 DISCHARGE INSTRUCTIONS PACEMAKER INSERTION Wound Care - You should be able to get back to your normal activities in 2 to 4 days. For 2 to 3 weeks, do not lift anything heavier than 10 to 15 pounds. Also, do not push, pull or twist too much. Do not lift your arm above your shoulder for several weeks. DO NOT wear clothes that rub on the wound for 2 or 3 weeks. Keep your incision completely dry for 5 days. Take sponge baths. Do not submerge incision into any water. After 5 days, you may take a shower and then pat the area dry. Always wash your hands before touching the wound. Follow-up - Your physician will tell you how often you will need to have your pacemaker checked. In most cases, it will be every 6 months to a year. The exam will take about 15 to 30 minutes. The batteries in your pacemaker should last 6 to 15 years. Regular checkups can detect if the battery is wearing down or if there are any problems with the leads (wires). Your provider will change both the generator and battery when the battery gets low. When to Call the Doctor - Call your physician if: Your wound looks infected (redness, increased drainage or pus, swelling, pain). You have an odor coming from the incision. You have openings at the edges of the incision. You have a temperature. You are having the symptoms you had before the pacemaker was implanted. You feel dizzy or short of breath. You have chest pain.
15 There are no stitches that need to be removed. Steri-strips of tape will begin to fall off in about days. Your incision should begin to look better every day. Call your physician if you have any questions. Be sure that you have the phone number of your physician s office. I have received the discharge instructions, and had an opportunity to ask any questions for clarification. Nestor J Patient Signature Date Diane H. RN Witness Signature Date
16 This medical record information is being used for study and is totally fictitious. Any similarity to a real person, living or dead, is incidental. The medical content of this record may not be totally clinically accurate, and therefore should not be used as an example for diagnosis or treatment.