BIDMC Continuity of Care Document

Problem	Effective Dates	Problem Status	Provider	Comments
FX MULT CERVICAL VERT-CL - 805.08	07/28/04	Active	02-239 - Dr. NICHOLAS E. TAWA	Inpatient discharge diagnosis
MV COLL W OTH OBJ-PASNGR - E815.1	07/28/04	Active	02-239 - Dr. NICHOLAS E. TAWA	Inpatient discharge diagnosis
CERVICAL SYNDROME NEC - 723.8	10/04/04	Active	14-127 - Dr. SIMCHA J. WELLER	Inpatient discharge diagnosis
FX C1 VERTEBRA-CLOSED - 805.01	07/24/04	Active	12-AIV - Dr. BARBARA A. MASSER	ED visit diagnosis
MV COLLISION NOS-PASNGR - E812.1	07/24/04	Active	12-AIV - Dr. BARBARA A. MASSER	ED visit diagnosis

Hematology
02 Oct 2004 06:45AM	8.3	3.55*	11.5*	33.4*	94	32.3*	34.3	12.4	287
01 Oct 2004 11:54AM	10.8#	3.96*	12.5	36.5	92	31.6	34.4	12.1	336
27 Sep 2004 11:45AM	6.1	4.09*	13.0	38.3	94	31.9	34.0	12.1	372
26 Jul 2004 03:09AM	7.7	3.66*	12.2	35.2*	96	33.4*	34.8	11.8	269
25 Jul 2004 02:19AM	9.0	3.75*	12.6	35.6*	95	33.5*	35.2*	12.4	249
24 Jul 2004 10:40AM	15.0*	4.11*	13.6	39.7	96	33.1*	34.3	12.1	357

DIFFERENTIAL	Neuts	Bands	Lymphs	Monos	Eos	Baso	Atyps	Metas	Myelos
02 Oct 2004 06:45AM	73.5*		21.0	4.4	0.7	0.4
01 Oct 2004 11:54AM	98*	0	1*	1*	0	0	0	0	0

RED CELL MORPHOLOGY	Hypochr	Anisocy	Poiklo	Macrocy	Microcy	Polychr
01 Oct 2004 11:54AM	NORMAL	NORMAL	NORMAL	NORMAL	NORMAL	NORMAL

BASIC COAGULATION (PT, PTT, PLT, INR)	PT	PTT	Plt Ct	INR(PT)
02 Oct 2004 06:45AM			287
01 Oct 2004 11:54AM			336
27 Sep 2004 11:45AM			372
27 Sep 2004 11:45AM	12.7 NOTE NEW NORMAL RANGE AS OF 12AM OF 08/10/2004	27.6		1.0
26 Jul 2004 03:09AM			269
25 Jul 2004 02:19AM			249
25 Jul 2004 02:19AM	13.1	28.9		1.1
24 Jul 2004 10:40AM			357

Chemistry
02 Oct 2004 06:45AM	83	8	0.5	141	4.3	106	26	13
01 Oct 2004 11:54AM	141*	9	0.6	144	3.8	111*	22	15
27 Sep 2004 11:45AM	78	12	0.9	140	3.9	102	25	17
27 Jul 2004 05:20AM	82	6	0.5	136	4.5		20*
26 Jul 2004 03:09AM	94	4*	0.5	138	3.7	103	25	14
25 Jul 2004 02:19AM	99	4*	0.5	138	3.6	104	25	13
24 Jul 2004 10:40AM		7	0.7
SPECIMEN MODERATELY HEMOLYZED

TOXICOLOGY, SERUM AND OTHER DRUGS	ASA	Ethanol	Acetmnp	Bnzodzp	Barbitr	Tricycl
24 Jul 2004 10:40AM	NEG NEG NEW UNITS IN USE AS OF 2/3/97	161* NEW UNITS IN USE AS OF 2/3/97: 80 (THESE UNITS) = 0.08 (% BY WEIGHT)	NEG	NEG	NEG	NEG
SPECIMEN MODERATELY HEMOLYZED

Blood Gas
24 Jul 2004 10:48AM	103	2.3*	148	4.4	109	27

Hematology
24 Jul 2004 10:40AM		Straw	Clear	1.009

DIPSTICK URINALYSIS	Blood	Nitrite	Protein	Glucose	Ketone	Bilirub	Urobiln	pH	Leuks
24 Jul 2004 10:40AM	LG	NEG	TR	NEG	NEG	NEG	NEG	5.0	NEG

MICROSCOPIC URINE EXAMINATION	RBC	WBC	Bacteri	Yeast	Epi	TransE	RenalEp
24 Jul 2004 10:40AM	0-2	0	NONE	NONE	0

URINE CRYSTALS	AmorphX
24 Jul 2004 10:40AM	FEW

Chemistry
24 Jul 2004 10:40AM	RANDOM
24 Jul 2004 10:40AM	RANDOM

LAB USE ONLY, URINE	Gr Hold
24 Jul 2004 10:40AM	HOLD HOLD SPECIMEN TO BE HELD 48 HOURS AND DISCARDED

TOXICOLOGY, URINE	bnzodzp	barbitr	opiates	cocaine	amphetm	mthdone
24 Jul 2004 10:40AM	NEG	NEG	POS	POS	NEG	NEG

