My Latest Cancer Battle

 Hey everyone,

Here at Prince Bay Farm in NC, it's Nick Prince, with some news to share.

As many of you know, I host volunteers and guests from all over the world. https://www.facebook.com/princebayfarm/

The farm has hosted over 500 folks from 52 countries in the last eleven years. They are taught about sustainability, organic farming practices, self-sufficiency & many life lessons. I also share knowledge, culture, history, food and my home with them. I'm full of stories--childhood, farm life, university years, military service, government work, hippie days, traveling tales, my kids--Justin, Dominique, Nicholas & Oliver, family, friends, history, and all the stuff crammed in my head--all shared with my guests. I've never met a question I didn't like and have been referred to as 'Nikipedia."

In communicating with the wonderful folks who have visited the farm, I noticed that my voice was becoming strained too often. In the spring of 2016, I decided to see the doctor. As anyone who knows me, the diagnosis was that I talk too much--a bowed vocal cord from over-use.

But two months later, during a follow-up visit, the doctor noticed a tiny spot on my vocal cords. A biopsy revealed it to be a stage one supraglottic squamous cell cancer. Doc said we were lucky to have found it so soon. I also lost my eldest son, Justin, the week before I recieved the biopsy results. My doctor said the sarcoma would be easy to treat with seven weeks of radiation treatments.

It appeared that the radiation treatments were a success. But the following year brought constant pain and many visits to the doctor. A second and third opinion was sought. Another biopsy was performed in November 2017. The biopsy results showed the sarcoma was back!

A total laryngectomy was performed on 2 January 2018. An esophagocutaneous fistula developed a short time after the laryngectomy. The tissues failed to heal due to the changes caused by the radiation therapy. The fistula necessitated a pectoral flap repair which restricted the use of my left arm.

I learned to speak again! First, I used an electrolarynx, sounding a lot like Darth Vader. Then, I mastered using a vocal prosthesis and now speak solely with it. I talk almost as much as I did before the laryngectomy. And I've continued to host guests and teaching as before.

Learning to live as a laryngectomee was challenging. And I mastered it! There were many side effects from the radiation treatments that I learned to live with.

In late summer last year, I noticed a burning in my throat, similar to acid reflux. At first, I was told that it was reflux. This diagnosis didn't seem right, as I've dealt with reflux for many years now. Being persistent, I finally got my care team to order an endoscopy of my throat.

My speech pathologist found an abnormal growth on the base of my tongue, and the C-word was mentioned. I received a referral for a biopsy. The biopsy revealed I had a new oropharyngeal squamous cell sarcoma!

Surgery in November: margins not clear after a one-hour surgery to remove the sarcoma. My surgeon was leaving MUSC for a new hospital. Scheduling another procedure for the excision of the remaining sarcoma was his first response.

The tumor board recommended radiotherapy, immunotherapy, and chemotherapy, instead of additional surgery. Consultation with the hospital patient advocate resulted in surgery being scheduled to remove remnants of the sarcoma.

Surgery in February: complete removal of sarcoma, all margins clear.

March brought a diagnostic blood test whose purpose was to detect the presence of cancer DNA. The test was positive. CT scans were ordered.

A new sarcoma was found in the exact location as the previous one. It had grown to nearly the same size as before in under two months.

Now I am looking at another surgery, immunotherapy, and another round of radiation.

I have also applied to participate in a clinical trial to treat my cancer with cryogenic therapy and several immunotherapy regimes. I'm told I am a good candidate for the program. The clinical trial is in Rochester, MI. If approved to participate, I would need to fly to Michigan and stay 2-4 days for the treatments. The clinical study should be in mid-May.

The expenses associated with the travel requirements needed for my various treatments are difficult for me to cover. They add up fast, especially with the cost of fuel today. Thus, I have launched this gofundme appeal to assist with expenses not covered by medical insurance.

Treatment regimes are still being planned, so I am still unclear on the scope of my medical care. Appointments with ENTs, surgeons, oncologists, radiation techs, dentists, palliative care, and immunotherapists are on schedule for the next few weeks.

Tests, scans, supplements, medications, and the list keeps growing, and the bills are piling up. I have my son, Nicholas, and a few volunteers here to keep everything on the farm rolling smoothly, as my activities have been severely restricted due to treatments.

All donations will be greatly appreciated!

Received a date for my surgery date.
Sarcoma removal via neck dissection, with neck reconstruction using latissimus dorsi transfer, will occur on 16 May!
No worries as I have undergone two previous neck dissections. First one was for my laryngectomy.
Second one for the fistula repair using my left pectoralis major.
If you want a glimpse at representative surgeries similar to mine, here's some youtube videos showing the procedures!

A neck dissection: https://youtu.be/TdKQ22w70t0

A latissimus dorsi transfer: https://youtu.be/-9rB4Te67UY

A fistula repair using the pectoralis major: https://youtu.be/fsV6llOpZNg

DONATIONS:  

 PayPal:  paypal.me/princebayfarm

GoFundMe:  https://gofund.me/fff2bb44

Facebook: https://www.facebook.com/donate/415588877061174

Latest update on the medical front:

I had surgery on a oropharynx sarcoma in November. Prior to my surgery, I was notified by letter that my surgeon was leaving the Wellin Head and Neck Cancer Clinic. I requested that another surgeon be assigned to my surgery. I was thinking ahead to the post operative check-ups and was concerned about someone different having to do the follow-up care. Would rather start fresh with someone new for entire surgical process. But my current surgeon was scheduled to do the procedure. All went well with the surgery and I spent a week in the hospital recovering.

At my post-op exam, a few days after I was discharged from the hospital, My surgeon told me that the margins of the tumor excision area were not clear. This meant that there were cancerous cells around the edges of where the sarcoma was removed. My surgeon said he was moving to the other hospital and was ready to schedule surgery there to remove the remnants "conveniently" left behind(imagine that). The surgeon was upset that I decided to stay with my care team at MUSC.

Side note: A rival hospital in N. Charleston started a cancer care center from scratch. They accomplished this by poaching a large pool of oncology talent from MUSC. My ENT was a part of this pool and was a ringleader in recruiting folks(on the down low) away from MUSC. Not just surgeons, but nurse practitioners, nurses, even receptionists and secretaries resigned and moved en masse to the rival hospital. It was discovered that there was also a clandestine side venture where the departing doctors spent several months copying their patient files as well(HIPAA violations anyone???). Part of the plan seemed to be taking MUSC patients along so there would be a readymade client base for the new cancer center.

Met my new ENT surgeon in December. Young, fresh out of extensive ENT specialty residencies, Dr. Mady was a new hire at MUSC due to the aforementioned exodus. I checked out her credentials(stellar) prior to our appointment and was highly impressed. I was extremely confident in her expertise as a surgeon. The appointment was the most thorough exam I had ever had at the Wellin clinic. After the exam, she said that she would present my case to the Tumor Board. The Tumor Board consists of oncology surgeons, radiation specialists, chemo specialists, immunotherapy specialists, etc. from both the Wellin clinic and the Hollings Cancer Center. The Tumor Board heard my case and decided that I wasn't a candidate for surgery. Thus I needed radiation, chemo and immunotherapy(imagine that). Video meetings were scheduled with radiation and chemo/immunotherapy specialists for the afternoon of 23 December.

Now, first round of cancer(laryngeal) in 2016 led to seven weeks of radiation therapy. Side effects were horrid--seven weeks of hell(extreme fatigue, pain, lost of taste, weight loss, etc.) and over three months before things were almost back to normal. Was told cancer was eradicated. Radiation damage was severe as cancer was only masked. Following year was hell. Asymptomatic before treatments, full-blown throat cancer symptoms afterwards. Over a year later, damage receded enough that cancer could be seen again. Finally diagnosed as recurrence, it resulted in my laryngectomy in 2018. Still dealing with damage from that round of radiation. Major dental issues, radiation fibrosis, the fistula which led to the pectoral flap repair, radiation necrosis, lung nodule, and the list grows each year. Thus, I am not a fan of radiation, which would cause even more and greater damage to my neck structures.

Video meetings started with the radiation specialist. She discussed radiation options. Weeks of daily treatments as before, over a hour drive to the nearest clinic, along with a myriad of horrible side-effects, some possibly life-threatening. I said 'no'. Next meeting was with the chemo/immunotherapy specialist. His resident discussed treatment options with me. Interesting options, but only in conjunction with radiation therapy. He told me that without treatment, I had 1-3 years left to live. Did mention to both that surgery was offered by previous surgeon. Was told I should go to him to get it done. Cast a huge pall over the holiday. Merry fricking Christmas to me!

After the holiday weekend, I reached out to the patient advocate at MUSC as I have before. They had eliminated unnecessary delays in getting my initial surgery scheduled. Explained current situation, the decision of the Tumor Board, the treatment options as presented on 23 Dec, and the fact that my previous surgeon was ready to operate again. They waded into the hospital system for me.

Got a call from my surgeon. She went over the possible risks of surgery and difficulty accessing site. Also presented option of gamma knife treatment. Gamma knife is a megadose of radiation delivered in a tiny beam with surgical precision. I said I would consider the gamma knife is surgery was definitely ruled out. She agreed to do another laryngoscopy/biopsy. This was to access if I would be a candidate for TORS(Transoral Robotic Surgery). A MRI was done to check out the nonvisual extent of the sarcoma remnants. Last Friday, the laryngoscopy was done, officially a suspension microlaryngoscopy(google it, really a fascinating procedure). Afterward, when I read the surgical notes, I finally had a huge glimmer of hope. There I found this statement: Expected return to OR: Yes. Reason for return: further management of disease!!!

Yesterday, I got a call from MUSC. Surgery scheduled for 10 February!!! Yaaaaaaaaaaaaaaaaaaaaaaay!!

ml.

Oncologist ordered a routine blood test a few weeks after my 10 Feb. surgery.

Results came back showing cancer DNA in my blood.

CT scan yesterday showed another sarcoma in exactly the same place as before and almost the same size! Still only completely localized.

Meet with two ENT surgeons on 20 Apr. Oncologist yesterday said this surgery will be followed by a round of radiation and immunotherapy. Not sure about chem. Overall prognosis isn't that great. Keep me in your thoughts.

Once this is done, I want to do some international travel. If anyone has any frequent flyer miles they would like to donate to me, let me know. Not sure of how long I have to do bucket list things, but I do want to check off a few things.

ALBERGOTTI, MD at 5/16/2022  1:18 PM

Operative Note   Patient: Nicholas L Prince MRN: 001631137 Case: 1304494 Date of Birth: 7/10/1965 Age: 56 y.o. Sex: male   Date: 5/16/2022   Pre-Op Diagnosis: Oropharynx cancer [C10.9]   Post-Op Diagnosis: Post-Op Diagnosis Codes: * Oropharynx cancer [C10.9]   Providers/Role: Surgeon(s) and Role: William Greer Albergotti III, MD - Primary Alana Nicole Aylward, MD - Fellow Circulator: Breanna Lizzi, RN Scrub Person: Dawn Elizabeth Sloan; Garrett Parrilla, RN Circulator Orientee: Leah Swift, RN Resident: Joshua E. Fabie, MD: James Sullivan, MD Facilitator: Tomeka Jennings   Procedure: - Pharyngectomy and base of tongue resection requiring free flap reconstruction - Level Ia resection - Bilateral neck dissection; level IIa, IIb, III, and IV on the left; level IIa, III, IV on the right - Left submandibular gland excision   Anesthesia: general   Estimated Blood Loss: 200cc   Urine Output: None Recorded   Specimens: ID Type Source Tests Collected by Time Destination 1 : Left level 4 neck dissection Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 9:40 AM   2 : Level 1A neck dissection Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 10:12 AM   3 : pharyngectomy for diagnosis. short stitch base of tongue, long stitch inferior Tissue Pharynx ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:00 AM   4 : Left level 2A neck dissection Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:19 AM   5 : Left level 2B neck dissection Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:20 AM   6 : Left level 3 neck dissection Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:20 AM   7 : Deep base of tongue Tissue Tongue ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:23 AM   8 : Left superior deep margin Tissue Pharynx ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:25 AM   9 : right level 2A neck dissection Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:17 PM   10 : right level 3 neck dissection Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:18 PM   11 : right level 4 neck dissection Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:18 PM   12 : anterior margin #2 Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:43 PM   13 : left digastric margin Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:44 PM     Implants: * No implants in log *   Drains and Retained Items (Surgical): Enterostomy Tube 01/17/18 1220 other (see comments) feeding (Active) Enterostomy Tube 02/23/18 0000 PEG (percutaneous endoscopic gastrostomy) (Active) Naso/Oral Tube 02/10/22 1317 nasogastric;other (see comments) right nostril (Active)     Surgeon Evaluation of Wound Class: II. Clean-contaminated: Resp, GI, GU tracts entered, controlled and No unusual contamination   Complications: None   Findings: 1. Exophytic left base of tongue lesion crossing midline. 2. All final frozen sections negative for malignancy. Deep margin at anterior deep tongue base positive on first round which was re-resected and negative. 3. Base of tongue and pharyngeal defect measuring approximately 6 centimeters in length and 4 cm in width that spanned from base of tongue superiorly to the superior boarder of his prior pectoralis flap inferiorly and including cuff of lateral wall pharyngeal mucosa as margin.  The left submandibular gland and the superior aspect of the pectoralis flap were included in the specimen.  4. Scattered mildly enlarged lymph nodes 5. Preservation of all relevant neurovascular structures including marginal mandibular, great auricular, hypoglossal, lingual, spinal accessory, and vagus nerves.  The carotid system was explored on the right and a common lingual-facial artery trunk, superior thyroid, and thyrocervical arteries were identified. External jugular vein, internal jugular vein, common, and retromandibular vein were preserved for the reconstructive surgical team bilaterally.   INDICATIONS: Nicholas L Prince is a 56 y.o. male with a history of ypT3NxcM0 laryngeal SCCa s/p salvage laryngectomy in 1/2018, c/b a pharyngocutaneous fistula requiring L pec flap and pharyngoplasty, he then developed a second primary cT2N0M0 oropharyngeal p16+ SCCa and underwent transoral laser excision of the L BoT 11/2021 and re-resection 2/2022 via TORS w/ negative margins. 4/7/2022 NavDx and CT neck showed recurrent 2 cm mass in area of resection. The case was presented at multi-disciplinary tumor board and the recommendation was for surgical resection and reconstruction with pathology-directed adjuvant therapy.  Risks, benefits, and alternatives were explained to the patient and the patient elected to proceed with the aforementioned procedures.   DESCRIPTION OF PROCEDURE:  Nicholas L Prince was identified in the preoperative holding area by name and date of birth.  The consent was reviewed and site marking verified.  The patient was brought to the operating suite by the anesthesia team and an endotracheal tube was placed in his stoma without difficulty. The patient received Unasyn for perioperative antibiotic prophylaxis. SCDs were placed for perioperative venous thromboembolism prophylaxis. The patient's eyes were taped for perioperative ocular protection. A surgical time out was performed. The patient was prepped and draped for surgery.  The proposed neck incisions and tracheotomy site was marked.   The case commenced with a the left neck dissection. We made the incision through the neck skin and subcutaneous tissue down to the level of the platysma.  Subplatysmal flaps were elevated superiorly to the inferior border of the mandible and inferiorly past the omohyoid muscle.  Care was taken not to communicate the neck with the stoma site.  The external jugular vein and great auricular nerve was identified and preserved. The inferior border of the submandibular gland was identified and a fascial flap of submandibular gland fascia was elevated in a plane superior to the inferior border of the mandible to protect the marginal mandibular nerve. Starting at the apex of 1A at the mentum, we outlined the limits of the dissection bounded by the anterior belly of the digastric muscle laterally, the mylohyoid deep, and the hyoid bone inferiorly. All of the fibrofatty tissue within this region was removed and sent as neck dissection level 1A. The anterior belly of the digastric muscle was traced inferolaterally to its tendon.  The common facial vein was identified and traced distally to the submandibular gland.   The posterior belly of the digastric was traced posterior to the mastoid tip.  The posterior edge of the mylohyoid was identified and the mylohyoid muscle retracted anteriorly to expose the deep submandibular space. The submandibular duct was identified and ligated and the left submandibular gland was removed. The hypoglossal nerve was identified one fascial plane deeper and preserved.    We then continued with dissection level 2A, 2B, 3, and 4 on the left.  The fascia was unwrapped off of the SCM from mastoid tip superiorly to inferior to the omohyoid inferiorly.  Cranial nerve XI was identified and traced superiorly and it was found to course lateral to the internal jugular vein.  The limits of the neck dissection encompassing level 2B, 2A, and 3 were identified.  They consisted of the skull base superiorly, the posterior border of the SCM posteriorly, the cervical rootlets overlying the deep layer of deep cervical fascia as the deep border, the omohyoid muscle inferiorly, and the lateral aspect of the strap muscles anteriorly.  All of the fibrofatty tissue encompassed by these boundaries was removed.  The internal jugular vein, external jugular vein, carotid artery, hypoglossal nerve, spinal accessory nerve, and vagus nerve were identified and preserved. A 1mm hole developed in the left internal jugular vein in the location of a small vessel eminating posteriorly during dissection, this was oversewn with 6-0 prolene. The specimen was divided into levels 2A, 2b, 3, and 4 and sent for routine pathologic analysis. No overtly suspicious nodes were appreciated.     We then turned our attention to dissection of level 2a, 3, and 4 on the right. These levels were dissected in similar fashion to the left with preservation of all relevant neurovascular structures. We then dissected towards the base of tongue while palpating the tumor and made a pharyngotomy on the right. Mucosal cuts were extended circumferentially around the tumor and across the skin from the prior pectoralis flap inferiorly. The pectoralis flap was then divided inferiorly in the neck given that its superior portion abutted tumor and superiorly the specimen was released from the geniohyoid, mylohyoid, and digastric muscles. The specimen was passed off the table with the left submandibular gland with a short stitch marking the base of tongue and a long stitch inferiorly. Margins for frozen section were collected off the specimen and returned negative other the deep margin at the tongue base which was re-resected in multiple areas and returned negative. The wound was copiously irrigated.  No fluid suspicious for chyle was noted. Hemostasis was obtained with bipolar cautery. A valsalva was performed. No additional bleeding was noted.   We then commenced the exploration of the carotid artery system on the right. Using a McCabe dissector, the common lingual-facial trunk, superior thyroid artery, terminal external carotid, and thyrocervical trunk were identified, traced, and freed circumferentially.   This marked the conclusion of the ablative portion of the procedure.  The patient was turned over to Dr. Skoner's reconstruction team for the planned latissimus free flap reconstruction.    Complications: None   Expected Return to OR: No   Attestations: Dr. Albergotti was present and scrubbed for the key portions of the procedure and was otherwise immediately available   Joshua E. Fabie, MD Resident Physician   I was present and scrubbed for all critical aspects of this procedure and was immediately available for all non-critical portions and agree with the documentation above.

