C10009534 / invoice 10000

Remi's results are back - complete margins, grade 1! Great news!

MST 790 days for this subtype, so hopefully given the early diagnosis he still has a long time to live.

Remi is going well, breathing well. Wound is looking great. Finished ABs last night. Still on panadol and gabapentin at home - given it when his patch was removed.
Drinking more than usual?
Recommended o to take in for bloods if increased drinking continues.
Still has his limp that he presented for initially - consider cortisone injection into the shoulder - but not until at least 3 weeks post thoractomy.

He is otherwise going really well, O has decided to cancel her oncology appointment as she is not likely to pursue chemo at this stage.

CLINICIAN: Kirsten Deruddere
PRESENTING COMPLAINT: Lung mass - right cranial lung lobe
HISTORY:
* See history. Here for thoracotomy today for lung mass removal.
* Remi has been well, we discussed the surgical plan for today.
CLINICAL FINDINGS: Remi is BAR in consult. He is panting but quite anxious in here.
DIAGNOSTIC TESTS: 
* Review of Remi's CT - confirmed side is the right side.
DIAGNOSIS: Right cranial lung lobe mass
SURGERY: A right sided 4th intercostal thoracotomy was performed. A skin incision was made caudal to the scapula on the right side. The latisimus dorsi was incised exposing the serratus ventralis muscles. The intercostal muscles were incised and the chest cavity entered. An intercostal nerve block using 0.5% bupivicaine was administered. There was a lung mass at the periphery of the right cranial lobe which was slightly adherent to the mediastinum. These adhesions were gently broken down and the lung mass removed via partial lung lobectomy with a TA30V3 stapling device. The wound was closed using large gauge single interrupted intercostal sutures, multiple muscular and sub cut closures and intradermal and skin sutures to finish. A Jackson-Pratt closed suction drain was placed to drain the pleural space.
PLAN: 
* Suture removal in 10-14 days. E-collar until then.
* Continue panadol and gabapentin at home. Cephalexin dispensed. Fentanyl patch placed.
* JP drain to be removed when no longer productive, hopefully lunch time tomorrow for discharge tomorrow afternoon if all goes well.
* Histo results should be through next week - I will call with the results when available, a copy will automatically be sent to Fiona as well.
PROGNOSIS: Pending grading of the mass. I gave a MST of 6-18 months depending on the grade if this is a pulmonary carcinoma. Complications discussed include: GA risk, infection, wound complications, recurrence, spread, incomplete resection, bleeding, pneumo/haemo-thorax, seroma.


Post-op PLAN:
MEDICATIONS: cephalexin 600mg - please give one tablet BID for 5 days, continue gabapentin, continue paracetamol.
SUTURES: Skin suture
BANDAGE/CAST: prima pore placed over wound
REST: 3 weeks strict rest
PATHOLOGY: vetnostics - histopathology tissue x1
REVISIT: 2 week revisit
OTHER:

NURSE: Sc
ASSISTANT: DD
SURGERY / PROCEDURE: R thoracotomy
PREMED: Medetomidine 0.005mg/kg & Methadone 0.3mg/kg @ 1240
ANAESTHETIC: Alfaxan 0.5mg/kg IV @1250 then maintained on Isoflurane / Oxygen
FLUIDS: Hartmanns 5ml/kg/hr @1240
PERIOPERATIVE ANALGESIA:
      1. Methadone 0.2mg/kg post premedication once fentanyl patch is active
      2. LK CRI
      3. F CRI
FENTANYL PATCH: Durogesic 50 ug placed @1200     
PERIOPERATIVE ANTIBIOTICS: Cephazolin 22mg/kg @1310 then q90mins if surgery
PERIOPERATIVE DRUGS:
IMPLANTS: JP drain to be removed tomorrow
NOTES: 
OTHER: patient placed on ventilator as per procedure protocol.