Procedure	Date	Provider	Comments
CERVICAL FUSION-POST TECH - 81.03	10/04/04	14-127 - Dr. SIMCHA J. WELLER	Inpatient Procedure
FUSION/REFUSION OF 4-8 VERTEBRAE - 81.63	10/04/04	14-127 - Dr. SIMCHA J. WELLER	Inpatient Procedure
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	08/17/04	14-127 - Dr. SIMCHA J. WELLER	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	09/07/04	14-127 - Dr. SIMCHA J. WELLER	Clinic visit
POSTOP FOLLOW-UP VISIT - 99024	10/12/04	14-127 - Dr. SIMCHA J. WELLER	Clinic visit
POSTOP FOLLOW-UP VISIT - 99024	11/02/04	14-127 - Dr. SIMCHA J. WELLER	Clinic visit
POSTOP FOLLOW-UP VISIT - 99024	11/23/04	14-127 - Dr. SIMCHA J. WELLER	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	01/11/05	14-127 - Dr. SIMCHA J. WELLER	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	02/01/05	14-127 - Dr. SIMCHA J. WELLER	Clinic visit
OFFICE CONSULTATION - 99243	08/30/05	14-AAE - Dr. EKKEHARD M. KASPER	Clinic visit


Encounters

 *** BIDMC Emergency Department Visit
Patient:    Sample,Susan      [DOB=10/17/77]

MRN:        7654321

Visit Date: 07/24/2004




  
 
BETH    ISRAEL    DEACONESS    MEDICAL CENTER
PATIENT DISCHARGE PLAN
PATIENT INFORMATION
Patient Name Susan Sample 
MRN#: 7654321
Case#: 1234567 8
DOB: SEP 16,1977
Patient Status: Admitted JUL 24,2004
Reason for Admission: S/P MVC;C-1 FRACTURE
Discharged to: Home 
Attending Physician: Dr. NICHOLAS E. TAWA 617-667-2084
DISCHARGE MEDICATIONS
1.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day).
   Disp:*60 Capsule(s)* Refills:*2*
2.Hydromorphone HCl 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours.
   Disp:*30 Tablet(s)* Refills:*2*
DISCHARGE INSTRUCTIONS
FINAL DIAGNOSIS
RECOMMENDED FOLLOW-UP
MAJOR SURGICAL OR INVASIVE PROCEDURES
CONDITION AT DISCHARGE
Discharge: Ordered by ZELLER,JULIE, MD on 07/28/04 @ 1318

  
 

Disch Sum  07/28/2004  Dr.  Tawa

DISCHARGE SUMMARY
 
TAWA,NICHOLAS E.
Signed Electronically by TAWA,NICHOLAS E. on MON AUG 23,2004 7:34 AM
 
 
Name:  Sample,Susan                   Unit No:   7654321
 
Admission Date:  07/24/04              Discharge Date:   07/28/04
 
Date of Birth:  10/17/77               Sex:   F
 
Service: SURG
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: TAWA,NICHOLAS E.
 
Chief Complaint:
MVC
 
Major Surgical or Invasive Procedure:
MRI of Cervical spine:  C1, C3, and C7 fractures. No spinal cord 
compression

 
History of Present Illness:
26 y.o. female involved in MVC. Pt was restrained passenger in 
rollover with +LOC. Transferred to another hospital where pt had 
CT of C-spine revealing C1, C3, and C7 fractures. Then 
transferred to BIDMC for further care.
 
Past Medical History:
anxiety
depression
polysubstance use
 
Social History:
single with three children in foster care
positive tobacco use 1-2 ppd
+EtOH 1-2 beers/day
 
Family History:
non-contributory
 
Physical Exam:
on arrival to the ED:

vitals: Temp 100.5 HR 94 RR 17 BP 136/64 sats 98% on RA, GCS 15
GEN: drowsy, but easily arousable to voice, answers questions 
appropriately, NAD
HEENT: PERRL, EOMI, sclera clear, laceration to right forehead 3 
cm in length, no nasal or oralpharyngeal trauma
NECK: trachea midline, c-collar in place
CHEST: equal BS bilaterally
CV: RRR
ABD: SNTND, FAST neg
PELVIS: stable to AP and lateral compression
RECTAL: normal tone, no gross blood, heme neg
BACK: NTTP of T and L spine, no step-offs or abrasions
EXT: movning all 4 ext, no obvious long bone deformities, 
palpable radial and DP pulses 2+ bilaterally
NEURO: alert and oriented x 3, CN II-XII intact, no focal motor 
or sensory deficits
 
Pertinent Results:
07/24/04 10:40AM BLOOD ASA-NEG Ethanol-161* Acetmnp-NEG 
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
07/24/04 10:40AM URINE bnzodzp-NEG barbitr-NEG opiates-POS 
cocaine-POS amphetm-NEG mthdone-NEG

T-SPINE; L-SPINE (AP & LAT)FINDINGS: AP and lateral views of the 
thoracic spine demonstrate preservation of vertebral bodies and 
intervertebral disc heights. No evidence of fracture.

AP and lateral views of the lumbar spine demonstrate an 
unremarkable appearance of the lumbar spine, with preservation 
of vertebral body and intraventricular heights. An S-shaped 
metallic object on the AP view may represent a naval ring, and 
multiple staples are seen projecting anterior to the L3 
vertebral body, but are not clearly localized on the AP view.

MR CERVICAL SPINE  07/25/04 10:03 AM 26-year-old female S/P MVA. 
C1, C3 and C7 fractures. To rule out traumatic injury.

Multiple sagittal T1 weighted images, T2 weighted images and 
multiple axial gradient echo images of the cervical spine are 
performed without administration of contrast.

FINDINGS:

There is straightening of cervical curvature noted. Increased 
signal is noted in the C7 and C3 vertebral bodies, consistent 
with known fractures. There is prevertebral soft tissue swelling 
noted from the level of C1 to C4. There is increased signal 
noted in the posterior soft tissues along the posterior elements 
from the level of C2 to C6, consistent with ligamentous injury.

No evidence of cord compression noted.

IMPRESSION:

1) Ligamentous injury as discussed above.

2) No evidence of cord compression noted.

 
Brief Hospital Course:
7/24/ to 7/28/04: The pt was initially admitted to the TSICU for 
Q1h neuro checks. Neurosurgery was consulted for the pt's 
cervical spine fractures. They felt these could be managed 
non-operatively. The pt was to remain in a hard collar (Miami J) 
for 12 weeks. The pt was transferred to the floor on 7/26. She 
remained in house working with physical therapy and modifying 
her pain control. The pt also met with addiction medicine 
because of her positive tox screen. At the time of discharge the 
pt was taking PO, her pain was under control and she was having 
regular bowel movements. 
 
Medications on Admission:
Xanax
Wellbutrin
 
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Hydromorphone HCl 4 mg Tablet Sig: One (1) Tablet PO every 
4-6 hours.
Disp:*30 Tablet(s)* Refills:*2*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
1) Fractures of C1, C3, and C7 vertebrae

 
Discharge Condition:
Good
 
Discharge Instructions:
You may resume light physical activity. Continue to wear the 
Miami J brace at all times. You will need to follow up in the 
neurosurgery clinic in 4 weeks with Dr. Weller. His assistant 
will be contacting you with dates and times of your appt. Prior 
to the appt you will need to have x-rays done of your neck. 
These will be ordered prior to your clinic appt.
When you are contacted by Dr. Weller's receptionist, please 
express to here that you would potentially like to follow up 
with a neurosurgeon closer to your home in Falmoth. She may be 
able to provide you with contact information and clinics in that 
area. 
 
Followup Instructions:
Follow up in the Neurosurgery clinic in 4 and 12 weeks from 
today. Dr. Weller's receptionist will be contacting you to 
schedule convenient dates and times for you. She can be reached 
at 617-632-9912 if you have any questions

 
                             NICHOLAS E. TAWA MD, PHD 02-239
 
Completed by: JULIE A. ZELLER MD 70-AXB 08/12/04 @ 1205

  
 

Telephone  08/02/2004  Dr. MARIANNE NP CARDELLO  Service: Neurosurgery

Date: 08/02/04
Signed by MARIANNE CARDELLO, NP on 08/02/04  Affiliation: HMFP
 
Ms. Sample called the office today. she is s/p MVA with cervical
spine fractures. she is in rigid cervical collar and is at home.
Has f/u appt on 8/17/04 with xrays. She c/o neck pain and is
running out of Dilaudid. She is taking Dilaudid 4 mg po
prn:q4-6hr. I mailed her same rx, #60 tabs, as well as Flexeril
10 mg po prn:q8h, #60 tab, one refill, and Motrin 800 mg po
prn:q8h, #60 tab, one refill. She will f/u on 8/17/04 and
continue wearing the collar at all times until then.

  
 

Telephone  08/04/2004  Dr. MARIANNE NP CARDELLO  Service: Neurosurgery

Date: 08/04/04
Signed by MARIANNE CARDELLO, NP on 08/04/04  Affiliation: HMFP
 
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Telephone  08/12/2004  Dr. MARIANNE NP CARDELLO  Service: Neurosurgery

Date: 08/12/04
Signed by MARIANNE CARDELLO, NP on 08/12/04  Affiliation: HMFP
 
Ms. Sample called the office last week. She is s/p MVA s/p
cervical spine fractures. She had f/u appt with Dr. Weller on
8/17/04 with xrays. She called reporting that she cannot get
transportation here to see Dr. Weller as her parents are unable
to drive her to Boston. She remains in Aspen cervical collar at
all times and is unable to drive herself. I explained that she
must follow up with a neurosurgeon re: the cervical fractures.
She asked if it would be possible to see someone locally. I have
recommended Dr. Stephen Johnson at South Shore Hospital. She will
call his office to see if she can see him in follow up instead. I
will let Dr. Weller know. I will cancel her appt on 8/17/04. If
she cannot get an appt soon with Dr. Johnson, she will let me
know.

  
 

Telephone  09/08/2004  Dr. MARIANNE NP CARDELLO  Service: Neurosurgery

Date: 09/08/04
Signed by MARIANNE CARDELLO, NP on 09/08/04  Affiliation: HMFP
 
Ms. Sample called the office today. She was seen by Dr. Weller
yesterday and discussed surgery (C3-7 posterior cervical fusion)
for probably dorsal ligamentous injury esp C6-7 after MVA
7/24/04. She has been in rigid cervical collar since then. She
asked for pain med as she has been taking Motrin 800 mg prn and
was advised by Dr. Weller to stop this so as to not interfere
with the fusion and also to stop prior to her surgery. She had
been taking Vicodin 1 tab prn:q4h and Motrin 800 mg prn:q8h. She
has minimal relief from Vicodin. I called in Vicodin 1-2 tab po
prn:Q4-6 hrs, max 8 tabs per 24h, #16 tabs to last until she
receives prescription in the mail for Percocet, 1-2 tab po
prn:q4-6h, disp #60 tabs, as I cannot call this in. Also I called
in Flexeril 10 mg po prn:q8h, disp #40, one refill to
123-555-1212, CVS pharmacy. I informed her of her surgery date on
10/1/04 at 8AM and we will call her with her preop testing date.
She will wear rigid collar until then.

  
 

Op Report  10/01/2004  Dr.  Simcha J. Weller

OPERATIVE REPORT
 
WELLER,SIMCHA J.
Signed Electronically by WELLER,SINCHA on MON NOV 22,2004 5:43 PM
 
Name:  Sample, Susan             Unit No:  7654321

Service:  NSU                     Date:  10/01/2004

Date of Birth:  10/17/1977        Sex:  F

Surgeon:  Simcha J. Weller, MD 14127


PREOPERATIVE DIAGNOSIS:  Posttraumatic cervical spine
instability.

POSTOPERATIVE DIAGNOSIS:  Posttraumatic cervical spine
instability.

PROCEDURE:  C3-C7 posterior cervical arthrodesis utilizing
autologous left iliac crest bone graft harvested through a
separate fascial incision.
C3-7 posterior cervical segmental spinal instrumentation
utilizing Blackstone ascent lateral mass screw rod fixation.

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  100 cc.

COMPLICATIONS:  None.

INDICATIONS FOR SURGERY:  The patient is a 27-year-old woman
who was involved in a motor vehicle accident and referred to
Beth Israel-Deaconess Medical Center for evaluation of
posttraumatic cervical spine instability.  She had been
maintained in a rigid cervical collar since her accident.

Numerous imaging studies demonstrated posttraumatic cervical
spine instability including an MRI scan which was consistent
with significant dorsal ligamentous injury and several serial
radiographic studies including dynamic films demonstrating
posttraumatic cervical kyphosis and instability.

In view of the appearance of her radiographic studies and her
persistent mechanical neck pain, surgical intervention was
offered.  The risks and benefits of surgery and treatment
alternatives were fully discussed with the patient in detail,
and she provided informed consent for the operation.

PROCEDURE IN DETAIL:  Following induction of satisfactory
general endotracheal anesthesia, prophylactic antibiotics
were administered intravenously.  A Foley catheter was
inserted, and the Mayfield-Keith thee-point skeletal fixation
system was applied to the patient's head.  The patient was
maintained in a rigid cervical collar while she was carefully
logrolled into the prone position onto the Wilson frame,
taking great care to pad all pressure points.  Her head was
affixed to the operating table in the neutral position, and
appropriate cervical lordosis was confirmed with a lateral
cervical radiograph.

The skin over the posterior cervical region and left
posterior iliac crest was then shave, and prepped and draped
in the usual sterile fashion.  A three-stage preparation was
used on the iliac crest consisting of alcohol followed by a
two-stage iodophor prep which was allowed to dry on the
patient's skin.

A four-stage prep was used in the posterior cervical region
which consisted of Chlorhexidine for the shaving followed by
alcohol which in turn was followed by a two-stage iodophor
prep which was allowed to dry on the patient's skin.

A linear vertical midline incision was marked out over the
posterior cervical region from the spinous process of C3 to
the spinous process of C7, as well as a vertical incision was
marked out over the left posterior iliac crest.  Each area
was infiltrated with 1 percent Xylocaine with 1:100,000
epinephrine.

Attention was first turned to harvesting the iliac crest bone
graft.  The skin was incised using a number Bard-Parker
blade, and hemostasis was obtained in the subcutaneous
tissues using bipolar cautery.  Monopolar cautery was used to
carry the incision down through the subcutaneous tissues to
the gluteal fascia.  The fascia was opened transversely over
the crest, and subperiosteal dissection was carried out on
the crest using monopolar cautery.

