Brief Summary/Flow of Events

11/04/XXXX

6 weeks pregnant, presented to Obstetrics for complaints of abdominal pain, exacerbation of Crohn’s disease.

11/16/XXXX – 11/22/XXXX

Multiple visits for the same condition. Taking Zoloft for depression.

12/03/XXXX

Dr. Mary ordered Zoloft 100 mg for anxiety and depression.

12/16/XXXX

Stopped taking Zoloft.

01/26/XXXX

Obstetrical Ultrasound: Left Ventricular Outflow Tract (LVOT) and Right Ventricular Outflow Tract (RVOT) not well visualized.

06/07/XXXX

Obstetrical Ultrasound:Amniotic Fluid index (AFI) below mean.

06/17/XXXX

Baby boy delivered with Truncus Arteriosus type 1 and other heart discrepancies.

06/21/XXXX & 06/25/XXXXX

Defect operated upon and corrected.

07/08/XXXX

Post op evaluation showed the boy was doing well after discharge.

Patient History

Past Medical History:Mother withCrohn’s disease. Mother treated with iron, Xanax, Remicaid every 4 weeks, Prednisone, Zoloft, Asacol, Darvocet, Phenergan, Rowasa, and Lialda.

Surgical History:No prior surgery

Family History:Cousin with hole in heart, hypertension, lung cancer.

Social History:Not applicable

Allergy: No known allergies

Brief Description of Injury: The patient was born with Truncus arteriosus type 1, Quadricuspid truncal valve with small left and right coronary cusps- thickened dysplastic truncal valve leaflets, Malaligned conoventricular ventricular septal defect, small patent ductus arteriosus and Patent Foramen Ovale.

Name of the Pharmacy: NA

Name of Medication Used/ Product ID / Dates of Use / Name of prescribing Health Care Provider
Zoloft / 11/22/XXXX
-
12/03/XXXX / NA
Zoloft / 12/03/XXXX
-
12/09/XXXX / Dr. Mary, M.D.

Detailed Chronology

DATE / PROVIDER / OCCURRENCE/TREATMENT / PDF Ref.
11/22/XXXX / Mary, M.D. / Initial Pregnancy Profile:
History: Headaches, nausea/vomiting, abdominal pain, contraception – BC pills used at age 18 yrs; spotting/irregular menses
Medications: Remicaid, Zoloft, Xanax, Iron, Prednisone, Zofran, Phenergan, Darvocet, Macrobid, Prenatal
Initial Physical Examination:
Ht – 5’8”, Wt – 152 lbs, Pre-gravid Wt – 169 lbs / 650
11/22/XXXX / Prenatal Flow Record:
Still has thrush, hard to eat, bland food, 1-2 stools/day. Pain resolved, no Darvocet. Xanax infrequently, on Zoloft 50 mg daily. Recommend flu vaccine – need to be checked with Dr. Charles. / 647
12/03/XXXX / Maryland Prenatal Risk Assessment:
Obstetrics History: 1 spontaneous abortion, 1 therapeutic abortion.
Psychosocial Risks: Current pregnancy unintended, physical disability – Crohn’s disease, exposure to long-term stress. Has PICC line, IV fluids.
Medical Risks: Anemia,Obsessive-compulsivedisorder (OCD) history of depression, abnormal PAP HGSIL / 686
12/03/XXXX / St. John’s Medical Center
Mary, M.D. / Doctor’s Orders: (Illegible Notes)
Admit Diagnosis: 11 week pregnancy with Crohn’s disease
  • Prednisone 20 mg by mouth (p.o.) daily
  • Zoloft 100 mg p.o. daily
  • Xanax 1 mg p.o. thrice daily (t.i.d.) p.r.n.
/ 698
12/13/XXXX / St. John’s Medical Center
Michael Stanford, M.D. / Nuchal Translucency Study:
There is an early intrauterine gestation with estimated gestational age of 12 weeks and 4 days. Fetal heart motion is documented. Nuchal translucency is 1.2 mm. / 689
12/16/XXXX / Prenatal Flow Record: (Illegible Notes)
Prednisone 40 mg, multivitamins, hasn’t needed Phenergan or Xanax, stopped Zoloft. Feeling better, appetite improved. Last exam today 2 PM. One normal stool a day. Patient very excited to see Dr. Aloysius _____, to see Dr. Charles 12/21/XXXX / 647
01/26/XXXX / Peninsula Imaging
Alexander Bell, M.D. / Obstetrical Ultrasound:
Indications: Anatomy, please evaluate for cleft palate
Conclusion: Intrauterine pregnancy of 18 weeks and 6 days
Fetal Anatomy:
  • The following structures are visualized with suspected abnormality: N/A
  • The following structures are normal for fetal age unless specified above: Lateral ventricles, thalamus, cerebellum/cisterna, fetal face, umbilical cord insert, 3 vessel cord, choroid plexus, fetal heart motion, diaphragm, kidneys, stomach, bladder, humerus, radius, ulna, femur, tibia and fibula.
  • The following structures are not well visualized: C-spine, T-spine, L-spine, S-spine, 4-chambered-heart, LVOT, and RVOT.
  • Other: Limited anatomy due to fetal position.
/ 651-652
06/07/2011 / Radiology Imaging
Marvin Nelson, M.D. / Limited Obstetrical Ultrasound:
Indications: Growth / Size / