Charles Tew Research Paper

CARDIAC IMAGING
Teresa Mann
19372634
1196782
Charles Tew, MD
BD: 10 November 60
2 January — —

HISTORY
CHEST PAIN.

CARDIAC IMAGING (Dobutrex/Myoview)
RESTING IMAGES WERE OBTAINED AFTER THE INJECTION OF 10 MCI OF MYOVIEW. SUBSEQUENTLY, THE PATIENT HAD DOBUTREX INFUSION ACCORDING TO OUR STANDARD PROTOCOL, REACHING A MAXIMUM HEART RATE ,WITH THE HELP OF 0.5 MG OF ATROPINE IV, OF 144 BPM WITH A TARGET HEART RATE OF 135 BPM. THERE WAS A RESTING LEFT BUNDLE BRANCH BLOCK WITH NO ISCHEMIC CHANGE FROM BASELINE WITH DOBUTREX AS MONITORED BY DR. RABB, WHO MONITORED THE TEST. POST STRESS, THE PATIENT DEVELOPED CHEST DISCOMFORT THAT WAS RELIEVED BY NITROGLYCERIN AND A SIGNIFICANT DOSAGE OF NUBAIN—10 MG IV. SHE HAD NO EKG CHANGES BUT DID START WITH A RESTING LEFT BUNDLE BRANCH BLOCK. THE STRESS PORTION OF THE TEST WAS MONITORED BY DR. RABB.

FINDINGS
COMPARISON OF THE REST AND STRESS IMAGES IN THE STANDARD CORONAL, TRANSVERSE, AND SAGITTAL VIEWS SHOWS A WORRISOME FOCUS OF INFEROLATERAL ATTENUATION, SUGGESTING REPERFUSION OR ISCHEMIA AND SOME DISTAL ANTERIOR WALL BLUSH, WHICH COULD BE
ACCOUNTED FOR ON THE BASIS OF BODY SIZE, BUT IS ALSO SUSPICIOUS FOR REPERFUSION OR ISCHEMIA.

IMPRESSION
ABNORMAL PERFUSION STUDY SUGGESTING INFEROLATERAL AND ANTEROAPICAL REPERFUSION OF ISCHEMIA.

Charles Tew, MD
Radiologist

CT:RE

D:1/02/ — —
T:1/02/ — —

OPERATIVE REPORT
JENKINS, AMANDA
2967898
Hal Russo, MD
June 29, 20 — —

PREOPERATIVE DIAGNOSIS
MEDICALLY REFRACTORY SEIZURES.

POSTOPERATIVE DIAGNOSIS
MEDICALLY REFRACTORY SEIZURES.

OPERATION
INSERTION OF LEFT VAGAL NERVE STIMULATOR.

SURGEON: Hal Russo, MD

1ST ASSISTANT: Wendy Quimby, MD

2ND ASSISTANT: Justin Dunn, MD

ANESTHESIA
GENERAL ENDOTRACHEAL.

HISTORY
THIS IS A SIX-YEAR-OLD, WHITE FEMALE WHO HAS HAD MEDICALLY REFRACTORY SEIZURES FOR MOST OF HER LIFE. SHE ARRIVES HERE AFTER FAILING MULTIPLE MEDICAL THERAPIES FOR INSERTION OF A VAGAL NERVE STIMULATOR IN THE PALLIATIVE TREATMENT OF HER SEIZURES.

PROCEDURE
THE PATIENT WAS BROUGHT TO THE OPERATING ROOM, INTUBATED, AND PLACED IN SUPINE POSITION WITH HER HEAD TURNED TO THE LEFT AND A SHOULDER ROLL PLACED UNDER THE LEFT SHOULDER. THE ANTERIOR PORTION OF HER NECK AND LEFT PECTORAL AND AXILLARY AREA WERE PREPARED WITH IODINE SOLUTION AND DRAPED IN A STERILE FASHION. FIRST, A HORIZONTAL INCISION WAS MADE IN THE MIDPORTION OF THE NECK FROM THE MIDLINE EXTENDING TO THE LEFT ANTERIOR BORDER OF THE STERNOCLEIDOMASTOID MUSCLE, AND DISSECTION CARRIED DOWN THROUGH THE PLATYSMA, EXPOSING THE STERNOCLEIDOMASTOID AND PARATRACHEAL FASCIA. THEN THIS FASCIAL PLANE WAS OPENED AND THIS EVENTUALLY EXPOSED THE CAROTID SHEATH. THE CAROTID SHEATH WAS INCISED SHARPLY, REVEALING THE INTERNAL JUGULAR VEIN SUPERFICIALLY, THE CAROTID ARTERY MORE MEDIALLY, AND THE VAGUS NERVE IN THE POSTEROLATERAL PART OF THE SHEATH. A 3.0-CM SEGMENT OF VAGUS NERVE WAS ISOLATED FROM ITS CONNECTIVE TISSUE, AND THE BIPOLAR ELECTRODE ARRAY OF THE STIMULATOR (CYBERONICS MODEL 101) WAS INSERTED ON THE NERVE, AS ACCORDING TO THE MANUFACTURER. THEN A DOUBLE STRAIN RELIEF LOOP WAS CREATED WITH THE TIE-DOWNS PROVIDED BY THE MANUFACTURER, THE ASCENDING LOOP ATTACHED TO THE FASCIA OF THE MEDIAL STERNOCLEIDOMASTOID, AND THE DESCENDING LOOP ATTACHED TO THE EXTERNAL FASCIA OF THE STERNOCLEIDOMASTOID.

Attention was then directed to the lateral pectoral margin on the left where a linear incision was made along this margin.
Dissection was carried down beneath the major pectoralis muscle and a pocket created deep to this. This extended medially and up toward the clavicle. Bleeding was controlled using cautery. A pocket was created large enough to contain the internal pulse generator. Then a tunneler was used to tunnel the leads from the neck down to the pocket over the clavicle on the left. These leads were connected to the generator. The generator was tucked into this pocket and closure begun.
All wounds were copiously irrigated with normal saline. The fascia was closed using interrupted 3–0 Vicryl sutures followed by a running 4–0 subcuticular stitch for the skin incisions. Dermabond was applied over both incisions and a sterile dressing.

ESTIMATED BLOOD
LOSS
LESS THAN 30 CC. ALL SPONGE COUNTS AND NEEDLE COUNTS WERE CORRECT. I WAS SCRUBBED AND PRESENT FOR ALL CRITICAL PORTIONS OF THIS PROCEDURE.

(continued)
OPERATIVE REPORT
PATIENT NAME: JENKINS, AMANDA
Hospital No.: 2967898
June 29, 20 — —
Page 2

PROGRAMMING PARAMETERS
MAGNET CURRENT ON 30 SECONDS/OFF 5 MINUTES; AMPLITUDE 0.25 MILLIAMPS, 60 HZ. MAGNET CURRENT 60 SECONDS ON 0.25 MILLISECONDS.

Electronically Signed by
Hal Russo, MD

D: 6/29/ — —
T: 6/30/ — —