A talar retractor was placed to maintain exposure, and a
variety of straight and curved osteotomes, a Capner gouge,
and curets were used to harvest cortical cancellous bone
graft from the iliac crest.  Great care was taken to preserve
the integrity of the anterior wall of the crest, as well as
to not violate the sacroiliac joint medially.

After harvesting a sufficient quantity of bone, the wound was
copiously irrigated with antibiotic irrigation, and
meticulous hemostasis was achieved using bone wax.  All
excess bone wax was removed.

The wound was then reapproximated anatomically in layers over
a 10 French Hemovac drain using interrupted 0 Vicryl to
reapproximate the muscle and fascia.  Inverted interrupted 0
Vicryl was used in the deep subcutaneous layer.  Inverted
interrupted 3-0 Vicryls were used in the superficial
subcutaneous layer.  Staples were applied to the skin.

Following completion of this procedure, attention was turned
to the posterior cervical region.  The skin was incised using
a number 10 Bard-Parker blade, and hemostasis was obtained in
the subcutaneous tissues using bipolar cautery.  Monopolar
cautery was used to carry the incision down through the
subcutaneous tissues and avascular ligamentum nuchae to the
dorsal arches from C3-C7 inclusive.

Subperiosteal dissection was carried out over the lateral
aspect of the lateral masses from C3-C7.  Self-retaining
retractors were placed to maintain the exposure, and the
intraoperative lateral cervical radiograph was obtained to
confirm the appropriate operative levels.

Next attention was turned to performing the spinal
stabilization with segmental spinal instrumentation.  The C3-
C4, C4-5, C5-6, and C6-7 fact joints were denuded of
articular cartilage using a small curet, and then the high-
speed bur was used to decorticate the interior of each joint.
The lateral aspects of the lateral masses from C3-7 inclusive
were decorticated bilaterally.

Next holes were drilled in each lateral mass from C3-7 in the
following fashion.  A small perforation in the dorsal
cortical bone of each lateral mass was made 1 mm medial to
the midpoint using a high-speed bur.  Next the 3.5 mm drill
bit was used to drill screw holes in each lateral mass using
standard trajectories for lateral mass screw fixation.  Each
hole was then carefully tacked using the 3.5 mm cancellous
bone tap, and then 3.5 mm cancellous mini-polyaxial screws
were inserted into each drilled hole.

After insertion of the screws bilaterally, great care was
taken to meticulously place the previously harvested
cancellous bone from the iliac crest into each lateral mass
at C3-4, C4-5, C5-6, and C6-7.  Next appropriate lengths of
3.0 mm diameter titanium rods were selected and contoured
into the appropriate degree of cervical lordosis.  Rods were
inserted between screws at midline, and the top tightening
set screws were inserted, and final tightening was
accomplished using the torque wrenching counter-torque
device.

After doing so, the posterior elements from C3-7 were
extensively decorticated including the spinous processes and
lamina bilaterally, and the previously harvested cortical
cancellous bone including cortical cancellous strips were
placed along the entire fusion surface and along the lateral
aspects of the lateral masses bilaterally.

The wound was copiously irrigated with antibiotic irrigation.
Meticulous hemostasis was achieved, and the wound was then
reapproximated anatomically in layers over a 15 French
Hemovac drain using interrupted 0 Vicryl to reapproximate the
muscle and fascia.  Inverted, interrupted 0 Vicryl was used
in the deep subcutaneous layer.  Inverted, interrupted 3-0
Vicryls were used in the superficial subcutaneous layer.
Staples and a dry sterile dressing were applied to the skin.

Following surgery, all needle, sponge, instrument, and
Cottonoid counts were correct times three.  There were no
intraoperative complications.

Following the operation, the Aspen collar was affixed to the
patient's neck, and she was carefully logrolled back into the
supine position where the Mayfield apparatus was removed.
The patient was then extubated and taken to the PACU in
satisfactory condition having tolerated the procedure well.


                        Simcha J. Weller, MD 14127
I certify that I was present in compliance with HCFA regulations.
 

Dictated By:  B. Zerris, MD

MEDQUIST36
D:  10/24/2004 10:20:20
T:  10/25/2004 09:18:20
Job#:  526889

  
 
BETH    ISRAEL    DEACONESS    MEDICAL CENTER
PATIENT DISCHARGE PLAN
PATIENT INFORMATION
Patient Name Susan Sample 
MRN#: 7654321
Case#: 1234587 9
DOB: SEP 16,1977
Patient Status: Admitted OCT 01,2004
Reason for Admission: CERVICAL INSTABILITY/SDA
Discharged to: Home 
Primary Physician: Dr. PLYMOUTH OB-GYN ASSOCIATES 508-746-1434
Attending Physician: Dr. SIMCHA J. WELLER 617-632-9912
DISCHARGE MEDICATIONS
1.Cyclobenzaprine HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed.
   Disp:*60 Tablet(s)* Refills:*0*
2.Alprazolam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed.
   Disp:*30 Tablet(s)* Refills:*0*
3.Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Alternate with hydromorphone prn.
   Disp:*30 Tablet(s)* Refills:*0*
4.Hydromorphone HCl 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed: Alternate with hydrocodone prn.
   Disp:*30 Tablet(s)* Refills:*0*
DISCHARGE INSTRUCTIONS
Wear hard collar at all times. Keep staples dry. Call for fever or any signs of infection - redness, swelling, drainage from wound.
FINAL DIAGNOSIS
cervical instability
RECOMMENDED FOLLOW-UP
Follow up with Dr. Weller for staple removal and xrays week of October 11th. Call for appointment 617-632-9912.
MAJOR SURGICAL OR INVASIVE PROCEDURES
Posterior cervical fusion C3-7
CONDITION AT DISCHARGE
Neurlogically stable
Discharge: Ordered by MCCOLL,PAMELA, PA on 10/04/04 @ 0804

  
 

Disch Sum  10/04/2004  Dr.  Simcha J. Weller

DISCHARGE SUMMARY
 
WELLER,SIMCHA J.
Signed Electronically by WELLER,SINCHA on MON NOV 22,2004 5:34 PM
 
Name:  Sample, Susan             Unit No:  7654321

Admission Date: 10/01/2004        Discharge Date: 10/04/2004

Date of Birth:  10/17/1977        Sex:  F

Service:  NSU


HISTORY OF PRESENT ILLNESS:  The patient is a 26-year-old
woman who was involved in a motor vehicle accident on
07/24/04.  She was initially treated at Jordan Hospital and
then transferred to Beth Israel Deaconess Medical Center,
where she was an inpatient for four days.  She was placed in
a Miami J collar and was discharged home with a diagnosis of
cervical ligamentous injury.  In followup, she continued to
complain of neck discomfort.  She has had muscle spasms
secondary to the collar.  She also felt she had some left
shoulder spasms secondary to the collar.  She complained of
left arm pain in the upper arm.  She denied any paresthesias.
She denied bowel or bladder dysfunction except for
constipation secondary to Dilaudid.

PAST MEDICAL HISTORY:  Unremarkable.

PAST SURGICAL HISTORY:  Tonsillectomy.

MEDICATIONS:  Dilaudid 4 mg b.i.d. p.r.n.

SOCIAL HISTORY:  She was a smoker of one-pack per day.  She
was out of work even prior to the MVA.

ALLERGIES:  She has no known drug allergies.

PHYSICAL EXAMINATION:  At the time of admission, her height
was 5 feet 6 inches, weight was 149 pounds, blood pressure
was 96/72, heart rate was 96, O2 saturation was 98 percent.
She was well developed, well nourished, and in no apparent
distress.  Heart showed normal S1 and S2, regular rate and
rhythm; no murmurs, rubs, or gallops.  Abdomen was soft,
nontender, nondistended, no masses.  She was normocephalic.
Pupils were equal, round, and reactive to light.  She was
nonicteric.  Lungs were clear to auscultation.  On her exam,
upper extremities were 5/5 bilaterally.  Lower extremities
were also 5/5 bilaterally.  Deep tendon reflexes were 1 plus
bilaterally at brachioradialis, biceps, triceps; 2 plus at
the knees and ankles.  She had no Hoffman's, no clonus sign.

LABORATORY DATA:  She had had an x-ray that showed
anterolisthesis at C3 and C4 with mild C4-C5 angulation with
widening of the interspinous space.  MRI done on 08/30/04
showed probable dorsal ligamentous injury, especially at C6-
C7.

HOSPITAL COURSE:  She was admitted and brought to the
operating room on 10/01/04, where under general anesthesia, a
C3 through C7 posterior fusion was performed by Dr. Weller.
She tolerated the procedure well.  Estimated blood loss was
50 cc.  She did have a Hemovac drain placed intraoperatively.
Postoperatively, her vital signs were stable.  She was
afebrile.  She did complain of a moderate amount of
incisional pain.  Her strength was full in the upper and
lower extremities.  Sensation was intact bilaterally.  She
was monitored in the PACU and then transferred to the floor.
Her activity was increased.  Her diet was also increased.
Her Hemovac drainage was monitored and was removed on
10/03/04.  The staples from the incision were clean, dry, and
intact.  The patient continued to wear her Miami J collar.
She will be discharged to home on 10/04/04.

DISCHARGE MEDICATIONS:  Her medications at the time of
discharge are,
1. Cyclobenzaprine 10 mg 1 p.o. t.i.d. p.r.n.
2. Alprazolam 1 mg tablets 1 p.o. b.i.d. p.r.n.
3. Hydrocodone with Tylenol 5/500 mg 1 to 2 tablets p.o. q.4
   h. to alternate with hydromorphone 4 mg tablets 1 tablet
   p.o. q.4 h.


DISCHARGE INSTRUCTIONS:  She was advised to continue to wear
the hard collar at all times.  She was advised to keep the
staples dry.  She was advised to call for any fevers or signs
of infection.  She will make an appointment to followup with
Dr. Weller for staple removal and x-rays in the week of
10/11/04.


DIAGNOSIS:  Cervical instability.



                        Simcha J. Weller, MD 14127

Dictated By:  Joyce Scally, P.A.