Brief Op Note by Judith M. Skoner, MD at 5/17/2022  3:35 AM

Brief Operative Note   Patient: Nicholas L Prince MRN: 001631137 Case: 1304494 Date of Birth: 7/10/1965 Age: 56 y.o. Sex: male   Date: 5/16/2022   Pre-Op Diagnosis: Oropharynx cancer [C10.9], RECURRENT; h/o larynx cancer; complex post-ablative defects; h/o HN XRT   Post-Op Diagnosis: Post-Op Diagnosis Codes: * Oropharynx cancer [C10.9], RECURRENT * Wound, open, pharynx, initial encounter [S11.20XA] * History of external beam radiation therapy [Z92.3] * History of cancer of larynx [Z85.21]   Providers/Role: Surgeon(s) and Role: Panel 1: * William Greer Albergotti III, MD - Primary * Alana Nicole Aylward, MD - Fellow Panel 2: * Judith M Skoner, MD - Primary * Julian D Amin, MD - Resident - Assisting Panel 3: * Edward Douglas Norcross, MD - Primary Circulator: Breanna Lizzi, RN; Michelle Simpson, RN Relief Circulator: Laura Michelle Holt, RN; Piscean Paterno, RN Scrub Person: Barbara J Baltimore; Dawn Elizabeth Sloan; Garrett Parrilla, RN Circulator Orientee: Leah Swift, RN Resident: Erick Yuen, MD; James Sullivan, MD; Joshua E. Fabie, MD; Mary Jordan, MD Facilitator: Tomeka Jennings   Procedures - RECONSTRUCTION/SKONER:   1. LEFT latissimus dorsi myocutaneous free tissue transplant with microvascular anastomoses (RIGHT superior thyroid artery, RIGHT facial vein) Procedure: FREE MUSCLE OR MYOCUTANEOUS FLAP W MICROVASCULAR ANASTOMOSIS CPT(R) Code: 15756 - PR FREE MUSC-SKIN FLAP W/MICROVASC ANAST   2. BACK donor site reconstruction (donor site size 15cm x 9cm) Procedure: ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM CPT(R) Code: 14301 - PR ADJ TISS XFER ANY AREA,30.1-60 SQCM 14302 - PR ADJ TISS XFER ANY AREA,EA ADD 30.0 SQCM   3. Pharyngoplasty/pharyngeal reconstruction with free tissue transplant (near-circumferential) Procedure: PHARYNGOPLASTY CPT(R) Code: 42950 - PR RECONSTRUCTION OF THROAT   4. RESTRATA (+mepitel) application over exposed latissimus muscle of free flap for anterior neck reconstruction (approx 300 cm2) Procedure: APPLICATION OF SKIN SUBSTITUTE GRAFT TO NECK,TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM;F CPT(R) Code: 15277 - PR SUB GRFT F/S/N/H/F/G/M/D >100CM       Anesthesia: general   Estimated Blood Loss: 250 mL   Urine Output: 2700 mL   Specimens: ID Type Source Tests Collected by Time Destination 1 : Left level 4 neck dissection Tissue Lymph Node ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 9:40 AM   2 : Level 1A neck dissection Tissue Lymph Node ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 10:12 AM   3 : pharyngectomy for diagnosis. short stitch base of tongue, long stitch inferior Tissue Pharynx ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:00 AM   4 : Left level 2A neck dissection Tissue Lymph Node ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:19 AM   5 : Left level 2B neck dissection Tissue Lymph Node ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:20 AM   6 : Left level 3 neck dissection Tissue Lymph Node ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:20 AM   7 : Deep base of tongue Tissue Tongue ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:23 AM   8 : Left superior deep margin Tissue Pharynx ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 11:25 AM   9 : right level 2A neck dissection Tissue Lymph Node ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:17 PM   10 : right level 3 neck dissection Tissue Lymph Node ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:18 PM   11 : right level 4 neck dissection Tissue Lymph Node ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:18 PM   12 : anterior margin #2 Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:43 PM   13 : left digastric margin Tissue Neck ROUTINE PATHOLOGY EXAM William Greer Albergotti III, MD 5/16/2022 12:44 PM       Implants: Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No. Used Action PROBE COK G21363 DP-SDP001 DOPPLER IMPLANTABLE - LOG1304494 Generic Implant PROBE COK G21363 DP-SDP001 DOPPLER IMPLANTABLE   COOK MEDICAL 01008270022136301725022810N186251 N/A 1 Implanted ENDURAGEN STRC 89225 3 X 8CM X 1.0MM COLLAGEN IMPLANTS - LOG1304494 Generic Implant ENDURAGEN STRC 89225 3 X 8CM X 1.0MM COLLAGEN IMPLANTS   STRYKER CRANIOMAXILLOFACIAL 107578117221202210004 N/A 1 Implanted COUPLER SVS GEM2755 SZ 3.5 - LOG1304494 Clip COUPLER SVS GEM2755 SZ 3.5   SYNOVIS MCA SP21C26-1519463 N/A 1 Implanted MATRIX ARA RWM1-4X5 WOUND RESTRATA 10CM X 12.5CM - LOG1304494 Generic Implant MATRIX ARA RWM1-4X5 WOUND RESTRATA 10CM X 12.5CM   ACERA SURGICAL 76404 N/A 1 Implanted   Drains and Retained Items (Surgical): Drain/Device Site 05/16/22 1716 Left upper;lateral back 10 Fr. Jackson- Pratt #1 (Active) General Output (mL) 5 05/17/22 0300 Drain/Device Site 05/16/22 1717 Left lateral back 10 Fr. Jackson- Pratt #2 (Active) General Output (mL) 25 05/17/22 0300 Drain/Device Site 05/17/22 0039 Left anterior neck 10 Fr. Bulb #3 (Active) General Output (mL) 10 05/17/22 0300 Drain/Device Site 05/17/22 0039 Left anterior neck 10 Fr. Bulb #4 (Active) General Output (mL) 5 05/17/22 0300 Drain/Device Site 05/17/22 0040 Right anterior neck 10 Fr. #5 (Active) General Output (mL) 15 05/17/22 0300 Enterostomy Tube 01/17/18 1220 other (see comments) feeding (Active) Enterostomy Tube 02/23/18 0000 PEG (percutaneous endoscopic gastrostomy) (Active) Naso/Oral Tube 02/10/22 1317 nasogastric;other (see comments) right nostril (Active)     Surgeon Evaluation of Wound Class: II. Clean-contaminated: Resp, GI, GU tracts entered, controlled and No unusual contamination   Complications: None   Findings: 1. DEFECT: near-circumferential pharyngeal defect from BOT (and up onto LEFT pharyngeal wall), down to and included a portion of the prior PECTORALIS FLAP NEO-PHARYNGEAL RECON. Length vertically of defect was approx 8cm. Near-circumferential pharynx defect except for approx 1cm strip posteriorly (widened at very top and very bottom of defect -- bilateral ND; R was Ib-IV, L was IIa -IV -- stoma was NOT RESECTED, this is same as preop and has pre-existing TEP prosthesis in place   2. VESSELS: LEFT -- L ejv good (but prior pec done on this side); NO TCA/V. L IJV was violated and defect sewn -- patent. Not great vessles RIGHT -- R ejv good; right facial veins good with branching distally. R superior thyroid artery short and tiny diameter but good pulse. R facial artery tortuous, good pulse proximally but not distally. R end-external carotid artery isolated but kept flowing     3. Flap start 1425, case end 2:30am to STICU   4. Skin paddle size 15cm x 9cm + lat mm   5. Ischemia start time 1654, END time 2345   6. 2 jps L neck, 1 R neck, 2 L back   7. #10 SALIVARY BYPASS TUBE sutured to tongue with 0-silk x2   8. Bivona hyperflex #7 trach tube   9. TDA to RIGHT superior thyroid artery end to end 9-0 nylon running 10. TDV to RIGHT facial vein (coming right off IJV) end to end with 3.5mm coupler   11. MAP GOAL >80; keep head extended and turned to LEFT   12. LOVENOX 30mg SQ for routine dvt prophylaxis given at 23:00 x1   14. PEDICLE UNDER RESTRATA/MEPITEL-- LOCATION MARKED BY one 6-0 prolene ( *blue)   15. VERY loose doppler around vein of flap   16. PROXIMAL lat mm (with tendon) at RIGHT side of neck, tucked around pedicle; more distal lat at LEFT side of neck     Expected Return to OR: Yes. Reason for return: complex case in multiply operated, radiated patient, high risk for return to OR   Attestations: I was present for all critical portions of the case and more.   #011159 dictation     Signed: Judith M. Skoner 5/17/2022 3:35 AM

Progress Notes by Joshua E. Fabie, MD at 5/17/2022  6:40 AM

For all Team C patient questions from 6am-5pm during the week please contact the Team C intern at 66296 or their pager. On weekdays between 5pm-6am and weekends please first attempt to contact the intern on call at 66296 or, secondarily, the junior ENT resident on call.   Otolaryngology - Head and Neck Surgery Progress Note   Patient Name: Nicholas Prince Date: 5/17/2022 Admission Date: 5/16/2022 Service: Otolaryngology - Head and Neck Surgery   Subjective:  Out of OR around 0230. Febrile (Tmax 101.3), other VSS. On propofol. On PS 10, FiO2 40%. Received albumin 5% x 1.   Objective: General: NAD, AVSS HEENT: Stoma w/ 7 Bivona, TEP in place, surgical incision sites c/d/i, JPs in place to bulb suction with ss output, #10 SBT sutured to tongue, exposed muscle and Prolene stitch above Mepitel marking pedicle, CV: pulses intact, regular rate Resp: no increased work of breathing Abd: soft, ND, PEG Ext: no cyanosis or swelling or rashes Neuro: CN II-XII intact, EOMI   Assessment:  56 y.o. male w/ h/o ypT3NxcM0 laryngeal SCCa s/p salvage laryngectomy & L pec flap 2018, then second primary cT2N0M0 oropharyngeal p16+ SCCa s/p transoral laser excision of L BoT 11/2021 and re-resection 2/2022 via TORS now w/ recurrence 1 Day Post-Op s/p PEG, partial glossectomy & oropharyngectomy, bl ND, L lat. Vessels: Right superior thyroid and facial vein.   Neuro: - Pain control   HEENT: - Head positioning: extended and slightly to left. No pillows, trach ties around neck - Routine JP care: Please strip JP q1-2h. Empty and record output q4h and prn. Notify MD for significantly increasing output or significant change in color/consistency -q1h RN flap checks, q4h ENT MD flap checks until 5/19 at 2:30 AM - Please discuss with ENT team intra-oral mouth care plan - Bacitracin ointment to incisions BID until POD#7. POD#8 and after Vaseline ointment to incisions BID   CV/Heme: - ASA81 - Goal MAP > 80 - Please discuss with ENT if Hb < 8. May consider transfusion at this threshold. - Notify MD if Systolic blood pressure > 170. - Notify MD for sustained pulse > 110 while pain is well controlled   Pulm: - Wean O2 to keep sats >92%   FENGI: - Replete electrolytes to keep K >4.0, Mg>2.0 - Diet NPO diet - NPO till 1 month post op - Bowel regimen - Likely start low volume TF today   GU: - Strict I/O's - Notify MD if UOP <30cc/h   ID: - Unasyn   ENDO: - Monitor glucose, SSI as indicated   PPx: - DVT: LVX, SCDs - GI: PPI, H2   MSK: - Will follow PT/OT recs when appropriate to work with them   Dispo - STICU   Joshua E. Fabie, MD Resident Physician ENT - Head & Neck Surgery 05/17/22 6:40 AM

H&P by Evert Eriksson, MD at 5/17/2022  4:20 AM

Progress Notes by Rebecca Fuller, RD-AP, LD, CNSC at 5/17/2022 12:49 PM

Nutrition Adult Nutrition Assessment Medical University of South Carolina   Patient Name: Nicholas Prince Age: 56 y.o. Sex: male MRN: 001631137 Date: 5/17/2022 Admission Date: 5/16/2022 Admit Diagnosis: Oropharynx cancer [C10.9] Reason for Assessment: RD screen ICU/Vent status and RN nutrition risk screen:chewing/swallowing   Assessment Food/Nutrition History Pt is intubated and sedated at time of visit. Pt unable to provide nutrition history at this time. Propofol infusing at 25.7mL/hr providing an estimated 678kcals/day. Plan to transition to precedex. Enteral access: PEG. Pain affecting PO intake: Unable to assess, patient intubated.   Current Nutrition Order: NPO diet Food Allergies/Intolerances: NKFA   Client History/Diagnoses Pt is a 56 y.o.male with recurrent laryngeal SCCa s/p partial glossectomy and oropharyngectomy, bl ND, left lateral, Bivona trach and PEG.   Past Medical History Past Medical History: Diagnosis Date • Cancer     laryngeal cancer • GERD (gastroesophageal reflux disease)   • Hx of head and neck radiation 10/2016     Surgical History Past Surgical History: Procedure Laterality Date • PR CREATE T-E FISTULA+SPEECH PROSTHESIS   1/2/2018   Procedure: ; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR DILATION ESOPHAGUS GUIDE WIRE Bilateral 3/12/2021   Procedure: DILATE ESOPHAGUS - SOUND BOUGIE; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR ESOPHAGOSCOPY RIGID TRNSO DX   3/12/2021   Procedure: ; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR GASTROSTOMY,OPEN,W/O TUBE CNSTR N/A 2/23/2018   Procedure: GEN STOMACH; Surgeon: Stuart M. Leon, MD; Location: MUSC MAIN OR; Service: General Surgery • PR LARYNGOSCOPY,DIRCT,OP,BIOPSY N/A 1/20/2022   Procedure: SUSPENSION MICROLARYNGOSCOPY WITH BIOPSY (31536); Surgeon: Leila Jean Mady, MD PhD; Location: MUSC MAIN OR; Service: Otolaryngology • PR LARYNGOSCOPY,DIRECT,DIAGNOSTIC Bilateral 9/20/2021   Procedure: DIRECT DX LARANGOSCOPY; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR MUSCLE-SKIN FLAP,TRUNK Unknown 2/19/2018   Procedure: OTO MUSCLE MYOCUT FASCIOCUT FLAP; TRUNK; Surgeon: Judith M Skoner, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR PART REMOVAL TONGUE, 1/2   2/10/2022   Procedure: ; Surgeon: Leila Jean Mady, MD PhD; Location: MUSC MAIN OR; Service: Otolaryngology • PR PART REMOVAL TONGUE,<1/2 N/A 11/12/2021   Procedure: GLOSSECTOMY, <1/2 TONGUE; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR PARTIAL REMOVAL OF PHARYNX   2/19/2018   Procedure: ; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR PARTIAL REMOVAL OF PHARYNX   2/10/2022   Procedure: ; Surgeon: Leila Jean Mady, MD PhD; Location: MUSC MAIN OR; Service: Otolaryngology • PR RAD RESEC TONSIL/PILLARS N/A 2/10/2022   Procedure: DAVINCI RADICAL RESECTION TONSIL W/O CLOSURE; Surgeon: Leila Jean Mady, MD PhD; Location: MUSC MAIN OR; Service: Otolaryngology • PR RECONSTRUCTION OF THROAT N/A 2/19/2018   Procedure: OTO PHARYNGOPLASTY; Surgeon: Judith M Skoner, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR REMOVAL OF LARYNX Unknown 1/2/2018   Procedure: OTO LARYNGECT; TOT W O RADL NCK DISSECT; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • schwannoma   10/2007   L 3- L4     I/O: I/O last 3 completed shifts: In: 7291.34 [I.V.:2176.34; Other:15; IV Piggyback:5100] Out: 3435 [Urine:3025; Other:160; Blood:250]   Medications/Vitamins/Herbals/Supplements Scheduled Meds: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • bacitracin zinc Topical BID • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 300 mg Per G Tube Q8H • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • sennosides 8.8 mg Per G Tube BID   Continuous Infusions: • dexmedeTOMIDine in NaCl 0.9 % 400mcg/100mL infusion • lactated ringers infusion 75 mL/hr (05/17/22 0800)   PRN Meds:.HYDROmorphone, oxycodone   Labs Lab Results Component Value Date   NA 142.0 05/17/2022   K 3.8 05/17/2022   CL 109 (H) 05/17/2022   GLUCOSE 149.0 (H) 05/17/2022   BUN 9 05/17/2022   CREATININE 1.1 05/17/2022   CALCIUM 8.5 05/17/2022   MG 1.9 05/17/2022   PHOSPHORUBLD 2.4 05/17/2022   PREALBUMIN 10.5 (L) 02/26/2018   Recent Labs 05/17/22 0237 GLUCOSEPCXWH 119.0*     Anthropometric Measurements Wt Readings from Last 3 Encounters: 05/16/22 94.6 kg (208 lb 8.9 oz) 05/12/22 95.3 kg (210 lb) 04/20/22 96.7 kg (213 lb 3 oz)   Estimated body mass index is 30.8 kg/m² as calculated from the following: Height as of this encounter: 175.3 cm (5' 9"). Weight as of this encounter: 94.6 kg (208 lb 8.9 oz). UBW: 210-220lbs IBW: 160lbs   Nutrition Focused Physical Exam No overt signs of fat loss of muscle wasting observed or palpated upon assessment (5/17/2022) Overall Appearance: WDL Dentition/Oral: WDL Cognitive/Neuro: sedated Edema: scleral edema Skin: incision(s) WDL GI/Abdominal Appearance: rounded,other (see comments) (PEG in place), passing flatus Last BM: , Vitals Temp: [37.5 °C (99.5 °F)-38.5 °C (101.3 °F)] 37.6 °C (99.68 °F) Heart Rate: [82-100] 85 Resp: [10-24] 24 BP: (146)/(68) 146/68 Arterial Line BP: (135-174)/(55-69) 174/69   General Vent Data (last 24 hours)   Flowsheet Row Name Average Min Max   Exhaled Vt 709 L/min 667 L/min 753 L/min   Minute Volume 8.5 L 7.8 L 8.9 L   PIP Analyzed (cm H2O) 18.93 cm H2O 18.7 cm H2O 19 cm H2O   MAP Analyzed (cm H2O) 10.73 cm H2O 10 cm H2O 11 cm H2O   Set PEEP (cm H2O) 8 cm H20 8 cm H20 8 cm H20   Auto PEEP (cm H2O) 0 cm H2O 0 cm H2O 0 cm H2O   O2 Set (%) 40 % 40 % 40 %   O2 Analyzed (%) 40.25 % 40 % 41 %   Sensitivity Flow 5 5 5   Pressure Support (cm H2O) 10 cm H2O 10 cm H2O 10 cm H2O     Estimated Nutritional Needs: Maintenance Penn State Equation: 2199kcals total kcal / day 1900-2375 kcal / kg / day 20-25 gm protein / day 114-143 gm protein / kg / day 1.2-1.5 ML water / day 2375-2660 mL / kg / day 25-28   Diet Education Needs: Pt will likely need HEN/diet instruction prior to d/c.   Nutrition Diagnosis Swallowing difficulty related to glossectomy as evidence by PEG placement.   Nutrition Interventions Modify composition of enteral nutrition Modify volume of enteral nutrition Modify rate of enteral nutrition Feeding tube flush Discharge and Transfer of Nutrition Care to New Setting or Provider   Enteral Nutrition Access: PEG Formula: Nutren 1.5 24HR Goal Volume: 1440mL Flush: 50mL Q4H Protein Modular:Prosource 30mL BID Provides: 2280 kcal / day 24 kcal / kg / day 253 gm CHO / day 128 gm Pro/ day 1.3 gm protein / kg / day 1100 mL free water   Enteral Nutrition (Bolus/Home) Access: PEG Formula: Nutren 1.5 Bolus Volume: 375mL Bolus Frequency: Q6H Flush before and after each bolus: 60mL Protein Modular: Prosource 30mL daily Provides: 2310 kcal / day 24 kcal / kg / day 264 gm CHO / day 117 gm Pro/ day 1.2 gm protein / kg / day 1146 mL free water   Nutrition Goals EN / PN: receive at least 80 % of prescribed kcalories / protein, EN: tolerate at goal rate without any difficulties reported, Labs: Euglycemia, Constipation / Diarrhea: achieve regular BM pattern and Diet Instruction: verbalize understanding of HEN diet   Monitoring and Evaluation Total energy intake (FH-1.1.1.1) Weight change (AD-1.1.4) Glucose/endocrine profile WDL (BD-1.5) Metabolic rate profile WDL (BD-1.8) Digestive system (mouth to rectum) (PD-1.1.5)   Nutrition Plan Initiate enteral nutrition with formula and goal as outlined above. When tolerating EN at continuous EN goal rate transition to bolus regimen - recommend: 375ml q6h + 30ml ProSource BID. Flush with 60 ml water before and after each bolus. If insurance unable to cover EN consider the following over the counter regimen: 6 cartons Boost Plus (or equivalent formula) daily + either 30 ml ProStat daily or 1 scoop of pure whey protein powder daily (assuming each scoop provides ~20g of protein). If pt is to discharge home on TF, please place referral to Outpatient Dietitian: Hollings Cancer Center or pt preferred provider for monitoring and surveillance of nutrition support. RD will continue to monitor pt clinical course and will adjust nutrition interventions PRN. Patient's plan of care discussed during multidisciplinary rounds or with member of the care team and/or orders acknowledged by physician in Epic. Rebecca Fuller, RD-AP, LD, CNSC Pager ID: 12763

Progress Notes by Kristen M Quinn, MD at 5/17/2022  7:57 PM

STICU Progress Note     Subjective: Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15, 1 Day Post-Op. Required bolus and neo for MAP>80.   Objective: Temp: [37.3 °C (99.14 °F)-38.5 °C (101.3 °F)] 37.9 °C (100.22 °F) Heart Rate: [60-100] 60 Resp: [10-24] 14 BP: (92-146)/(48-68) 114/48 Arterial Line BP: (97-174)/(51-77) 125/77   Temp: 37.9 °C (100.22 °F) Temp Avg: 37.8 °C (100.1 °F) Min: 37.3 °C (99.14 °F) Max: 38.5 °C (101.3 °F) Heart Rate: 60 Pulse Avg: 82 Min: 60 Max: 100 BP: 114/48 BP Min: 92/53 Max: 146/68     I/O this shift: In: 25 [I.V.:25] Out: -   Recent Labs 05/17/22 0441 WBC 8.21 HGB 11.3* HCT 35.4* PLT 184   Recent Labs 05/16/22 2108 05/17/22 0441 05/17/22 0445 NA -- 142.0 -- K -- 3.8 -- CL 114 111* 109* BUN 9 10 9 CREATININE 0.9 1.0 1.1       Assessment and Plan   Patient seen and examined. Pertinent lab and imaging reviewed, as well as recent vital and urine output trends. Plan from day team reviewed and no additional plans made for overnight shift.    - 500cc over 2 hr bolus to support MAP>80 and neo wean - wean vent as able - start trickle TFs via PEG Kristen M Quinn, MD Department of Surgery, PGY-3 Medical University of South Carolina Pager: 15868 May 17, 2022

Progress Notes by Kristen M Quinn, MD at 5/17/2022  7:57 PM

STICU Progress Note     Subjective: Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15, 1 Day Post-Op. Required bolus and neo for MAP>80.   Objective: Temp: [37.3 °C (99.14 °F)-38.5 °C (101.3 °F)] 37.9 °C (100.22 °F) Heart Rate: [60-100] 60 Resp: [10-24] 14 BP: (92-146)/(48-68) 114/48 Arterial Line BP: (97-174)/(51-77) 125/77   Temp: 37.9 °C (100.22 °F) Temp Avg: 37.8 °C (100.1 °F) Min: 37.3 °C (99.14 °F) Max: 38.5 °C (101.3 °F) Heart Rate: 60 Pulse Avg: 82 Min: 60 Max: 100 BP: 114/48 BP Min: 92/53 Max: 146/68     I/O this shift: In: 25 [I.V.:25] Out: -   Recent Labs 05/17/22 0441 WBC 8.21 HGB 11.3* HCT 35.4* PLT 184   Recent Labs 05/16/22 2108 05/17/22 0441 05/17/22 0445 NA -- 142.0 -- K -- 3.8 -- CL 114 111* 109* BUN 9 10 9 CREATININE 0.9 1.0 1.1       Assessment and Plan   Patient seen and examined. Pertinent lab and imaging reviewed, as well as recent vital and urine output trends. Plan from day team reviewed and no additional plans made for overnight shift.    - 500cc over 2 hr bolus to support MAP>80 and neo wean - wean vent as able - start trickle TFs via PEG Kristen M Quinn, MD Department of Surgery, PGY-3 Medical University of South Carolina Pager: 15868 May 17, 2022

