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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

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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

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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

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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,

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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

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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

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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:

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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.

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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

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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

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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

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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

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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

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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:

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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 aortopulmonary collaterals) without PA-VSD

Attending Involvement Today: I personally examined the patient at the bedside with the CICU team. BP 80/54 | Pulse 107 | Temp 97 (Tympanic) | Resp 28 | Ht 97 cm | Wt 12.4 kg | SpO2 84%

(MR # Printed by [103311] at 10/11/13 9:48 AM Page 17

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

Progress Notes – All Notes (continued)

Today, I saw and discussed with the CICU Team the following results: ECG ECHO CXR Ultrasound Cardiac Cath MRI Labs Other

Based upon the above results, I established a plan of care today which includes management of: Enteral and parenteral nutrition· Optimization of hemodynamics· Cardiac Rhythm· Invasive / Noninvasive Ventilation· Pain and sedation· Infectious disease / Risk for infectious disease· Endocrinological dysfunction· Neurologic dysfunction· Gastrointestinal dysfunction· ENT·

The time spent with the patient included personal communication with spoke with CT Surgery, spoke with referrring Cardiologist and counseled family 10 mins.

I examined the patient multiple times today. Time spent on any procedures is not included in today's billed critical care time.

Jonathan M. Kaufman, M.D.

Nutrition Inpatient Assessment:

Current Nutrition Order: Regular diet

Supplements: none

Provides: Current calorie intake varies and not quantified

Estimated Needs: (Using: RDA range; 12.20kg) 1-3yr: Energy: 75-100 kcal/kg (930-1240 kcal/d) Protein(post-op):2-2.5 g/kg (25-30 g/d) Fluid: per team.

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