  
 

Telephone  10/06/2004  Dr. MARIANNE NP CARDELLO  Service: Neurosurgery

Date: 10/06/04
Signed by MARIANNE CARDELLO, NP on 10/06/04  Affiliation: HMFP
 
Ms. Sample called the office yesterday and today. She wanted to
know how to schedule her pain meds. she was discharged home with
alternating doses of Dilaudid and Vicodin. She reports taking
Dilaudid q4h, with Vicodin 2 tabs, 2 hours later, then Dilaudid 2
hours later. I advised her that she is taking too high of a dose
of acetaminophen (ingredient in the Vicodin) and the max dose of
Vicodin is 8 tabs per day.(500 mg acetaminophen in each tablet).
I advised her to take the Dilaudid instead of the Vicodin, since
that seems to provide better relief of her neck pain. She also
reports muscle spasm in her shoulders, and is taking Flexeril 10
mg q8h, with minimal relief of her spasm. She reports difficulty
sleeping and is awake "all night". She reports difficulty
urinating since taking Flexeril. She is voiding voluntarily, but
needs to "push" at times. I told her that this may be due to
the Flexeril, as it is a muscle relaxant, and to try a different
muscle relaxant. I called in Soma 350 mg po prn:tid, disp #60, no
refills, instead.She reports that she has not had a bowel
movement since surgery, and that he abdomen feels bloated and
firm, I advised her to take Mg Citrate 1/2 bottle and Colace
(which she is already taking). She has tried MOM without effect
as of yet. She continues smoking cigarettes, although she was
advised to stop so as to not interfere with the fusion. I mailed
her a prescription for Dilaudid 2 mg tabs, take 1-2 tabs prn:q4-6
hours, #60 tabs, and she will f/u in the office on 10/12/04 for
staple removal. I will discuss this with Dr. Weller today.

  
 

Telephone  10/18/2004  Dr. MARIANNE NP CARDELLO  Service: Neurosurgery

Date: 10/18/04
Signed by MARIANNE CARDELLO, NP on 10/18/04  Affiliation: HMFP
 
Ms. Sample called the office today reporting that she has some
bloody dng on her incision area under the steristrips. I advised
her to have her mother remove the steristrips and assess the
incision. She called back to say that there is a "hole" or "sore"
with purulent dng, I discussed this with Dr. Weller, who ordered
Levaquin 500 mg po QD, x 7 days, and Keflex 500 mg po QID, x
7 days. I asked her to come into the office tomorrow to be
evaluated. She is trying to get transportation here and will let
me know. I told her that she could come at any time tomorrow. She
will go for xrays of the cervical spine first. I asked if she had
a fever, she is not sure, she thinks she may feel like she has
had a fever lately. I told her that if her temp is >100.5, she
should go to the local ER.

  
 

Telephone  10/25/2004  Dr. MARIANNE NP CARDELLO  Service: Neurosurgery

Date: 10/25/04
Signed by MARIANNE CARDELLO, NP on 10/25/04  Affiliation: HMFP
 
Ms. Sample called the office today requesting script for
Vicodin. She is currently taking Dilaudid 2 mg prn:bid and
Vicodin 1-2 tab prn:bid. I advised her to wean off the Dilaudid
and take vicodin instead and also to wean off the Vicodin. She
c/o shoulder discomfort, presumably d/t the Aspen collar, which
she wears 24 hours/day. She also c/o discomfort at the iliac
crest bone graft site and numbness in her middle lower back since
the surgery. She is also taking Soma prn:tid with good relief.
She has had difficulty sleeping and sleeps only a few hours per
night. She has been taking Ambien 5 mg without effect. I advised
her to increase the Ambien to 10 mg at hs. I have called in
Vicodin 1-2 tab po prn:q4-6 hours, max 8 tabs/24 hours, disp #60,
no refills, and Ambien 5 mg, 1-2 tab, po prn:hs, #30 tabs, one
refill, to her pharmacy. 123-555-1212. She will f/u next week in
the office.

  
 

Telephone  03/28/2005  Dr. MARIANNE NP CARDELLO  Service: Neurosurgery

Date: 03/28/05
Signed by MARIANNE CARDELLO, NP on 03/28/05  Affiliation: HMFP
 
Ms. Sample called the office today requesting refill on Ultram
to last until she sees Dr. Weller on 4/5/05. I called in Ultram
50 mg 1-2 tablets prn: q4-6 hours, max 8 tabs per 24 hours, #40,
no refills to CVS pharmacy, 123-555-1212. She will f/u next week.