Adult Critical Care History and Physical Note Medical University of South Carolina     Patient Name: Nicholas Prince Age: 56 y.o. Sex: male MRN: 001631137 Date: 5/17/2022 Admission Date: 5/16/2022 ICU Day #: 1 Post-Op Day: 1 Day Post-Op   Admission Diagnosis: <principal problem not specified> Admitting Provider: William Greer Albergotti III, MD Surgical Service: Otolaryngology Surgeon: Surgeon(s): Edward Douglas Norcross, MD Judith M Skoner, MD Julian D Amin, MD William Greer Albergotti III, MD Alana Nicole Aylward, MD   HPI   Mr. Prince is a 56 year old man with a a history of ypT3NxcM0 laryngeal squamous cell carcinoma status post salvage laryngectomy, complicated by pharyngocutatneous flap requiring pectoralis major reconstruction in 2018. He presented with a second primary cT2N0M0 oropharynx p16+ squamous cell carcinoma status post partial resection of left base of tongue. He underwent re-resection of L BOT SCC on 2/10/22 and was noted to have a recurrence. He underwent today a pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap. He is admitted to STICU after surgical intervention. Procedure went well, EBL 250 ml, UOP 2700. Admitted not on pressors, on propofol., received 1750 ml of LR and 4 L of plasmalyte.   Review of Systems: General ROS: negative Hematological and Lymphatic ROS: negative Endocrine ROS: negative Respiratory ROS: no cough, shortness of breath, or wheezing, previous trach. Cardiovascular ROS: no chest pain or dyspnea on exertion Musculoskeletal ROS: negative Neurological ROS: no TIA or stroke symptoms Dermatological ROS: negative   Past Medical History: Past Medical History: Diagnosis Date • Cancer     laryngeal cancer • GERD (gastroesophageal reflux disease)   • Hx of head and neck radiation 10/2016     Past Surgical History: Past Surgical History: Procedure Laterality Date • PR CREATE T-E FISTULA+SPEECH PROSTHESIS   1/2/2018   Procedure: ; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR DILATION ESOPHAGUS GUIDE WIRE Bilateral 3/12/2021   Procedure: DILATE ESOPHAGUS - SOUND BOUGIE; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR ESOPHAGOSCOPY RIGID TRNSO DX   3/12/2021   Procedure: ; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR GASTROSTOMY,OPEN,W/O TUBE CNSTR N/A 2/23/2018   Procedure: GEN STOMACH; Surgeon: Stuart M. Leon, MD; Location: MUSC MAIN OR; Service: General Surgery • PR LARYNGOSCOPY,DIRCT,OP,BIOPSY N/A 1/20/2022   Procedure: SUSPENSION MICROLARYNGOSCOPY WITH BIOPSY (31536); Surgeon: Leila Jean Mady, MD PhD; Location: MUSC MAIN OR; Service: Otolaryngology • PR LARYNGOSCOPY,DIRECT,DIAGNOSTIC Bilateral 9/20/2021   Procedure: DIRECT DX LARANGOSCOPY; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR MUSCLE-SKIN FLAP,TRUNK Unknown 2/19/2018   Procedure: OTO MUSCLE MYOCUT FASCIOCUT FLAP; TRUNK; Surgeon: Judith M Skoner, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR PART REMOVAL TONGUE, 1/2   2/10/2022   Procedure: ; Surgeon: Leila Jean Mady, MD PhD; Location: MUSC MAIN OR; Service: Otolaryngology • PR PART REMOVAL TONGUE,<1/2 N/A 11/12/2021   Procedure: GLOSSECTOMY, <1/2 TONGUE; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR PARTIAL REMOVAL OF PHARYNX   2/19/2018   Procedure: ; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR PARTIAL REMOVAL OF PHARYNX   2/10/2022   Procedure: ; Surgeon: Leila Jean Mady, MD PhD; Location: MUSC MAIN OR; Service: Otolaryngology • PR RAD RESEC TONSIL/PILLARS N/A 2/10/2022   Procedure: DAVINCI RADICAL RESECTION TONSIL W/O CLOSURE; Surgeon: Leila Jean Mady, MD PhD; Location: MUSC MAIN OR; Service: Otolaryngology • PR RECONSTRUCTION OF THROAT N/A 2/19/2018   Procedure: OTO PHARYNGOPLASTY; Surgeon: Judith M Skoner, MD; Location: MUSC MAIN OR; Service: Otolaryngology • PR REMOVAL OF LARYNX Unknown 1/2/2018   Procedure: OTO LARYNGECT; TOT W O RADL NCK DISSECT; Surgeon: Eric J Lentsch, MD; Location: MUSC MAIN OR; Service: Otolaryngology • schwannoma   10/2007   L 3- L4     Family History: Family History Problem Relation Age of Onset • Alzheimer's disease Mother   • Diabetes Father   • Heart disease Father   • Heart attack Sister   • Hypertension Sister       Social History: Social History   Socioeconomic History • Marital status: Single     Spouse name: Not on file • Number of children: Not on file • Years of education: Not on file • Highest education level: Not on file Occupational History • Not on file Tobacco Use • Smoking status: Former Smoker     Packs/day: 2.00     Years: 30.00     Pack years: 60.00     Types: Cigarettes     Quit date: 2/13/2017     Years since quitting: 5.2 • Smokeless tobacco: Never Used Substance and Sexual Activity • Alcohol use: No     Alcohol/week: 0.0 standard drinks • Drug use: No • Sexual activity: Not on file Other Topics Concern • Not on file Social History Narrative • Not on file   Social Determinants of Health   Financial Resource Strain: Not on file Food Insecurity: Not on file Transportation Needs: Not on file Physical Activity: Not on file Stress: Not on file Social Connections: Not on file Housing Stability: Not on file     V/S, Labs, Hemodynamics, I&O, Daily Weights   Vital Signs: Temp: [36.1 °C (97 °F)-38.5 °C (101.3 °F)] 38.5 °C (101.3 °F) Heart Rate: [61-100] 93 Resp: [11-18] 11 BP: (146-179)/(68-75) 146/68 Arterial Line BP: (151)/(62) 151/62   Ins and Outs:   Intake/Output Summary (Last 24 hours) at 5/17/2022 0421 Last data filed at 5/17/2022 0400 Gross per 24 hour Intake 6825 ml Output 3295 ml Net 3530 ml   I&O Last 3 shifts I/O last 3 completed shifts: In: 4350 [I.V.:1000; IV Piggyback:3350] Out: 1925 [Urine:1775; Blood:150]   Lab results: Lab Results Component Value Date   WBC 8.73 02/15/2022   HGB 13.9 (L) 02/15/2022   HCT 43.9 02/15/2022   MCV 86.9 02/15/2022   PLT 215 02/15/2022   Lab Results Component Value Date   NA 141.0 02/15/2022   K 4.4 02/15/2022   CL 114 05/16/2022   CO2CT 27 02/15/2022   BUN 9 05/16/2022   CREATININE 0.9 05/16/2022   GLUCOSE 107.0 (H) 02/15/2022   No results found for: ALT, AST, GGT, ALKPHOS, BILITOT Lab Results Component Value Date   INR 1.06 02/10/2022   PTT 29.9 02/10/2022     Rass, Cam-ICU: CAM Result: Negative Hemodynamic Parameters: Daily Weight & BMI: Wt Readings from Last 1 Encounters: 05/16/22 94.6 kg (208 lb 8.9 oz) Body mass index is 30.8 kg/m².     Physical Exam   General: no acute distress. Neuro: Sedation : RASS -3 Deep sedation HEENT: multiple drains with serosanguineous drainage, flap with small dark areas but overall perfused. Connected to monitor and venous probe. Tracheostomy in place with no signs of infection or bleeding. CVS: RRR Resp: CTAB O2 Set (%): 40 % Set PEEP (cm H2O): 8 cm H20 GI: S/ND/NT Renal: Foley in place MSK: Moves all extremities against gravity. No edema or cyanosis. Tissues: Intact / Healthy and See HENT   Current Diet: NPO diet Last BM: Code Status: Resuscitate     Medications   Continuous: • lactated ringers infusion 75 mL/hr (05/17/22 0300) • propofoL (Diprivan) 10mg/mL injection 60 mcg/kg/min (05/17/22 0300)   Scheduled: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • bacitracin zinc Topical BID • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 300 mg Per G Tube Q8H • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • sennosides 8.8 mg Per G Tube BID   PRN: HYDROmorphone, oxycodone       Radiology   No results found.     Assessment & Plan   56 y.o. male sp pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap.   Active Problems: * No active hospital problems. *     Neuro Pain control: tylenol, oxycodone dilauid Propofol for sedation, will wean in AM. HEENT Q1h flap checks, venous probe #7 Bivona in place (old) MAP goal >80 Multiple drains (3 in neck, 2 in left upper back) CV HDS, CTM, Phenylephrine to MAP goal >80 Resp Keep O2 sats above 90% Vent wean as able Pulm toilet GI Diet: NPO, Gtube in place. Bilious output, seems well positioned on AXR. Bowel regimen Antiemetics PRN GU Strict I&O's Foley Replace electrolytes PRN Endo No active problems MSK No issues Skin Routine wound care,flap checks per ENT. Heme Transfuse if Hgb<7 or symptomatic ID Unasyn per ENT. PPx DVT: SCDs, Lovenox GI: Protonix Dispo STICU     Raphael Parrado Pager ID: 10348 Date: 5/17/2022 Time: 4:21 AM   Attending Attestation   I have reviewed and discussed with the house staff / physician extenders the clinical course and findings above, as well as laboratory reports, X-ray reports, X-ray films, results of additional medical testing and monitored output as noted above. I personally examined the patient and discussed care plans on rounds with the house staff / physician extenders. My additional comments are:   Resp failure - cont full vent support Flap checks Anemia (acute blood loss) - will monitor hemoglobin level and follow hemodynamic status for signs of hemorrhage. Will consider transfusion for hemoglobin between 7 and 8 or for signs of hemorrhage. Hyperglycemia - Control blood sugar. Increase intensity of therapy for blood sugar > 140. If sustained high, insulin drip is needed. G-Tube feeds in AM NPO     Patient is critically ill / injured. I spent 45 minutes providing critical care to this patient. This time is exclusive of time performing procedures or teaching. Overall risk of complications / mortality: High.     Evert Eriksson Pager ID: 14761 5/17/2022 7:27 AM Progress Notes by Michaela Close, MD at 5/17/2022  7:58 AM Adult Critical Care Progress Note - Date: 5/17/2022 Patient Name: Nicholas Prince MRN: 001631137 Admission Date: 5/16/2022 ICU Day #: 1   Admitting Physician: William Greer Albergotti III, MD Surgeon(s): Surgeon(s): Edward Douglas Norcross, MD Judith M Skoner, MD Julian D Amin, MD William Greer Albergotti III, MD Alana Nicole Aylward, MD     Brief Hx:   Mr. Prince is a 56 year old man with a a history of ypT3NxcM0 laryngeal squamous cell carcinoma status post salvage laryngectomy, complicated by pharyngocutatneous flap requiring pectoralis major reconstruction in 2018. He presented with a second primary cT2N0M0 oropharynx p16+ squamous cell carcinoma status post partial resection of left base of tongue. He underwent re-resection of L BOT SCC on 2/10/22 and was noted to have a recurrence. He underwent today a pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap. He is admitted to STICU after surgical intervention. Procedure went well, EBL 250 ml, UOP 2700. Admitted not on pressors, on propofol., received 1750 ml of LR and 4 L of plasmalyte.  Recent (24 hour) Events & Subjective Complaints:   5/17: Admitted to STICU overnight. Febrile overnight (Tmax 101.3). Remains sedated on propofol and on pressure support (40%, 10/8) via Bivona. UOP low this morning, plan to bolus 500cc / 2h per ENT. Will plan to wean vent and sedation today.   Vital Signs: Temp: [37.9 °C (100.2 °F)-38.5 °C (101.3 °F)] 37.9 °C (100.2 °F) Heart Rate: [82-100] 82 Resp: [10-18] 12 BP: (146)/(68) 146/68 Arterial Line BP: (135-156)/(55-62) 156/62 Ins and Outs: Intake/Output Summary (Last 24 hours) at 5/17/2022 0758 Last data filed at 5/17/2022 0600 Gross per 24 hour Intake 7254.24 ml Output 3435 ml Net 3819.24 ml   Lab results: Lab Results Component Value Date   WBC 8.21 05/17/2022   HGB 11.3 (L) 05/17/2022   HCT 35.4 (L) 05/17/2022   MCV 88.1 05/17/2022   PLT 184 05/17/2022   Lab Results Component Value Date   NA 142.0 05/17/2022   K 3.8 05/17/2022   CL 109 (H) 05/17/2022   CO2CT 24 05/17/2022   BUN 9 05/17/2022   CREATININE 1.1 05/17/2022   GLUCOSE 149.0 (H) 05/17/2022   No results found for: ALT, AST, GGT, ALKPHOS, BILITOT Lab Results Component Value Date   INR 1.06 02/10/2022   PTT 29.9 02/10/2022     Physical Exam General: sedated on vent Neuro: Sedation : RASS  -3 Deep sedation HEENT: S/p flap reconstruction with paddle on right neck. Multiple drains with serosanguineous drainage. Flap vessel connected to venous doppler. Bivona in place via laryngectomy stoma. SBT sutured in place. CVS: RRR Resp: On vent Device (Oxygen Therapy): ventilator (05/17 0648) Oxygen Concentration (%): [40] 40 (05/17 0648) O2 Set (%): [40 %] 40 % (05/17 0649) Set PEEP (cm H2O): [8 cm H20] 8 cm H20 (05/17 0649) Pressure Support (cm H2O): [10 cm H2O] 10 cm H2O (05/17 0649) GI: S/ND/NT. PEG in place. Renal: Foley in place with clear yellow urine. MSK: No edema or cyanosis. Tissues: Intact / Healthy and See HENT   Medications Continuous: • lactated ringers infusion 75 mL/hr (05/17/22 0300) • propofoL (Diprivan) 10mg/mL injection 60 mcg/kg/min (05/17/22 0600)   Scheduled: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • bacitracin zinc Topical BID • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 300 mg Per G Tube Q8H • lactated ringers 500 mL Intravenous Once • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • potassium chloride 20 mEq Per PEG Tube Once • sennosides 8.8 mg Per G Tube BID   PRN: HYDROmorphone, oxycodone   Radiology Recent pertinent imaging: XR Abdomen AP   Result Date: 5/17/2022 EXAMINATION: ABDOMEN, 1 VIEW 5/17/2022 3:43 AM ACCESSION NUMBER: 19578004 INDICATION: sp PEG ENT ca s/p flap COMPARISON: none TECHNIQUE: AP supine radiograph of the mid abdomen was obtained on 2 cassettes. FINDINGS: The gastrostomy tube balloon overlies L mid abdomen. Jackson Pratt drain over L upper abdomen The intestinal gas pattern is normal. No calcifications over the biliary or urinary tract are visible. Temperature probe over rectum   IMPRESSION: gastrostomy tube balloon over stomach. I, Stephen Schabel, MD, have reviewed the study and agree with the findings in this report. 5/17/2022 7:20 AM       Review daily on every patient   Lovenox (or other VTE prophylaxis) ordered? yes   Cervical spine cleared? not applicable   Tube feeds at goal? no   Gastritis prophylaxis required? yes   Bowel regime ordered? yes   Foley removed? no   D/C antibiotics? no   Convert IV narcotics to PO? no   Glucose controlled? yes   D/C central line? not applicable           Assessment and Plan Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15.     Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery     Neuro Pain control: SCH tylenol, gaba; PRN oxycodone, dilaudid Sedation: on propofol, plan to wean today HEENT #Oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer on 5/15: q1h flap checks per ENT MAP goal >80 ASA 81mg and LVX #7 Bivona in place (s/p prior laryngectomy) Multiple drains (3 in neck, 2 in left upper back), mgmt per ENT CV HDS, CTM, MAP goal >80 Resp Keep O2 sats above 90% Vent wean as able Pulm toilet GI Diet: NPO diet S/p PEG on 5/16 Bowel regimen Antiemetics PRN GU Strict I&O's Low UOP overnight, will bolus 500cc (okay per ENT) Foley Replace electrolytes PRN Endo No active problems MSK No issues Skin Routine wound care, flap care per ENT Heme Transfuse if Hgb<7 or symptomatic ASA 81mg ID Unasyn per ENT.  PPx DVT: SCDs, Lovenox 30mg BID GI: pepcid, protonix Dispo STICU     Michaela F. Close Otolaryngology-Head & Neck Surgery, PGY-1 Pager ID: 10569 May 17, 2022 7:58 AM Progress Notes by Kristen M Quinn, MD at 5/18/2022 12:57 AM Called to bedside Pt with acute increase in agitation, pulling at airway, desaturation per report Pt bag mask ventilated and quickly recovered. Propofol gtt started and patient stabilized. Will optimize sedation with propofol and wean off precedex, continue to wean off neo. ENT updated Progress Notes by Christina Thieman, RRT at 5/18/2022  4:11 AM Reason No SBT : Underlying Issue not resolved (TC trials during the day) Progress Notes by James Sullivan, MD at 5/18/2022  7:10 AM For all Team C patient questions from 6am-5pm during the week please contact the Team C intern at 66296 or their pager. On weekdays between 5pm-6am and weekends please first attempt to contact the intern on call at 66296 or, secondarily, the junior ENT resident on call.   Otolaryngology - Head and Neck Surgery Progress Note   Patient Name: Nicholas Prince Date: 5/18/2022 Admission Date: 5/16/2022 Service: Otolaryngology - Head and Neck Surgery   Subjective:  Tmax 101.1, other VSS. Transitioned from propofol to precedex yesterday morning to assist with wean vent. MAP 60-70s so LR bolus x 3 and added Neo. Had acute increase in agitation, pulling at airway, so restarted on propofol at midnight. Stable vent settings, on PS 10, FiO2 50%. Started on trickle feeds. Started on home valium.     Objective: General: NAD, AVSS HEENT: Stoma w/ 7 Bivona, TEP in place, surgical incision sites c/d/i, JPs in place to bulb suction with ss output, #10 SBT sutured to tongue, exposed muscle and Prolene stitch above Mepitel marking pedicle, CV: pulses intact, regular rate Resp: no increased work of breathing Abd: soft, ND, PEG Ext: no cyanosis or swelling or rashes Neuro: CN II-XII intact, EOMI   Assessment:  56 y.o. male w/ h/o ypT3NxcM0 laryngeal SCCa s/p salvage laryngectomy & L pec flap 2018, then second primary cT2N0M0 oropharyngeal p16+ SCCa s/p transoral laser excision of L BoT 11/2021 and re-resection 2/2022 via TORS now w/ recurrence 2 Days Post-Op s/p PEG, partial glossectomy & oropharyngectomy, bl ND, L lat. Vessels: Right superior thyroid and facial vein.   