tokens: Admission Date : 2016-11-21 Discharge Date : 2016-11-30 Date of Birth : 1953-10-19 Sex : M Service : CMED CCU CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS : Mr. Jackson is a 63-year-old male with squamous cell carcinoma of the floor of mouth ( stage T2 N0 ) that was biopsied by his dentist . Pathology was reviewed revealing invasive squamous cell carcinoma . He presented on 2016-11-21 for resection . He was admitted on 2016-11-21 following his surgery . He underwent a joint procedure by Otolaryngology and Plastic Surgery . PAST MEDICAL HISTORY : Includes hypertension and chronic obstructive pulmonary disease . PAST SURGICAL HISTORY : Polypectomy in 2011 , tooth extraction ( all ) in 1980 , and hernia in 1977 . ALLERGIES : TOMATO ( causing anaphylaxis ) and TETANUS SHOT . MEDICATIONS ON ADMISSION : Triamterene/hydrochlorothiazide 37.5/25 mg one tablet by mouth once daily and lorazepam 1 mg three times daily as needed ( for anxiety ) . SOCIAL HISTORY : He has a half-pack per day smoking history and drinks approximately three to four alcoholic beverages per day . PROCEDURES PERFORMED: 1. Tracheostomy . 2. Diagnostic laryngoscopy and biopsy . 3. Bilateral supraomohyoid neck dissection . 4. Resection of floor of mouth tumor . SUMMARY OF HOSPITAL COURSE : Surgeon was Dr. Kelsey K Sanchez . Assistant was Dr. Justin K.. Velez . Frozen section sent to pathology revealing invasive squamous cell carcinoma . No complications . The Plastic Team then took over for reconstruction consisting of radial forearm free flap to floor of mouth . Surgeon was Dr. Jude. Christopher Swinney . Total intravenous fluids of 7300 cc . Estimated blood loss of 300 cc . Urine output of 900 cc . No complications . In addition , the patient was prepared for an attempted percutaneous endoscopic gastrostomy tube . The percutaneous endoscopic gastrostomy was unsuccessful , and the procedure was converted to an open gastrostomy tube which then proceeded without complications . The patient was admitted to the Surgical Intensive Care Unit postoperatively . He was sedated and ventilated by his tracheostomy 6 cuff Shiley tube . He had three Westwood-Pocasset drains - two in the neck and one in his right arm . G-tube was to gravity , Foley to gravity , left radial A-line . The flap was pink with a strong Doppler signal . He underwent flap checks every 15 minutes initially with a dextran infusion . He was placed on Unasyn 3 grams IV q.6h. Nothing by mouth initially with morphine as needed for pain and Ativan around the clock for delirium tremens prophylaxis . In addition , he received metoprolol q.4.h. , a regular insulin sliding scale , and adequate gastrointestinal prophylaxis with Protonix . Postoperative laboratories revealed sodium was 134 , potassium was 4.1 , chloride was 102 , bicarbonate was 28 , blood urea nitrogen was 18 , creatinine was 0.8 , and glucose was 148 . Calcium was 7.6 . Magnesium was 2.2 . Complete blood count revealed white count was 5.4 , hematocrit was 31.3 , and platelets were 160 . ALT was 14 , AST was 31 , alkaline phosphatase was 42 , total bilirubin was 0.9 , albumin was 2.2 . A chest x-ray postoperatively showed clear lung fields . Tracheostomy tube in good position . No pneumothorax . By systems : CMED CSRU and Plastic Surgery flap checks , tracheostomy care , and Westwood-Pocasset management. Cardiovascular : Lopressor 5 intravenously q.4.h. Respiratory : Nebulizers as needed , weaning from ventilation . Gastrointestinal : Medications per gastrostomy tube on postoperative day one . Genitourinary : Foley catheter for strict monitoring of ins and outs . Hematologic : Hematocrit stable . Infectious Disease : Unasyn for antibiotic coverage . Flap checks carried out q.2h. initially in the Surgical Intensive Care Unit showing positive biphasic Doppler signals . Pink flap with good refill . Right arm neurovascularly intact . He was weaned from ventilation on postoperative day one to pressure support ventilation and then to spontaneous breathing on postoperative day two . His Westwood-Pocasset output for postoperative day one on the left was 60 , right neck 93 , in the arm 20 . Tube feedings were started 48 hours after the procedure . The cuff on his tracheostomy tube was put down on 11-23 , postoperative day two which he tolerated well with minimal secretions and a strong adequate cough . Due to bed issues , he was transferred from the Surgical Intensive Care Unit to the Medical Intensive Care Unit on postoperative day three . His tube feedings were advanced . He was out of bed to a chair . He continued with pulmonary toilet and q.2h. flap checks . The Westwood-Pocasset in his right arm was removed on 2016-11-25 . His tracheostomy was changed to a 6 cuffless Shiley on 2016-11-26 and sutures in place with a 3-0 silk . The patient tolerated this procedure well . This is the end of part 1 of this dictation summary for Patricia Jackson . To be continued in a separate dictation . Nola Daniel , Hawaii 31699 Dictated By:Joe C. Roa , M.D. MEDQUIST36 D : 2016-11-30 10:56:11 T : 2016-11-30 11:44:01 Job# : 77004 Signed electronically by : DR. Michael Z Waldroup on : MON 2016-12-19 10:13 AM ( End of Report )