  
 

Letter  08/30/2005  Dr. EKKEHARD KASPER  Service: Neurosurgery

 
--Title: Dr. Corsini
August 30, 2005


Juliann Corsini, MD
Plymouth Ob-Gyn Associates
110 Long Pond Rd
Plymouth, MA  02360

RE: Susan Sample (BID# 765-43-21, DOB 10/17/1977)

Dear Dr. Corsini:

This is a brief office note on patient Susan Sample who saw me
in the office today in the presence of her daughter.  As you may
recall, she is a 27-year old female who was admitted to BIDMC in
January 2005 after an accident.  She underwent a cervical
posterior instrumented fusion at C3 to C7 by Dr. Simcha Weller.
The patient reported that she had much improved afterwards.  She
developed pain again approximately 2 months after.  The pain
radiates to her left arm.  She also describes intermittent
periods of numbness in both fingertips associated with tingling.
Tingling is distributed in all fingertips, bilaterally in the
hands, and accompanied by subjective discomfort.  She also has
trouble lifting.  The patient is otherwise stable after surgery.
She is not taking any medications except occasional Ultram.  She
has no known drug allergies.  She works as a housewife.  She has
a history of smoking approximately 1 pack a day for the last 10
years.  She drinks socially only.  Her past medical history is
otherwise unremarkable.  She has a negative review of system.

On examination she is awake, alert and oriented.  She is in no
acute distress.  She has normal speech and recall.  She has a
motor exam that is remarkable only for minimal decreased grip in
the right side, otherwise she has full strength and normal bulk
and tone.  Deep tendon reflexes are 2+ bilaterally.  Skin
sensation is normal bilaterally.

She had a repeat CT scan performed on 8/30/05.  The
formal read is not yet available.  To our eye on the
monitor, this shows an unremarkable post-operative
scan after a posterior instrumented fusion with
lateral mass plates.  The plates are well aligned.
The screws are in adequate position.  There is no sign of new
fracture, dislocation or increased ability in adjacent segments.

In summary, Susan Sample presented to our office after a
posterior cervical instrumented fusion by Dr. Weller in early
2005.  She is doing well.  We think that her symptoms of
fingertip tingling are not related to her C-spine surgery.  We
recommended to her to undergo replacement of thiamine folate as
well as calcium and follow up with her PCP.  Should her symptoms
get progressively worse or if she develops any new symptoms, we
encouraged her to call back and be re-evaluated.

Sincerely,



Ekkehard Kasper, MD

EK:pt

ENZYMES & BILIRUBIN	ALT	AST	LD(LDH)	CK(CPK)	AlkPhos	Amylase	TotBili	DirBili
24 Jul 2004 10:40AM						42
SPECIMEN MODERATELY HEMOLYZED

CHEMISTRY	Calcium	Phos	Mg
02 Oct 2004 06:45AM	9.4	3.6	1.9
01 Oct 2004 11:54AM	9.3	2.6*	1.7
27 Jul 2004 05:20AM	9.2	3.4	1.7
26 Jul 2004 03:09AM	8.5	3.0	1.8
25 Jul 2004 02:19AM	8.9	2.9	1.5*

Hematology
COMPLETE BLOOD COUNT	WBC	RBC	Hgb	Hct	MCV	MCH	MCHC	RDW	Plt Ct
02 Oct 2004 06:45AM	8.3	3.55*	11.5*	33.4*	94	32.3*	34.3	12.4	287
01 Oct 2004 11:54AM	10.8#	3.96*	12.5	36.5	92	31.6	34.4	12.1	336
27 Sep 2004 11:45AM	6.1	4.09*	13.0	38.3	94	31.9	34.0	12.1	372
26 Jul 2004 03:09AM	7.7	3.66*	12.2	35.2*	96	33.4*	34.8	11.8	269
25 Jul 2004 02:19AM	9.0	3.75*	12.6	35.6*	95	33.5*	35.2*	12.4	249
24 Jul 2004 10:40AM	15.0*	4.11*	13.6	39.7	96	33.1*	34.3	12.1	357

Chemistry
RENAL & GLUCOSE	Glucose	UreaN	Creat	Na	K	Cl	HCO3	AnGap
02 Oct 2004 06:45AM	83	8	0.5	141	4.3	106	26	13
01 Oct 2004 11:54AM	141*	9	0.6	144	3.8	111*	22	15
27 Sep 2004 11:45AM	78	12	0.9	140	3.9	102	25	17
27 Jul 2004 05:20AM	82	6	0.5	136	4.5		20*
26 Jul 2004 03:09AM	94	4*	0.5	138	3.7	103	25	14
25 Jul 2004 02:19AM	99	4*	0.5	138	3.6	104	25	13
24 Jul 2004 10:40AM		7	0.7
SPECIMEN MODERATELY HEMOLYZED

Blood Gas
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY	Glucose	Lactate	Na	K	Cl	calHCO3
24 Jul 2004 10:48AM	103	2.3*	148	4.4	109	27

Hematology
GENERAL URINE INFORMATION	Type	Color	Appear	Sp Grav
24 Jul 2004 10:40AM		Straw	Clear	1.009

Chemistry
URINE CHEMISTRY	Hours
24 Jul 2004 10:40AM	RANDOM
24 Jul 2004 10:40AM	RANDOM

PATIENT INFORMATION
Patient Name	Susan Sample
MRN#:	7654321
Case#:	1234567 8
DOB:	SEP 16,1977
Patient Status:	Admitted JUL 24,2004
Reason for Admission:	S/P MVC;C-1 FRACTURE
Discharged to:	Home
Attending Physician:	Dr. NICHOLAS E. TAWA	617-667-2084