Neuro: - Pain control - wean sedation per STICU   HEENT: - Head positioning: extended and slightly to left. No pillows, trach ties around neck - Routine JP care: Please strip JP q1-2h. Empty and record output q4h and prn. Notify MD for significantly increasing output or significant change in color/consistency -q1h RN flap checks, q4h ENT MD flap checks until 5/19 at 2:30 AM - Please discuss with ENT team intra-oral mouth care plan - Bacitracin ointment to incisions BID until POD#7. POD#8 and after Vaseline ointment to incisions BID   CV/Heme: - ASA81 - Goal MAP > 80 - Please discuss with ENT if Hb < 8. May consider transfusion at this threshold. - Notify MD if Systolic blood pressure > 170. - Notify MD for sustained pulse > 110 while pain is well controlled   Pulm: - Wean O2 to keep sats >92%   FENGI: - Replete electrolytes to keep K >4.0, Mg>2.0 - Diet NPO diet Nutren 1.5 - NPO till 1 month post op - Bowel regimen - Likely start low volume TF today   GU: - Strict I/O's - Notify MD if UOP <30cc/h   ID: - Unasyn -Investigate source of fevers per STICU.   ENDO: - Monitor glucose, SSI as indicated   PPx: - DVT: LVX, SCDs - GI: PPI, H2   MSK: - Will follow PT/OT recs when appropriate to work with them   Dispo - STICU   James Sullivan, MD Resident Physician, PGY-2 Otolaryngology-Head and Neck Surgery Pager: 10393 Progress Notes by Michaela Close, MD at 5/18/2022  7:55 AM Adult Critical Care Progress Note - Date: 5/18/2022 Patient Name: Nicholas Prince MRN: 001631137 Admission Date: 5/16/2022 ICU Day #: 2   Admitting Physician: William Greer Albergotti III, MD Surgeon(s): Surgeon(s): Edward Douglas Norcross, MD Judith M Skoner, MD Julian D Amin, MD William Greer Albergotti III, MD Alana Nicole Aylward, MD     Brief Hx:   Mr. Prince is a 56 year old man with a a history of ypT3NxcM0 laryngeal squamous cell carcinoma status post salvage laryngectomy, complicated by pharyngocutatneous flap requiring pectoralis major reconstruction in 2018. He presented with a second primary cT2N0M0 oropharynx p16+ squamous cell carcinoma status post partial resection of left base of tongue. He underwent re-resection of L BOT SCC on 2/10/22 and was noted to have a recurrence. He underwent today a pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap. He is admitted to STICU after surgical intervention. Procedure went well, EBL 250 ml, UOP 2700. Admitted not on pressors, on propofol., received 1750 ml of LR and 4 L of plasmalyte.  Recent (24 hour) Events & Subjective Complaints:   5/17: Admitted to STICU overnight. Febrile overnight (Tmax 101.3). Remains sedated on propofol and on pressure support (40%, 10/8) via Bivona. UOP low this morning, plan to bolus 500cc / 2h per ENT. Will plan to wean vent and sedation today. Trickle TF started. Restarted home valium.   5/18: Continues to be febrile (Tmax 101.2). Overnight, became more agitated and pulling at lines, so propofol added in addition to precedex. Restarted neo to maintain MAP goal >80. Starting seroquel and prn ativan. Holding tube feeds this morning due to concern for regurgitation of tube feeds out of mouth.   Vital Signs: Temp: [37.3 °C (99.14 °F)-38.4 °C (101.12 °F)] 37.7 °C (99.86 °F) Heart Rate: [55-122] 93 Resp: [12-28] 21 BP: (91-141)/(42-61) 91/61 Arterial Line BP: (80-188)/(42-81) 168/73 Ins and Outs:   Intake/Output Summary (Last 24 hours) at 5/18/2022 0755 Last data filed at 5/18/2022 0700 Gross per 24 hour Intake 4653.28 ml Output 2074 ml Net 2579.28 ml   Lab results: Lab Results Component Value Date   WBC 11.72 (H) 05/18/2022   HGB 11.2 (L) 05/18/2022   HCT 35.3 (L) 05/18/2022   MCV 88.5 05/18/2022   PLT 205 05/18/2022   Lab Results Component Value Date   NA 143.0 05/18/2022   K 4.2 05/18/2022   CL 112 (H) 05/18/2022   CO2CT 24 05/18/2022   BUN 8 05/18/2022   CREATININE 0.9 05/18/2022   GLUCOSE 115.0 (H) 05/18/2022   No results found for: ALT, AST, GGT, ALKPHOS, BILITOT Lab Results Component Value Date   INR 1.06 02/10/2022   PTT 29.9 02/10/2022     Physical Exam General: sedated on vent Neuro: Sedation : RASS  -3 Deep sedation HEENT: S/p flap reconstruction with paddle on right neck. Multiple drains with serosanguineous drainage. Flap vessel connected to venous doppler. Bivona in place via laryngectomy stoma. SBT sutured in place. CVS: RRR Resp: On vent Device (Oxygen Therapy): ventilator (05/18 0237) Oxygen Concentration (%): [40-60] 50 (05/18 0237) O2 Set (%): [60 %] 60 % (05/18 0237) Set PEEP (cm H2O): [8 cm H20] 8 cm H20 (05/18 0237) Pressure Support (cm H2O): [10 cm H2O] 10 cm H2O (05/18 0237) GI: S/ND/NT. PEG in place. Renal: Foley in place with clear yellow urine. MSK: No edema or cyanosis. Tissues: Intact / Healthy and See HENT   Medications Continuous: • dexmedeTOMIDine in NaCl 0.9 % 400mcg/100mL infusion Stopped (05/18/22 0400) • lactated ringers infusion 75 mL/hr (05/17/22 2100) • phenylephrine (Neo-Synephrine) 160 mcg/mL in NaCl 0.9% 250 mL infusion 60 mcg/min (05/18/22 0700) • propofoL (Diprivan) 10mg/mL injection 30 mcg/kg/min (05/18/22 0700)   Scheduled: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • bacitracin zinc Topical BID • diazePAM 2 mg Oral Daily • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 400 mg Per G Tube Q8H • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • potassium phosphate up to 15 mmol IVPB (peripheral) 15 mmol Intravenous Q2H • protein supplement 30 mL Oral Daily • QUEtiapine 25 mg Per OG/NG Tube Q8H • sennosides 8.8 mg Per G Tube BID   PRN: HYDROmorphone, LORazepam, oxycodone   Radiology Recent pertinent imaging: XR Abdomen AP   Result Date: 5/17/2022 EXAMINATION: ABDOMEN, 1 VIEW 5/17/2022 3:43 AM ACCESSION NUMBER: 19578004 INDICATION: sp PEG ENT ca s/p flap COMPARISON: none TECHNIQUE: AP supine radiograph of the mid abdomen was obtained on 2 cassettes. FINDINGS: The gastrostomy tube balloon overlies L mid abdomen. Jackson Pratt drain over L upper abdomen The intestinal gas pattern is normal. No calcifications over the biliary or urinary tract are visible. Temperature probe over rectum   IMPRESSION: gastrostomy tube balloon over stomach. I, Stephen Schabel, MD, have reviewed the study and agree with the findings in this report. 5/17/2022 7:20 AM       Review daily on every patient   Lovenox (or other VTE prophylaxis) ordered? yes   Cervical spine cleared? not applicable   Tube feeds at goal? no   Gastritis prophylaxis required? yes   Bowel regime ordered? yes   Foley removed? no   D/C antibiotics? no   Convert IV narcotics to PO? no   Glucose controlled? yes   D/C central line? not applicable           Assessment and Plan Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15.     Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery     Neuro Pain control: SCH tylenol, gaba; PRN oxycodone, dilaudid Sedation: On propofol overnight. Switched to precedex with plans to wean today Seroquel, and prn ativan added HEENT #Oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer on 5/15: q1h flap checks per ENT MAP goal >80 ASA 81mg and LVX #7 Bivona in place (s/p prior laryngectomy) Multiple drains (3 in neck, 2 in left upper back), mgmt per ENT CV HDS, CTM, MAP goal >80 Resp Keep O2 sats above 90% Vent wean as able Pulm toilet GI Diet: NPO diet Nutren 1.5 S/p PEG on 5/16 Bowel regimen Antiemetics PRN GU Strict I&O's Foley Replace electrolytes PRN Endo No active problems MSK No issues Skin Routine wound care, flap care per ENT Heme Transfuse if Hgb<7 or symptomatic ASA 81mg ID Unasyn per ENT.  PPx DVT: SCDs, Lovenox 30mg BID GI: pepcid, protonix Dispo STICU     Michaela F. Close Otolaryngology-Head & Neck Surgery, PGY-1 Pager ID: 10569 May 18, 2022 7:58 AM Progress Notes by James Sullivan, MD at 5/18/2022 11:17 AM ENT Flap Check Note   Flap examined at bedside. Scoped through bivona due to report of short episode of desaturation with tacypnea. Trach is in good position above the carina. On Precedex   Color: no skin paddle Turgor: Good with no evidence of edema or congestion Venous Signal: Triphasic in relation to respiration, strong   Will continue q1hr nursing and q4hr MD flap checks through 0230 5/19   James Sullivan, MD Resident Physician, PGY-2 Otolaryngology-Head and Neck Surgery Pager: 10393 Plan of Care by Nurse Brianna V at 5/18/2022  7:32 PM Mr. Prince remains in the NSICU with Phenylephrine gtt infusing. Pt had several episodes of anxiety/restlessness followed by HTN sys 320s, SpO2 desaturations into mid 80s; recovered after bagging with Ambu and increasing sedation, then placing on higher ventilatory support. Team at bedside each episode, Bivona tube advanced by MD. Pt on and off precedex throughout the day, PRNs administered for pain/anxiety as needed with episodes. This evening, Pt dropped BP (70s/40s) both on A-line and NIBP; Manual BP done (100/36). Phenylephrine maxed, 500mL LR administered. Infectious workup completed; Chest X-ray, EKG done, labs sent. VSS now stable at this time. Will continue to monitor. Problem: Adult Inpatient Plan of Care Goal: Plan of Care Review Outcome: Ongoing, Progressing Goal: Patient-Specific Goal (Individualization) Outcome: Ongoing, Progressing Goal: Absence of Hospital-Acquired Illness or Injury Outcome: Ongoing, Progressing Goal: Optimal Comfort and Wellbeing Outcome: Ongoing, Progressing Goal: Readiness for Transition of Care Outcome: Ongoing, Progressing Goal: Rounds/Family Conference Outcome: Ongoing, Progressing Problem: Fall Injury Risk Goal: Absence of Fall and Fall-Related Injury Outcome: Ongoing, Progressing Problem: Skin Injury Risk Increased Goal: Skin Health and Integrity Outcome: Ongoing, Progressing Progress Notes by Leonardo D Gonzalez Parrilla, MD at 5/18/2022  9:24 PM ENT Flap Check Note   Flap examined at bedside. This afternoon, had episode of hypotension, MAPs to 50s. Flap remained stable. Given 500cc of IVF with good response. Fever workup negative so far. CXR with stable/improved pulmonary edema. Currently with MAPs in the 90s on 80 of Neo. Off Propofol and Precedex.   Color: no skin paddle Turgor: Good with no evidence of edema or congestion Venous Signal: Triphasic in relation to respiration, strong Please avoid narcotics use. Will continue q1hr nursing and q4hr MD flap checks through 0230 5/19.   Leonardo Gonzalez-Parrilla, MD Otolaryngology - Head & Neck Surgery PGY-3 Resident Pager: 10127 Progress Notes by Leonardo D Gonzalez Parrilla, MD at 5/19/2022  1:05 AM ENT Flap Check Note   Flap examined at bedside. US vena cava suggested low in fluid, given another 500cc IVF. Around 9:40pm, became agitated after weaning sedation. Bivona backwalling, causing airway obstruction and desat to low 70s. Bivona removed and ETT placed with better airflow. Placed back on Precedex and back on the vent.   Color: no skin paddle Turgor: Good with no evidence of edema or congestion Venous Signal: Triphasic in relation to respiration, strong Please avoid narcotics use. Will continue q1hr nursing and q4hr MD flap checks.   Leonardo Gonzalez-Parrilla, MD Otolaryngology - Head & Neck Surgery PGY-3 Resident Pager: 10127   Progress Notes by Joshua E. Fabie, MD at 5/19/2022  6:59 AM For all Team C patient questions from 6am-5pm during the week please contact the Team C intern at 66296 or their pager. On weekdays between 5pm-6am and weekends please first attempt to contact the intern on call at 66296 or, secondarily, the junior ENT resident on call.   Otolaryngology - Head and Neck Surgery Progress Note   Patient Name: Nicholas Prince Date: 5/19/2022 Admission Date: 5/16/2022 Service: Otolaryngology - Head and Neck Surgery   Subjective:  AF, sBP 230s x 1 overnight, other VSS. TF held yesterday. Multiple episodes of desats with agitation. Scoped at bedside, concern for backwalling so advanced 2 cm. Transitioned from propofol to precedex overnight, now back on Precedex. Required increasing pressor requirement to maintain MAP goals, now weaning Neo. 500 cc bolus x 2, BP responded. Flap checks stable during this time. Trach aspirate with GNR. Fever workup (EKG, Bcx, CXR, UA) negative thus far. Overnight, desat to low 70s, Bivona completely backwalled despite reposition so switched to ETT and sutured in place.   Objective: General: NAD, AVSS HEENT: Stoma w/ 7 Bivona, TEP in place, surgical incision sites c/d/i, JPs in place to bulb suction with ss output, #10 SBT sutured to tongue, exposed muscle and Prolene stitch above Mepitel marking pedicle, CV: pulses intact, regular rate Resp: no increased work of breathing Abd: soft, ND, PEG Ext: no cyanosis or swelling or rashes Neuro: CN II-XII intact, EOMI   Assessment:  56 y.o. male w/ h/o ypT3NxcM0 laryngeal SCCa s/p salvage laryngectomy & L pec flap 2018, then second primary cT2N0M0 oropharyngeal p16+ SCCa s/p transoral laser excision of L BoT 11/2021 and re-resection 2/2022 via TORS now w/ recurrence 3 Days Post-Op s/p PEG, partial glossectomy & oropharyngectomy, bl ND, L lat. Vessels: Right superior thyroid and facial vein.   Neuro: - Please hold all narcotics - Wean sedation per STICU   HEENT: - Head positioning: extended and slightly to left. No pillows, trach ties around neck - Routine JP care: Please strip JP q1-2h. Empty and record output q4h and prn. Notify MD for significantly increasing output or significant change in color/consistency -q1h RN flap checks, q4h ENT MD flap checks until 5/19 at 2:30 AM - Please discuss with ENT team intra-oral mouth care plan - Bacitracin ointment to incisions BID until POD#7. POD#8 and after Vaseline ointment to incisions BID   CV/Heme: - ASA81 - Goal MAP > 80 - Please discuss with ENT if Hb < 8. May consider transfusion at this threshold. - Notify MD if Systolic blood pressure > 170. - Notify MD for sustained pulse > 110 while pain is well controlled   Pulm: - Wean O2 to keep sats >92%   FENGI: - Replete electrolytes to keep K >4.0, Mg>2.0 - Diet NPO diet Nutren 1.5 - NPO till 1 month post op - Bowel regimen   GU: - Strict I/O's - Notify MD if UOP <30cc/h   ID: - Unasyn   ENDO: - Monitor glucose, SSI as indicated   PPx: - DVT: LVX, SCDs - GI: PPI, H2   MSK: - Will follow PT/OT recs when appropriate to work with them   Dispo - STICU   Joshua E. Fabie, MD Resident Physician Progress Notes by Benjamin Coenen, DDS at 5/19/2022  7:58 AM Adult Critical Care Progress Note - Date: 5/19/2022 Patient Name: Nicholas Prince MRN: 001631137 Admission Date: 5/16/2022 ICU Day #: 3   Admitting Physician: William Greer Albergotti III, MD Surgeon(s): Surgeon(s): Edward Douglas Norcross, MD Judith M Skoner, MD Julian D Amin, MD William Greer Albergotti III, MD Alana Nicole Aylward, MD     Brief Hx: Mr. Prince is a 56 year old man with a a history of ypT3NxcM0 laryngeal squamous cell carcinoma status post salvage laryngectomy, complicated by pharyngocutatneous flap requiring pectoralis major reconstruction in 2018. He presented with a second primary cT2N0M0 oropharynx p16+ squamous cell carcinoma status post partial resection of left base of tongue. He underwent re-resection of L BOT SCC on 2/10/22 and was noted to have a recurrence. He underwent today a pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap. He is admitted to STICU after surgical intervention. Procedure went well, EBL 250 ml, UOP 2700. Admitted not on pressors, on propofol., received 1750 ml of LR and 4 L of plasmalyte.  Recent (24 hour) Events & Subjective Complaints:   5/17: Admitted to STICU overnight. Febrile overnight (Tmax 101.3). Remains sedated on propofol and on pressure support (40%, 10/8) via Bivona. UOP low this morning, plan to bolus 500cc / 2h per ENT. Will plan to wean vent and sedation today. Trickle TF started. Restarted home valium.   5/18: Continues to be febrile (Tmax 101.2). Overnight, became more agitated and pulling at lines, so propofol added in addition to precedex. Restarted neo to maintain MAP goal >80. Starting seroquel and prn ativan. Holding tube feeds this morning due to concern for regurgitation of tube feeds out of mouth.'   5/19: Back walled airway overnight with agitation, severe hypertension and tachycardia, decision to place ETT, valium sch 2.5 BID, 1 L LR given overnight   Vital Signs: Temp: [36.8 °C (98.2 °F)-38.3 °C (100.94 °F)] 36.8 °C (98.2 °F) Heart Rate: [59-153] 68 Resp: [10-30] 15 BP: (79-234)/(45-138) 92/69 Arterial Line BP: (89-343)/(41-151) 175/71 Ins and Outs:   Intake/Output Summary (Last 24 hours) at 5/19/2022 0758 Last data filed at 5/19/2022 0700 Gross per 24 hour Intake 3671.63 ml Output 2009 ml Net 1662.63 ml   Lab results: Lab Results Component Value Date   WBC 7.18 05/19/2022   HGB 9.0 (L) 05/19/2022   HCT 28.4 (L) 05/19/2022   MCV 88.8 05/19/2022   PLT 148 05/19/2022   Lab Results Component Value Date   NA 143.0 05/19/2022   K 4.5 05/19/2022   CL 112 05/19/2022   CO2CT 22 05/19/2022   BUN 7 (L) 05/19/2022   CREATININE 0.7 05/19/2022   GLUCOSE 125.0 (H) 05/19/2022   No results found for: ALT, AST, GGT, ALKPHOS, BILITOT Lab Results Component Value Date   INR 1.26 (H) 05/18/2022   PTT 40.4 (H) 05/18/2022     Physical Exam General: ill-appearing male Neuro: Sedation HEENT: S/p flap reconstruction with paddle on right neck. Multiple drains with serosanguineous drainage. Flap vessel connected to venous doppler. Bivona in place via laryngectomy stoma. SBT sutured in place. CVS: RRR Resp: On vent, ETT O2 Set (%): [40 %] 40 % (05/19 0330) Set PEEP (cm H2O): [8 cm H20] 8 cm H20 (05/19 0330) Pressure Support (cm H2O): [10 cm H2O] 10 cm H2O (05/19 0330) GI: S/ND/NT. PEG in place. Renal: Foley in place with clear yellow urine. MSK: No edema or cyanosis. Tissues: Intact / Healthy and See HENT   Medications Continuous: • dexmedeTOMIDine in NaCl 0.9 % 400mcg/100mL infusion 0.75 mcg/kg/hr (05/19/22 0700) • phenylephrine (Neo-Synephrine) 160 mcg/mL in NaCl 0.9% 250 mL infusion 40 mcg/min (05/19/22 0700) • propofoL (Diprivan) 10mg/mL injection Stopped (05/19/22 0145)   Scheduled: • acetaminophen 650 mg Per G Tube Q6H • aspirin 81 mg Per G Tube Daily • bacitracin zinc Topical BID • diazePAM 2.5 mg Per PEG Tube BID • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 400 mg Per G Tube Q8H • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • protein supplement 30 mL Oral Daily • QUEtiapine 25 mg Per OG/NG Tube Q8H • sennosides 8.8 mg Per G Tube BID   PRN: LORazepam   Radiology Recent pertinent imaging: XR Abdomen AP   Result Date: 5/17/2022 EXAMINATION: ABDOMEN, 1 VIEW 5/17/2022 3:43 AM ACCESSION NUMBER: 19578004 INDICATION: sp PEG ENT ca s/p flap COMPARISON: none TECHNIQUE: AP supine radiograph of the mid abdomen was obtained on 2 cassettes. FINDINGS: The gastrostomy tube balloon overlies L mid abdomen. Jackson Pratt drain over L upper abdomen The intestinal gas pattern is normal. No calcifications over the biliary or urinary tract are visible. Temperature probe over rectum   IMPRESSION: gastrostomy tube balloon over stomach. I, Stephen Schabel, MD, have reviewed the study and agree with the findings in this report. 5/17/2022 7:20 AM   Assessment and Plan Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15.     Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery     Neuro - Pain control: tyl, gaba, d/c PRN oxycodone, dilaudid which could be adding to pressor requirements per ENT - Sedation: precedex, prop - Anxiety: Seroquel, valium 2.5 BID (home med), ativan prn   HEENT #Oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer on 5/15: q1h flap checks per ENT MAP goal >80 ASA 81mg and LVX #7 Bivona in place (s/p prior laryngectomy) Multiple drains (3 in neck, 2 in left upper back), mgmt per ENT   CV #Hypotensive - MAP goal >80 - wean propofol - d/c PRN oxycodone, dilaudid which could be adding to pressor requirements per ENT   Resp #Acute respiratory failure - 5/19: ETT placed overnight - Keep O2 sats above 90% - Vent wean as able   GI #Protien calorie malnutrition - Diet: NPO diet Nutren 1.5 - S/p PEG on 5/16 - Bowel regimen - Antiemetics PRN GU - Strict I&O's - Foley - Replace electrolytes PRN Endo - No active problems MSK - No issues Skin - Routine wound care, flap care per ENT Heme - Transfuse if Hgb<7 or symptomatic - Hgb 9.0 a.m. - ASA 81mg ID 5/18: Trach asp - GNR   Antibiotic hx - Unasyn (5/17-   PPx - DVT: SCDs, Lovenox 30mg BID - GI: pepcid, protonix Dispo - STICU   Benjamin Coenen, DDS Oral and Facial Surgery PGY-2 Pager: 10383 May 19, 2022 Progress Notes by PEREZ, PENNY LEIGH, NP at 5/18/2022  7:55 PM STBICU Progress Note I personally evaluated and treated this critically ill patient while in the hospital overnight.     Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery     Vitals: Patient Vitals for the past 24 hrs:   BP Temp Temp src Pulse Resp SpO2 05/18/22 1355 — — — 65 19 95 % 05/18/22 1300 140/71 38 °C (100.4 °F) Foley 65 19 97 % 05/18/22 1228 — — — 62 19 96 % 05/18/22 1200 97/51 38.3 °C (100.94 °F) Foley 65 19 96 % 05/18/22 1100 117/54 — — 69 19 98 % 05/18/22 1003 — — — 88 28 100 % 05/18/22 1000 113/64 — — 88 20 100 % 05/18/22 0910 — — — 67 16 100 % 05/18/22 0900 106/52 37.9 °C (100.22 °F) Foley 64 17 100 % 05/18/22 0800 102/51 38 °C (100.4 °F) Foley 79 18 97 % 05/18/22 0700 — 37.7 °C (99.86 °F) — 93 21 100 % 05/18/22 0600 91/61 37.7 °C (99.86 °F) — 93 20 100 % 05/18/22 0500 106/49 37.6 °C (99.68 °F) — 69 22 100 % 05/18/22 0400 119/55 37.7 °C (99.86 °F) — 71 22 100 % 05/18/22 0300 141/60 38 °C (100.4 °F) — 70 22 100 % 05/18/22 0237 — — — 59 20 100 % 05/18/22 0200 107/52 38.4 °C (101.1 °F) — 64 22 100 % 05/18/22 0100 103/61 38.4 °C (101.12 °F) — 107 27 98 % 05/18/22 0052 — — — 122 28 97 % 05/18/22 0000 122/51 37.8 °C (100.04 °F) — 55 14 100 % 05/17/22 2300 110/44 38 °C (100.4 °F) — 63 14 100 % 05/17/22 2200 119/42 38.3 °C (100.94 °F) — 62 16 100 % 05/17/22 2100 135/52 38.2 °C (100.76 °F) — 73 18 100 % 05/17/22 2011 — — — 70 18 100 % 05/17/22 2000 121/54 38.1 °C (100.58 °F) — 63 14 100 % 05/17/22 1900 114/48 37.9 °C (100.22 °F) — 60 14 100 % 05/17/22 1801 — — — 62 18 100 % 05/17/22 1800 110/59 37.9 °C (100.22 °F) — 64 19 100 % 05/17/22 1713 — 37.8 °C (100.04 °F) — 64 14 100 % 05/17/22 1700 92/53 37.8 °C (100.04 °F) — 63 14 100 % 05/17/22 1600 92/49 37.7 °C (99.86 °F) — 69 13 100 % 05/17/22 1500 110/55 37.4 °C (99.32 °F) — 64 13 100 % 05/17/22 1430 — 37.4 °C (99.32 °F) — 66 12 100 %     I/O: I/O last 3 completed shifts: In: 7594.62 [I.V.:3175.62; Other:519; NG/GT:250; IV Piggyback:3650] Out: 3584 [Urine:2605; Other:879; Blood:100]   Meds Scheduled: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • bacitracin zinc Topical BID • diazePAM 2 mg Oral Daily • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 400 mg Per G Tube Q8H • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • protein supplement 30 mL Oral Daily • QUEtiapine 25 mg Per OG/NG Tube Q8H • sennosides 8.8 mg Per G Tube BID     Meds PRN: HYDROmorphone, LORazepam, oxycodone   Labs: Recent Labs Lab 05/17/22 0441 05/17/22 0445 05/18/22 0406 05/18/22 0845 WBC 8.21 -- 11.72* -- HGB 11.3* -- 11.2* -- HCT 35.4* -- 35.3* -- PLT 184 -- 205 -- NA 142.0 -- 143.0 -- K 3.8 -- 4.2 -- CL 111* < > 112* 111 CREATININE 1.0 < > 0.9 1.0 BUN 10 < > 8 8 < > = values in this interval not displayed.     Physical Examination: General appearance - alert, well appearing, and in no distress Mental status - awake, alert Eyes - PERRL Mouth - flap, sutures on both sides of mouth Neck - flap, edematous, incision with JP drains Chest - coarse bilateral breath sounds O2 Set (%): 50 % S VT: 500 mL Set PEEP (cm H2O): 8 cm H20 Pressure Support (cm H2O): 10 cm H2O S RR: 22 br/min Heart - normal rate and regular rhythm, S1 and S2 normal Abdomen - distended, soft, hypoactive bowel sounds GU Male - Foley Neurological - opens eyes to voice, follows commands, no focal deficits Musculoskeletal - no joint tenderness, deformity or swelling Extremities - intact peripheral pulses   A/P: Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15.   Respiratory Failure - currently on PRVC, will transition to PS trials this evening. Plan to wean to TC. Continue pulmonary toilet.   MAP goal per ENT > 80 - will continue Neo gtt titration for MAP goal. Hypovolemia, variation noted in arterial line. IVC < 2cm with some collapsibility. Will give 1L LR bolus over 2 hours.   Anemia (acute blood loss) - will monitor hemoglobin level and follow hemodynamic status for signs of hemorrhage. Will consider transfusion for hemoglobin between 7 and 8 or for signs of hemorrhage.   Hypomagnesemia - replace to level of 2   Hypophosphatemia - Replace IV. Monitor level with renal function changes. Given critical illness replacement will aide in respiratory management.   Malnutrition - abdominal distention, PEG tube placed to gravity. Holding TFs for now, will restart in AM.   The patient is critically ill with a high risk of complications due to the problems/condition(s) documented above.     My total direct critical care time spent on this patient's care today was 55 minutes, during which time period the patient was at significant risk of physiologic decompensation due to illness.  This includes my review of recent events and diagnostic results, my direct examination and assessment time, my rounding with the multidisciplinary ICU team including discussion of care goals and plans, as well as my discussion with the patient/family and other consultants.  It does not include time for procedures billed separately.   Penny Leigh Perez, NP Department of General Surgery STBICU Pager: 11890 5/18/2022   ADDENDUM 5/18/2022 9:35PM - call to bedside for hypertension w/ severe agitation. SBP 300s, HR 150s, O2 sat 80s, cyanotic. RT having hard time bagging patient. ENT Dr. Gonzalez notified and came to bedside. Propofol started for sedation. Bivona exchanged for ETT into stoma. Improvement in ventilation and saturations. ETT secured with sutures by Dr. Gonzalez. Placed on PRVC. CXR ordered.   Progress Notes by Tyler M Rist, MD at 5/19/2022  7:11 PM ENT Flap Check Note   Called to bedside shortly after PM rounds when the patient was switched from a ETT to a Bivona. The patient was hypertensive, tachycardia, and uncomfortable with concerns for difficultly breathing. Scoped Bivona and it was found to be backwalling. Attempted to replace ETT (7.5 reinforced ETT and 7-0 regular ETT) without subjective improvement. Replaced the Bivona and was able to advance past the area of backwalling. Checked on the patient an hour later and he appeared more comfortable and was satting well. Will continue to monitor.   Flap examined at bedside   Color: no skin paddle Turgor: Good with no evidence of edema or congestion Venous Signal: Triphasic in relation to respiration, strong   Will continue q1hr nursing and q4hr MD flap checks through 0230 5/19   Tyler M Rist, MD Otolaryngology PGY-3 Medical University of South Carolina Pager ID: 10129   05/19/22 9:18 PM Progress Notes by PEREZ, PENNY LEIGH, NP at 5/19/2022  6:40 PM STBICU Progress Note I personally evaluated and treated this critically ill patient while in the hospital overnight.     Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery • Acute blood loss anemia • Moderate protein-calorie malnutrition     Vitals: Patient Vitals for the past 24 hrs:   BP Temp Temp src Pulse Resp SpO2 Weight 05/19/22 2300 116/59 — — 64 16 100 % — 05/19/22 2200 106/55 — — 65 15 99 % — 05/19/22 2100 113/61 — — 69 14 98 % — 05/19/22 2008 — — — 75 15 99 % — 05/19/22 2000 127/66 — — 82 17 99 % — 05/19/22 1930 — — — 82 17 99 % — 05/19/22 1900 (!) 201/92 — — 111 22 100 % — 05/19/22 1818 — — — 92 15 100 % — 05/19/22 1800 — — — 96 16 97 % — 05/19/22 1759 — — — 105 23 97 % — 05/19/22 1746 — — — 80 13 100 % — 05/19/22 1726 — — — 74 21 100 % — 05/19/22 1700 — — — 80 18 100 % — 05/19/22 1600 — 36.7 °C (98.1 °F) Axillary 83 23 100 % — 05/19/22 1500 — — — 61 20 100 % — 05/19/22 1400 — — — 61 18 100 % — 05/19/22 1300 — — — 61 19 100 % — 05/19/22 1200 — 37.1 °C (98.8 °F) Axillary 62 19 100 % — 05/19/22 1100 — — — 63 17 100 % — 05/19/22 1000 — — — 62 15 100 % — 05/19/22 0900 — — — 61 15 100 % — 05/19/22 0800 — 37 °C (98.6 °F) Axillary 62 13 100 % — 05/19/22 0700 — — — 68 15 100 % — 05/19/22 0600 — — — 67 13 99 % — 05/19/22 0500 — — — 67 13 100 % — 05/19/22 0400 — 36.8 °C (98.2 °F) — 62 14 100 % — 05/19/22 0330 — — — 60 14 100 % — 05/19/22 0300 — — — 60 15 99 % — 05/19/22 0200 — — — 68 13 98 % — 05/19/22 0100 — — — 71 10 94 % — 05/19/22 0000 — 36.9 °C (98.4 °F) Axillary 73 11 96 % 99.9 kg (220 lb 3.8 oz)     I/O: I/O last 3 completed shifts: In: 5135.95 [I.V.:2627.95; Other:488; NG/GT:170; IV Piggyback:1850] Out: 3438.5 [Urine:2705; Other:733.5]   Meds Scheduled: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • diazePAM 2.5 mg Per PEG Tube BID • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 400 mg Per G Tube Q8H • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • protein supplement 30 mL Oral Daily • QUEtiapine 25 mg Per OG/NG Tube Q8H • sennosides 8.8 mg Per G Tube BID     Meds PRN: LORazepam, ondansetron   Labs: Recent Labs Lab 05/18/22 1802 05/19/22 0241 05/19/22 0427 05/19/22 0603 WBC 8.00 -- 7.18 -- HGB 9.4* -- 9.0* -- HCT 30.5* -- 28.4* -- PLT 157 -- 148 -- NA 143.0 -- 143.0 -- K 3.4* -- 4.5 -- CL 114* < > 114* 112 CREATININE 0.9 < > 0.7 0.7 BUN 8 < > 7* 7* < > = values in this interval not displayed.     Physical Examination: General appearance - alert, well appearing, and in no distress Mental status - awake, alert Eyes - PERRL Mouth - flap, sutures on both sides of mouth Neck - flap, edematous, incision with JP drains Chest - coarse bilateral breath sounds O2 Set (%): 50 % Set PEEP (cm H2O): 8 cm H20 Pressure Support (cm H2O): 8 cm H2O Heart - normal rate and regular rhythm, S1 and S2 normal Abdomen - distended, soft, hypoactive bowel sounds GU Male - Foley Neurological - opens eyes to voice, follows commands, no focal deficits Musculoskeletal - no joint tenderness, deformity or swelling Extremities - intact peripheral pulses   A/P: Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15.   Respiratory Failure - continue PS unless tires. Plan to wean to TC. Continue pulmonary toilet. Bivona backwalled again. ENT at bedside. Attempted exchange to ETT with no improvement. Bivona advanced with improvement.   MAP goal per ENT > 80 - Not requiring pressors for MAP goal.   Anemia (acute blood loss) - will monitor hemoglobin level and follow hemodynamic status for signs of hemorrhage. Will consider transfusion for hemoglobin between 7 and 8 or for signs of hemorrhage.   Malnutrition - pepup started via PEG tube. Will advance TF to goal.   The patient is critically ill with a high risk of complications due to the problems/condition(s) documented above.     My total direct critical care time spent on this patient's care today was 31 minutes, during which time period the patient was at significant risk of physiologic decompensation due to illness.  This includes my review of recent events and diagnostic results, my direct examination and assessment time, my rounding with the multidisciplinary ICU team including discussion of care goals and plans, as well as my discussion with the patient/family and other consultants.  It does not include time for procedures billed separately.   Penny Leigh Perez, NP Department of General Surgery STBICU Pager: 11890 5/19/2022 Progress Notes by Abby Sheppard, RRT at 5/20/2022  5:39 AM Respiratory Therapy Note:   Trach collar trial initiated at 0535. Progress Notes by Michaela Close, MD at 5/20/2022  7:07 AM Adult Critical Care Progress Note - Date: 5/20/2022 Patient Name: Nicholas Prince MRN: 001631137 Admission Date: 5/16/2022 ICU Day #: 4   Admitting Physician: William Greer Albergotti III, MD Surgeon(s): Surgeon(s): Edward Douglas Norcross, MD Judith M Skoner, MD Julian D Amin, MD William Greer Albergotti III, MD Alana Nicole Aylward, MD     Brief Hx: Mr. Prince is a 56 year old man with a a history of ypT3NxcM0 laryngeal squamous cell carcinoma status post salvage laryngectomy, complicated by pharyngocutatneous flap requiring pectoralis major reconstruction in 2018. He presented with a second primary cT2N0M0 oropharynx p16+ squamous cell carcinoma status post partial resection of left base of tongue. He underwent re-resection of L BOT SCC on 2/10/22 and was noted to have a recurrence. He underwent today a pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap. He is admitted to STICU after surgical intervention. Procedure went well, EBL 250 ml, UOP 2700. Admitted not on pressors, on propofol., received 1750 ml of LR and 4 L of plasmalyte.  Recent (24 hour) Events & Subjective Complaints:   5/17: Admitted to STICU overnight. Febrile overnight (Tmax 101.3). Remains sedated on propofol and on pressure support (40%, 10/8) via Bivona. UOP low this morning, plan to bolus 500cc / 2h per ENT. Will plan to wean vent and sedation today. Trickle TF started. Restarted home valium.   5/18: Continues to be febrile (Tmax 101.2). Overnight, became more agitated and pulling at lines, so propofol added in addition to precedex. Restarted neo to maintain MAP goal >80. Starting seroquel and prn ativan. Holding tube feeds this morning due to concern for regurgitation of tube feeds out of mouth.'   5/19: Back walled airway overnight with agitation, severe hypertension and tachycardia, decision to place ETT, valium sch 2.5 BID, 1 L LR given overnight   5/20: Patient with continued need for vent, precedex, and neo this morning, with plans to wean. Overnight, issue with Bivona backwalling, now resolved.   Vital Signs: Temp: [36.7 °C (98.1 °F)-37.1 °C (98.8 °F)] 37.1 °C (98.8 °F) Heart Rate: [57-111] 58 Resp: [11-23] 11 BP: (102-201)/(45-92) 110/55 Arterial Line BP: (73-221)/(55-100) 102/67 Ins and Outs:   Intake/Output Summary (Last 24 hours) at 5/20/2022 0707 Last data filed at 5/20/2022 0625 Gross per 24 hour Intake 2316.81 ml Output 2330 ml Net -13.19 ml   Lab results: Lab Results Component Value Date   WBC 5.93 05/20/2022   HGB 8.5 (L) 05/20/2022   HCT 27.3 (L) 05/20/2022   MCV 89.8 05/20/2022   PLT 162 05/20/2022   Lab Results Component Value Date   NA 140.0 05/20/2022   K 4.0 05/20/2022   CL 112 (H) 05/20/2022   CO2CT 22 05/20/2022   BUN 9 05/20/2022   CREATININE 0.8 05/20/2022   GLUCOSE 122.0 (H) 05/20/2022   No results found for: ALT, AST, GGT, ALKPHOS, BILITOT Lab Results Component Value Date   INR 1.26 (H) 05/18/2022   PTT 40.4 (H) 05/18/2022     Physical Exam General: ill-appearing male Neuro: Sedation HEENT: S/p flap reconstruction with paddle on right neck. Multiple drains with serosanguineous drainage. Flap vessel connected to venous doppler. Bivona in place via laryngectomy stoma. SBT sutured in place. CVS: RRR Resp: On vent, ETT Device (Oxygen Therapy): tracheostomy collar;humidified (05/20 0535) Oxygen Concentration (%): [40-50] 50 (05/20 0535) Oxygen Flow (L/min): [12] 12 (05/20 0535) O2 Set (%): [40 %-50 %] 40 % (05/20 0404) Set PEEP (cm H2O): [8 cm H20] 8 cm H20 (05/20 0404) Pressure Support (cm H2O): [8 cm H2O] 8 cm H2O (05/20 0404) GI: S/ND/NT. PEG in place. Renal: Foley in place with clear yellow urine. MSK: No edema or cyanosis. Tissues: Intact / Healthy and See HENT   Medications Continuous: • dexmedeTOMIDine in NaCl 0.9 % 400mcg/100mL infusion Stopped (05/20/22 0625) • phenylephrine (Neo-Synephrine) 160 mcg/mL in NaCl 0.9% 250 mL infusion 80 mcg/min (05/20/22 0557)   Scheduled: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • diazePAM 2.5 mg Per PEG Tube BID • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 400 mg Per G Tube Q8H • magnesium sulfate 1 g Intravenous Once • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • potassium phos-sodium phosphate 1 tablet Per PEG Tube Once • protein supplement 30 mL Oral Daily • QUEtiapine 25 mg Per OG/NG Tube Q8H • sennosides 8.8 mg Per G Tube BID   PRN: LORazepam, ondansetron, oxycodone   Radiology Recent pertinent imaging: XR Abdomen AP   Result Date: 5/17/2022 EXAMINATION: ABDOMEN, 1 VIEW 5/17/2022 3:43 AM ACCESSION NUMBER: 19578004 INDICATION: sp PEG ENT ca s/p flap COMPARISON: none TECHNIQUE: AP supine radiograph of the mid abdomen was obtained on 2 cassettes. FINDINGS: The gastrostomy tube balloon overlies L mid abdomen. Jackson Pratt drain over L upper abdomen The intestinal gas pattern is normal. No calcifications over the biliary or urinary tract are visible. Temperature probe over rectum   IMPRESSION: gastrostomy tube balloon over stomach. I, Stephen Schabel, MD, have reviewed the study and agree with the findings in this report. 5/17/2022 7:20 AM   Assessment and Plan Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15.     Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery • Acute blood loss anemia • Moderate protein-calorie malnutrition     Neuro - Pain control: tyl, gaba; PRN oxycodone. Dilaudid held in the setting of continued need for pressors - Sedation: precedex - Anxiety: Seroquel, valium 2.5 BID (home med), ativan prn   HEENT #Oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer on 5/15: q1h flap checks per ENT MAP goal >80 ASA 81mg and LVX #7 Bivona in place (s/p prior laryngectomy) Multiple drains (3 in neck, 2 in left upper back), mgmt per ENT   CV #Hypotension, now resolved - Currently still requiring pressors to maintain MAP goal >80 per flap requirements. Plan to wean as able.   Resp #Acute respiratory failure - Remains on vent, with plan to wean to TC as tolerated - Keep O2 sats above 90% - Vent wean as able   GI #Protien calorie malnutrition - Diet: NPO diet Nutren 1.5 - S/p PEG on 5/16 - Bowel regimen - Antiemetics PRN GU - Strict I&O's - Foley - Replace electrolytes PRN Endo - No active problems MSK - No issues Skin - Routine wound care, flap care per ENT Heme - Transfuse if Hgb<7 or symptomatic - Hgb 8.5 this AM - ASA 81mg ID 5/18: Trach asp - GNR   Antibiotic hx - Unasyn (5/17-   PPx - DVT: SCDs, Lovenox 30mg BID - GI: pepcid, protonix Dispo - STICU   Michaela F. Close Otolaryngology-Head & Neck Surgery, PGY-1 Pager ID: 10569 May 20, 2022 7:14 AM   Procedures by Heather Evans, MD MS at 5/20/2022  2:49 PM Procedures 1. ARTERIAL LINE INSERTION [RT101] Arterial Line Placement Note   Patient: Nicholas L Prince Date of birth: 7/10/1965 MRN: 001631137 Date of procedure: 05/20/22   Indication: Need for close blood pressure monitoring Procedure: Left radial arterial line insertion   Description of procedure: An Allen's test was performed prior to the procedure. The patient's Left wrist was prepped and draped in a normal sterile fashion. While using ultrasound guidance, the Left radial artery was verified. It was a pulsatile noncompressible vessel. Once it was visualized, the patient's wrist was anesthetized using 1% lidocaine without epinephrine. After it was anesthetized the Arrow Dart kit was used to enter the radial artery under direct visualization of the ultrasound. Once the artery was entered, a bright red pulsatile flow was noted in the catheter in the guidewire was advanced through the introducer needle. After the guidewire was introduced smoothly without resistance, the catheter was advanced over the guidewire to the vessel. Once the catheter was in the vessel the guidewire and needle were removed and discarded. There was bright red pulsatile blood coming from the arterial catheter. At this time the arterial line transducer was connected to the arterial line and a waveform was verified on the monitor. The catheter was then sutured to the skin and a sterile dressing was applied using a Tegaderm and Biopatch. The patient tolerated the procedure well.     Jose Gallegos, MD Department of Surgery, PGY-1 Pager: 10937 May 20, 2022   ATTENDING STATEMENT I was immediately available during the entire procedure. Heather Evans Pager ID: 14479 5/20/2022 3:35 PM   Plan of Care by Nurse Brianna V at 5/18/2022  7:32 PM Mr. Prince remains in the NSICU with Phenylephrine gtt infusing. Pt had several episodes of anxiety/restlessness followed by HTN sys 320s, SpO2 desaturations into mid 80s; recovered after bagging with Ambu and increasing sedation, then placing on higher ventilatory support. Team at bedside each episode, Bivona tube advanced by MD. Pt on and off precedex throughout the day, PRNs administered for pain/anxiety as needed with episodes. This evening, Pt dropped BP (70s/40s) both on A-line and NIBP; Manual BP done (100/36). Phenylephrine maxed, 500mL LR administered. Infectious workup completed; Chest X-ray, EKG done, labs sent. VSS now stable at this time. Will continue to monitor. Problem: Adult Inpatient Plan of Care Goal: Plan of Care Review Outcome: Ongoing, Progressing Goal: Patient-Specific Goal (Individualization) Outcome: Ongoing, Progressing Goal: Absence of Hospital-Acquired Illness or Injury Outcome: Ongoing, Progressing Goal: Optimal Comfort and Wellbeing Outcome: Ongoing, Progressing Goal: Readiness for Transition of Care Outcome: Ongoing, Progressing Goal: Rounds/Family Conference Outcome: Ongoing, Progressing Problem: Fall Injury Risk Goal: Absence of Fall and Fall-Related Injury Outcome: Ongoing, Progressing Problem: Skin Injury Risk Increased Goal: Skin Health and Integrity Outcome: Ongoing, Progressing Progress Notes by Julie  Blair, MS CCC-SLP at 5/20/2022  5:42 PM Medical University Hospital Authority Speech-Language Pathology Charting Report POST-OPERATIVE LARYNGECTOMY EVALUATION   Date of Service: 5/20/2022 Patient: Nicholas L Prince MRN: 001631137 CSN: 1172209793 DOB: 7/10/1965 Age: 56 y.o.   Attending Provider: Evert Eriksson, MD  Referring Provider: Albergotti, William Gre* Location of Treatment: STICU Date Therapy Plan Established (30): 05/20/22 Date Patient First Became Aware of Symptoms (11): 05/18/22 Date Service Initiated by Billing Provider (45): 05/20/22 Funding: Payor: MEDICARE / / / Primary Diagnosis: 1. S/P laryngectomy 2. Oropharynx cancer Treatment Diagnosis: 1. S/P laryngectomy 2. Oropharynx cancer   Patient Problem List [ICD-10]   Diagnosis Date Noted • Acute blood loss anemia [D62]   • Moderate protein-calorie malnutrition [E44.0]   • Acute respiratory failure following trauma and surgery [J95.821]   • Carcinoma of base of tongue [C01] 12/22/2021 • Oropharyngeal dysphagia [R13.12]   • S/P laryngectomy [Z90.02]   • Pharyngocutaneous fistula [J39.2] 02/09/2018 • Chronic obstructive pulmonary disease [J44.9]   • Intermittent asthma [J45.20]   • Gastroesophageal reflux disease without esophagitis [K21.9]   • Laryngeal cancer [C32.9] 12/18/2017 • Larynx cancer [C32.9] 08/28/2017   Pain: 6/10 (0=no pain to 10=E.R.) Pain reported by: patient Precautions: tracheostoma, PEG, NPO, IV, drain , post-operative, incision/suture site, O2 via tracheostomy mask, pulse oximetry, salivary bypass tube Allergies: The patient has No Known Allergies. Activity Status: Skill not obtained at this time Nutritional Screen: Patient is NPO Barriers to Learning: No Barriers   History of Present Illness: Mr. Prince is a 56 year old man with a a history of ypT3NxcM0 laryngeal squamous cell carcinoma status post salvage laryngectomy, complicated by pharyngocutatneous flap requiring pectoralis major reconstruction in 2018. He presented with a second primary cT2N0M0 oropharynx p16+ squamous cell carcinoma status post partial resection of left base of tongue. He underwent re-resection of L BOT SCC on 2/10/22 and was noted to have a recurrence. He underwent today a pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap. He is admitted to STICU after surgical intervention. Patient referred for consideration of transition to Moore tube and HME from Bivona. Patient familiar from prior admissions and ongoing TEP care. Past Medical History: The patient has a past medical history of Cancer, GERD (gastroesophageal reflux disease), and head and neck radiation (10/2016). Past Surgical History: The patient has a past surgical history that includes schwannoma (10/2007); pr removal of larynx (Unknown, 1/2/2018); pr create t-e fistula+speech prosthesis (1/2/2018); pr partial removal of pharynx (2/19/2018); pr muscle-skin flap,trunk (Unknown, 2/19/2018); pr reconstruction of throat (N/A, 2/19/2018); pr gastrostomy,open,w/o tube cnstr (N/A, 2/23/2018); pr esophagoscopy rigid trnso dx (3/12/2021); pr dilation esophagus guide wire (Bilateral, 3/12/2021); pr laryngoscopy,direct,diagnostic (Bilateral, 9/20/2021); pr part removal tongue,<1/2 (N/A, 11/12/2021); pr laryngoscopy,dirct,op,biopsy (N/A, 1/20/2022); pr rad resec tonsil/pillars (N/A, 2/10/2022); pr part removal tongue, 1/2 (2/10/2022); pr partial removal of pharynx (2/10/2022); pr resec pharyn wall,clos myocut flap (5/16/2022); pr excision submaxillary gland (5/16/2022); pr free musc-skin flap w/microvasc anast (5/16/2022); pr adj tiss xfer any area,30.1-60 sqcm (N/A, 5/16/2022); pr adj tiss xfer any area,ea add 30.0 sqcm (N/A, 5/16/2022); pr reconstruction of throat (N/A, 5/16/2022); pr egd percutaneous placement gastrostomy tube (N/A, 5/16/2022); pr removal nodes, neck,cerv mod rad (5/16/2022); pr removal nodes, neck,cerv mod rad (5/16/2022); and pr sub grft f/s/n/h/f/g/m/d >100cm (5/16/2022). Social History: The patient reports that he quit smoking about 5 years ago. His smoking use included cigarettes. He has a 60.00 pack-year smoking history. He has never used smokeless tobacco. He reports that he does not drink alcohol and does not use drugs. Current Mode of Communication: writing     EVALUATION Mental Status: alert Laryngectomy Evaluation (CPT 92597)   Stoma Observations - Condition: swelling from recent surgery narrowing stoma and resulting in colapse when unsupported - Diameter: 10mm - Stoma Support: Bivona, hyperflex, Size: 8 - Stoma Protection: trach collar - TEP Location: not visible at this time   The Bivona cuff was deflated and the sutures were clipped. The tube was removed and repalced with a #8 Moore tube without difficulty. The patient was then fit with a thermovent HME filter to maintain thin and manageable secretions. O2 remained at 87-89. An adaptor was placed on the incentive spirometer and the patient was able to reach volumes of 1500 and O2 increased to 96%   Handouts provided and reviewed with staff: Laryngectomy Anatomy Moore tube care and instructions   IMPRESSIONS Patient transitioned to Moore tube with HME without difficulty.   RECOMMENDATIONS Patient to use HME to maintain pulmonary health Patient to continue to write for communication Replacement of TEP once cleared for manipulation of prosthesis by managing team. Long-term goal: The patient will achieve adequate alaryngeal speech using TEP to be understood in a variety of settings meeting personal and professional communication needs. The patient will maintain an adequate airway using stoma stent and pulmonary health with HME Short-term goals: The patient will be able place and remove HME without cuing/assistance The patient will be able to place and remove laryngectomy tube without cuing/assistance The patient will be able to perform stoma care without cuing/assistance The patient will be re-evaluated on an ongoing basis to determine the appropriate plan of care following each therapy session. Upon the tenth therapy session or upon discharge, the patient will be formally re-evaluated and a new plan of care established. Thank you for allowing me to participate in the care of your patient. Please feel free to contact me at (843) 876-7200 if I may be of further assistance. Julie Blair, MA.CCC-SLP, BCS-S Speech-Language Pathologist Board Certified Specialist in Swallowing and Swallowing Disorders Scheduling: 843-876-7200 Office: 843-792-6953 Fax: (843)876-2881 Pager 11014 Progress Notes by Julie  Blair, MS CCC-SLP at 5/20/2022  5:42 PM Medical University Hospital Authority Speech-Language Pathology Charting Report POST-OPERATIVE LARYNGECTOMY EVALUATION   Date of Service: 5/20/2022 Patient: Nicholas L Prince MRN: 001631137 CSN: 1172209793 DOB: 7/10/1965 Age: 56 y.o.   Attending Provider: Evert Eriksson, MD  Referring Provider: Albergotti, William Gre* Location of Treatment: STICU Date Therapy Plan Established (30): 05/20/22 Date Patient First Became Aware of Symptoms (11): 05/18/22 Date Service Initiated by Billing Provider (45): 05/20/22 Funding: Payor: MEDICARE / / / Primary Diagnosis: 1. S/P laryngectomy 2. Oropharynx cancer Treatment Diagnosis: 1. S/P laryngectomy 2. Oropharynx cancer   Patient Problem List [ICD-10]   Diagnosis Date Noted • Acute blood loss anemia [D62]   • Moderate protein-calorie malnutrition [E44.0]   • Acute respiratory failure following trauma and surgery [J95.821]   • Carcinoma of base of tongue [C01] 12/22/2021 • Oropharyngeal dysphagia [R13.12]   • S/P laryngectomy [Z90.02]   • Pharyngocutaneous fistula [J39.2] 02/09/2018 • Chronic obstructive pulmonary disease [J44.9]   • Intermittent asthma [J45.20]   • Gastroesophageal reflux disease without esophagitis [K21.9]   • Laryngeal cancer [C32.9] 12/18/2017 • Larynx cancer [C32.9] 08/28/2017   Pain: 6/10 (0=no pain to 10=E.R.) Pain reported by: patient Precautions: tracheostoma, PEG, NPO, IV, drain , post-operative, incision/suture site, O2 via tracheostomy mask, pulse oximetry, salivary bypass tube Allergies: The patient has No Known Allergies. Activity Status: Skill not obtained at this time Nutritional Screen: Patient is NPO Barriers to Learning: No Barriers   History of Present Illness: Mr. Prince is a 56 year old man with a a history of ypT3NxcM0 laryngeal squamous cell carcinoma status post salvage laryngectomy, complicated by pharyngocutatneous flap requiring pectoralis major reconstruction in 2018. He presented with a second primary cT2N0M0 oropharynx p16+ squamous cell carcinoma status post partial resection of left base of tongue. He underwent re-resection of L BOT SCC on 2/10/22 and was noted to have a recurrence. He underwent today a pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap. He is admitted to STICU after surgical intervention. Patient referred for consideration of transition to Moore tube and HME from Bivona. Patient familiar from prior admissions and ongoing TEP care. Past Medical History: The patient has a past medical history of Cancer, GERD (gastroesophageal reflux disease), and head and neck radiation (10/2016). Past Surgical History: The patient has a past surgical history that includes schwannoma (10/2007); pr removal of larynx (Unknown, 1/2/2018); pr create t-e fistula+speech prosthesis (1/2/2018); pr partial removal of pharynx (2/19/2018); pr muscle-skin flap,trunk (Unknown, 2/19/2018); pr reconstruction of throat (N/A, 2/19/2018); pr gastrostomy,open,w/o tube cnstr (N/A, 2/23/2018); pr esophagoscopy rigid trnso dx (3/12/2021); pr dilation esophagus guide wire (Bilateral, 3/12/2021); pr laryngoscopy,direct,diagnostic (Bilateral, 9/20/2021); pr part removal tongue,<1/2 (N/A, 11/12/2021); pr laryngoscopy,dirct,op,biopsy (N/A, 1/20/2022); pr rad resec tonsil/pillars (N/A, 2/10/2022); pr part removal tongue, 1/2 (2/10/2022); pr partial removal of pharynx (2/10/2022); pr resec pharyn wall,clos myocut flap (5/16/2022); pr excision submaxillary gland (5/16/2022); pr free musc-skin flap w/microvasc anast (5/16/2022); pr adj tiss xfer any area,30.1-60 sqcm (N/A, 5/16/2022); pr adj tiss xfer any area,ea add 30.0 sqcm (N/A, 5/16/2022); pr reconstruction of throat (N/A, 5/16/2022); pr egd percutaneous placement gastrostomy tube (N/A, 5/16/2022); pr removal nodes, neck,cerv mod rad (5/16/2022); pr removal nodes, neck,cerv mod rad (5/16/2022); and pr sub grft f/s/n/h/f/g/m/d >100cm (5/16/2022). Social History: The patient reports that he quit smoking about 5 years ago. His smoking use included cigarettes. He has a 60.00 pack-year smoking history. He has never used smokeless tobacco. He reports that he does not drink alcohol and does not use drugs. Current Mode of Communication: writing     EVALUATION Mental Status: alert Laryngectomy Evaluation (CPT 92597)   Stoma Observations - Condition: swelling from recent surgery narrowing stoma and resulting in colapse when unsupported - Diameter: 10mm - Stoma Support: Bivona, hyperflex, Size: 8 - Stoma Protection: trach collar - TEP Location: not visible at this time   The Bivona cuff was deflated and the sutures were clipped. The tube was removed and repalced with a #8 Moore tube without difficulty. The patient was then fit with a thermovent HME filter to maintain thin and manageable secretions. O2 remained at 87-89. An adaptor was placed on the incentive spirometer and the patient was able to reach volumes of 1500 and O2 increased to 96%   Handouts provided and reviewed with staff: Laryngectomy Anatomy Moore tube care and instructions   IMPRESSIONS Patient transitioned to Moore tube with HME without difficulty.   RECOMMENDATIONS Patient to use HME to maintain pulmonary health Patient to continue to write for communication Replacement of TEP once cleared for manipulation of prosthesis by managing team. Long-term goal: The patient will achieve adequate alaryngeal speech using TEP to be understood in a variety of settings meeting personal and professional communication needs. The patient will maintain an adequate airway using stoma stent and pulmonary health with HME Short-term goals: The patient will be able place and remove HME without cuing/assistance The patient will be able to place and remove laryngectomy tube without cuing/assistance The patient will be able to perform stoma care without cuing/assistance The patient will be re-evaluated on an ongoing basis to determine the appropriate plan of care following each therapy session. Upon the tenth therapy session or upon discharge, the patient will be formally re-evaluated and a new plan of care established. Thank you for allowing me to participate in the care of your patient. Please feel free to contact me at (843) 876-7200 if I may be of further assistance. Julie Blair, MA.CCC-SLP, BCS-S Speech-Language Pathologist Board Certified Specialist in Swallowing and Swallowing Disorders Scheduling: 843-876-7200 Office: 843-792-6953 Fax: (843)876-2881 Pager 11014       Physician's Statement: In accordance with MUSC/Medicare guidelines, I certify (by co-signing this document) the need for these services furnished under this plan of treatment and while under my care. Progress Notes by Stuart M. Leon, MD at 5/20/2022  7:00 PM Critical Care Attending Note   Date May 20, 2022 Name McLovin L. Prince Time 7:00 PM MRN 1631137 Provider  Stuart M. Leon, MD DOB 07/101965   Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery • Acute blood loss anemia • Moderate protein-calorie malnutrition     Critical care conditions/services with ongoing management needs to prevent further organ failure or life threatening deterioration:   ‌‌ Respiratory Failure               ‌‌ Hypoxic  ‌‌ Hypercapnic             ‌‌ Requiring mechanical ventilatory support             ‌‌ Requiring VV ECMO ‌‌ Hypoxemia requiring supplemental oxygen ‌‌ Maintenance of invasive airway for aspiration prevention ‌‌ Cardiogenic shock  ‌‌ Heart Failure             ‌‌Inotropic support ‌‌Vasodilator titration             ‌‌IABP  ‌‌Impella  ‌‌LVAD  ‌‌RVAD  ‌‌VA ECMO             ‌‌PA catheter-guided therapy and interpretation ‌‌ Distributive Shock most likely contributed to by:             ‌‌ Sepsis  ‌‌ SIRS  ‌‌ Neurogenic vasoplesia  ‌‌ Adrenal insufficiency ‌‌ Trauma ‌‌ Hypovolemic Shock requiring blood product and/or fluid resuscitation             ‌‌ GI Bleed ‌‌ Periprocedural bleed ‌‌ Neurogenic shock secondary to spine injury ‌‌ Hypertensive urgency/emergency requiring anytihypertensive titration ‌‌ Metabolic acidosis ‌‌ Mixed acid-base disorder ‌‌ Liver failure ‌‌ Acute Kidney Injury  ‌‌ Acute Renal Failure ‌‌ Chronic Renal Failure             ‌‌ Renal Replacement Therapy ‌‌ Myocardial infarction or demand ischemia ‌‌ Cardiac dysrythmia management             ‌‌ Atrial ‌‌ Ventricular ‌‌ Atrial Fibrillation, new onset, Vent rate >150 ‌‌ Cardiopulmonary arrest resucitation time:    minutes today ‌‌ Post-cardiac arrest care/stabilization             ‌‌ Targeted temperature management / Therapeutic hypothermia ‌‌ Cerebrovascular Stroke             ‌‌ Ischemic ‌‌ Hemorrhagic ‌‌ Traumatic brain injury             ‌‌ With loss of consciousness >30min ‌‌ With loss of consciousness <30min ‌‌ Severe Delirium/Agitation or Encephalopathy ‌‌ Severe protein calorie malnutrition ‌‌ Other:   Overall Assessment/Plan:    The patient is critically ill with a high risk of complications due to the problems/condition(s) documented above.     Respiratory - tolerating trach trials. Oxygenating and ventilating well. No changes planned for tonight unless patient tires / has increased work of breathing. Continue pulmonary toilet.   CV - Anemia (acute blood loss) - will monitor hemoglobin level and follow hemodynamic status for signs of hemorrhage. Will consider transfusion for hemoglobin <7 or for signs of hemorrhage. Continue Lovenox for DVT prophylaxis. Hypertension - continue prn Labetalol.   GI - Severe protein calorie malnutrition. Tolerating goal tube feeds ( Nutren 1.5 @ 40 cc/hr). Continue Pepcid and Protonix per ENT protocol. Continue bowel regimen.   Renal - continue foley to gravity for now. Hypomagnesemia and Hypophosphatemia - Mg++ and PO4 replaced earlier today   ID - continue Unasyn   Endocrine - Good blood glucose control - not requiring insulin coverage at this time. Continue to monitor.   Neuro - Agitation. Off of Precedex. Will continue Valium and Seroquel. Pain control - continue Tylenol and Neurontin, and prn Oxycodone.   HEENT - Oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer on 5/15. Will continue flap checks. Follow drain output and character. Continue to aintain MAP > 80 (currently off of neo).   I have reviewed and discussed with the house staff the clinical course and findings above, as well as laboratory reports, X-ray reports, X-ray films, results of additional medical testing and monitored output as noted above. I personally examined the patient and discussed care plans on rounds with the house staff and health care team.     Stuart M. Leon, MD. Pager ID: 14339 Date: May 20, 2022 Time: 9:07 PM Progress Notes by PEREZ, PENNY LEIGH, NP at 5/20/2022  8:45 PM STBICU Progress Note I personally evaluated and treated this critically ill patient while in the hospital overnight.     Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery • Acute blood loss anemia • Moderate protein-calorie malnutrition     Vitals: Patient Vitals for the past 24 hrs:   BP Temp Temp src Pulse Resp SpO2 05/20/22 1400 138/66 — — 80 12 92 % 05/20/22 1300 152/72 — — 65 11 99 % 05/20/22 1200 119/68 37.2 °C (99 °F) Axillary 59 11 98 % 05/20/22 1100 135/65 — — 61 9 93 % 05/20/22 1000 133/69 — — 69 13 97 % 05/20/22 0835 — — — 70 17 98 % 05/20/22 0800 130/70 36.9 °C (98.4 °F) Axillary 66 14 100 % 05/20/22 0700 110/55 — — 58 11 95 % 05/20/22 0600 102/45 — — 65 12 93 % 05/20/22 0535 — — — 62 15 96 % 05/20/22 0500 134/66 — — 57 14 99 % 05/20/22 0404 — — — 58 15 99 % 05/20/22 0400 112/57 37.1 °C (98.8 °F) Axillary 59 16 99 % 05/20/22 0300 — — — 64 16 98 % 05/20/22 0211 — — — 62 19 99 % 05/20/22 0200 — — — 63 22 99 % 05/20/22 0100 — — — 65 19 100 % 05/20/22 0000 115/53 — — 66 17 99 % 05/19/22 2356 — — — 64 17 99 % 05/19/22 2300 116/59 — — 64 16 100 % 05/19/22 2200 106/55 — — 65 15 99 % 05/19/22 2100 113/61 — — 69 14 98 % 05/19/22 2008 — — — 75 15 99 % 05/19/22 2000 127/66 — — 82 17 99 % 05/19/22 1930 — — — 82 17 99 % 05/19/22 1900 (!) 201/92 — — 111 22 100 % 05/19/22 1818 — — — 92 15 100 % 05/19/22 1800 — — — 96 16 97 % 05/19/22 1759 — — — 105 23 97 % 05/19/22 1746 — — — 80 13 100 % 05/19/22 1726 — — — 74 21 100 % 05/19/22 1700 — — — 80 18 100 % 05/19/22 1600 — 36.7 °C (98.1 °F) Axillary 83 23 100 %     I/O: I/O last 3 completed shifts: In: 4652.04 [I.V.:2396.04; Other:626; NG/GT:280; IV Piggyback:1350] Out: 3578 [Urine:2985; Other:593]   Meds Scheduled: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • diazePAM 2.5 mg Per PEG Tube BID • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 400 mg Per G Tube Q8H • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • protein supplement 30 mL Oral Daily • QUEtiapine 25 mg Per OG/NG Tube Q8H • sennosides 8.8 mg Per G Tube BID     Meds PRN: LORazepam, ondansetron, oxycodone   Labs: Recent Labs Lab 05/19/22 0427 05/19/22 0603 05/20/22 0428 WBC 7.18 -- 5.93 HGB 9.0* -- 8.5* HCT 28.4* -- 27.3* PLT 148 -- 162 NA 143.0 -- 140.0 K 4.5 -- 4.0 CL 114* 112 112* CREATININE 0.7 0.7 0.8 BUN 7* 7* 9     Physical Examination: General appearance - alert, well appearing, and in no distress Mental status - awake, alert, writing on paper Eyes - PERRL Mouth - flap, sutures on both sides of mouth Neck - flap, edematous, incision with JP drains, Moore tube in place Chest - coarse bilateral breath sounds O2 Set (%): 40 % Set PEEP (cm H2O): 8 cm H20 Pressure Support (cm H2O): 8 cm H2O Heart - normal rate and regular rhythm, S1 and S2 normal Abdomen - distended, soft GU Male - Foley Neurological - opens eyes to voice, follows commands, no focal deficits Musculoskeletal - no joint tenderness, deformity or swelling Extremities - intact peripheral pulses   A/P: Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15.   Respiratory Failure - weaned to TC via Moore tube. Continue pulmonary toilet. And wean oxygen for sats > 94%.   MAP goal per ENT > 80 - Not requiring pressors for MAP goal.   Anemia (acute blood loss) - will monitor hemoglobin level and follow hemodynamic status for signs of hemorrhage. Will consider transfusion for hemoglobin between 7 and 8 or for signs of hemorrhage.   Malnutrition - continue enteral feedings via PEG tube.   Hypomagnesemia - replace to level of 2   Hypophosphatemia - Replace IV. Monitor level with renal function changes. Given critical illness replacement will aide in respiratory management.   The patient is critically ill with a high risk of complications due to the problems/condition(s) documented above.     My total direct critical care time spent on this patient's care today was 31 minutes, during which time period the patient was at significant risk of physiologic decompensation due to illness.  This includes my review of recent events and diagnostic results, my direct examination and assessment time, my rounding with the multidisciplinary ICU team including discussion of care goals and plans, as well as my discussion with the patient/family and other consultants.  It does not include time for procedures billed separately.   Penny Leigh Perez, NP Department of General Surgery STBICU Pager: 11890 5/20/2022 Progress Notes by Heather Evans, MD MS at 5/21/2022  6:33 AM Adult Critical Care Progress Note - Date: 5/21/2022 Patient Name: Nicholas Prince MRN: 001631137 Admission Date: 5/16/2022 ICU Day #: 5   Admitting Physician: William Greer Albergotti III, MD Surgeon(s): Surgeon(s): Edward Douglas Norcross, MD Judith M Skoner, MD Julian D Amin, MD William Greer Albergotti III, MD Alana Nicole Aylward, MD     Brief Hx: Mr. Prince is a 56 year old man with a a history of ypT3NxcM0 laryngeal squamous cell carcinoma status post salvage laryngectomy, complicated by pharyngocutatneous flap requiring pectoralis major reconstruction in 2018. He presented with a second primary cT2N0M0 oropharynx p16+ squamous cell carcinoma status post partial resection of left base of tongue. He underwent re-resection of L BOT SCC on 2/10/22 and was noted to have a recurrence. He underwent today a pharyngectomy and base of tongue resection, bilateral neck dissection, left submandibular gland excision and reconstruction with left latissimus dorsi flap. He is admitted to STICU after surgical intervention. Procedure went well, EBL 250 ml, UOP 2700. Admitted not on pressors, on propofol., received 1750 ml of LR and 4 L of plasmalyte.  Recent (24 hour) Events & Subjective Complaints:   5/17: Admitted to STICU overnight. Febrile overnight (Tmax 101.3). Remains sedated on propofol and on pressure support (40%, 10/8) via Bivona. UOP low this morning, plan to bolus 500cc / 2h per ENT. Will plan to wean vent and sedation today. Trickle TF started. Restarted home valium.   5/18: Continues to be febrile (Tmax 101.2). Overnight, became more agitated and pulling at lines, so propofol added in addition to precedex. Restarted neo to maintain MAP goal >80. Starting seroquel and prn ativan. Holding tube feeds this morning due to concern for regurgitation of tube feeds out of mouth.'   5/19: Back walled airway overnight with agitation, severe hypertension and tachycardia, decision to place ETT, valium sch 2.5 BID, 1 L LR given overnight   5/20: Patient with continued need for vent, precedex, and neo this morning, with plans to wean. Overnight, issue with Bivona backwalling, now resolved. Bivona changed to Moore in afternoon. Became hypertensive in PM, requiring prn labetalol.   5/21: NAEO. Patient remained stable off pressors. On 8L 30% TC. Trach culture resulted with Klebsiella aerogenes and moderate budding yeast.   Vital Signs: Temp: [36.4 °C (97.5 °F)-37.8 °C (100 °F)] 36.4 °C (97.5 °F) Heart Rate: [58-93] 76 Resp: [9-22] 11 BP: (110-161)/(55-85) 151/78 Arterial Line BP: (102-213)/(61-139) 147/139 Ins and Outs:   Intake/Output Summary (Last 24 hours) at 5/21/2022 0633 Last data filed at 5/21/2022 0626 Gross per 24 hour Intake 1657.5 ml Output 4402 ml Net -2744.5 ml   Lab results: Lab Results Component Value Date   WBC 6.08 05/21/2022   HGB 9.5 (L) 05/21/2022   HCT 29.6 (L) 05/21/2022   MCV 87.3 05/21/2022   PLT 225 05/21/2022   Lab Results Component Value Date   NA 143.0 05/21/2022   K 3.5 05/21/2022   CL 110 (H) 05/21/2022   CO2CT 27 05/21/2022   BUN 9 05/21/2022   CREATININE 0.8 05/21/2022   GLUCOSE 146.0 (H) 05/21/2022   No results found for: ALT, AST, GGT, ALKPHOS, BILITOT Lab Results Component Value Date   INR 1.26 (H) 05/18/2022   PTT 40.4 (H) 05/18/2022     Physical Exam General: alert, in no acute distress Neuro: AAO x3 HEENT: S/p flap reconstruction with paddle on right neck. Multiple drains with serosanguineous drainage. Flap vessel connected to venous doppler. Bivona in place via laryngectomy stoma. SBT sutured in place. CVS: RRR Resp: No increased work of breathing Device (Oxygen Therapy): humidified;tracheostomy collar (05/21 0600) Oxygen Concentration (%): [30] 30 (05/21 0600) Oxygen Flow (L/min): [4-8] 8 (05/21 0600) GI: S/ND/NT. PEG in place. Renal: Foley in place with clear yellow urine. MSK: No edema or cyanosis. Tissues: Intact / Healthy and See HENT   Medications Continuous: Scheduled: • acetaminophen 650 mg Per G Tube Q6H • ampicillin-sulbactam 3 g Intravenous Q6H • aspirin 81 mg Per G Tube Daily • diazePAM 2.5 mg Per PEG Tube BID • docusate sodium 100 mg Per G Tube BID • enoxaparin 30 mg Subcutaneous 2 times per day • famotidine 20 mg Per G Tube BID • gabapentin 400 mg Per G Tube Q8H • ondansetron 8 mg Intravenous 3 times per day • pantoprazole 40 mg Per G Tube Before bfast & before dinner • potassium chloride 40 mEq Per OG/NG Tube Once • protein supplement 30 mL Oral Daily • QUEtiapine 25 mg Per OG/NG Tube Q8H • sennosides 8.8 mg Per G Tube BID   PRN: HYDROmorphone, ipratropium-albuterol, labetalol, LORazepam, ondansetron, oxycodone   Radiology Recent pertinent imaging: XR Abdomen AP   Result Date: 5/17/2022 EXAMINATION: ABDOMEN, 1 VIEW 5/17/2022 3:43 AM ACCESSION NUMBER: 19578004 INDICATION: sp PEG ENT ca s/p flap COMPARISON: none TECHNIQUE: AP supine radiograph of the mid abdomen was obtained on 2 cassettes. FINDINGS: The gastrostomy tube balloon overlies L mid abdomen. Jackson Pratt drain over L upper abdomen The intestinal gas pattern is normal. No calcifications over the biliary or urinary tract are visible. Temperature probe over rectum   IMPRESSION: gastrostomy tube balloon over stomach. I, Stephen Schabel, MD, have reviewed the study and agree with the findings in this report. 5/17/2022 7:20 AM   Assessment and Plan Nicholas L Prince is a 56 y.o. male with oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer, as well as PEG on 5/15.     Patient Active Problem List Diagnosis • Larynx cancer • Laryngeal cancer • Chronic obstructive pulmonary disease • Intermittent asthma • Gastroesophageal reflux disease without esophagitis • Pharyngocutaneous fistula • Oropharyngeal dysphagia • S/P laryngectomy • Carcinoma of base of tongue • Acute respiratory failure following trauma and surgery • Acute blood loss anemia • Moderate protein-calorie malnutrition     Neuro - Pain control: tyl, gaba; PRN oxycodone, dilaudid - Anxiety: Seroquel, valium 2.5 BID (home med), ativan prn   HEENT #Oropharyngeal SCC s/p partial glossectomy & oropharyngectomy, bilateral neck dissection, and reconstruction via left latissimus free tissue transfer on 5/15: q1h flap checks per ENT MAP goal >80 ASA 81mg and LVX Moore tube in place (s/p prior laryngectomy) Multiple drains (3 in neck, 2 in left upper back), mgmt per ENT   CV #Hypotension, now resolved - Hypotension formerly requiring pressors and fluid resuscitation   #Hypertension - Patient reportedly not on antihypertensives at home - prn labetalol   Resp #Acute respiratory failure, resolved - Tolerating trach collar - Keep O2 sats above 90% - Vent wean as able   GI #Moderate Protein calorie malnutrition - Diet: NPO diet Nutren 1.5 - S/p PEG on 5/16 - Bowel regimen - Antiemetics PRN GU - Strict I&O's - Foley - Replace electrolytes PRN Endo - No active problems MSK - No issues Skin - Routine wound care, flap care per ENT Heme - Transfuse if Hgb<7 or symptomatic - ASA 81mg ID 5/18: Trach asp - GNR, klebsiella (enterobacter) aerogenes, moderate budding yeast   Antibiotic hx - Unasyn (5/17-   PPx - DVT: SCDs, Lovenox 30mg BID - GI: pepcid, protonix Dispo - STICU   Michaela F. Close Otolaryngology-Head & Neck Surgery, PGY-1 Pager ID: 10569 May 21, 2022 6:38 AM   ATTENDING STATEMENT This note was created with contributions by residents, nurses, students and/or other members of the medical team. Resident and medical student activities follow teaching physician guidelines.   I have confirmed the history with the patient and personally examined the patient at bedside. I have reviewed, edited as needed, and agree with contents of this note. I participated in assessments and plans and have updated and edited the assessment and plan for each problem as needed.   Moderate protein calorie malnutrition - continue tube feeds, increase to goal OK for transfer to HDU today   Time Factor Billing: The total amount of time spent with the patient was 25 minutes, with greater than 50% spent in consultation, education, and coordination of care.   Heather Evans, MD MS Pager ID: 14479 5/21/2022 10:18 AM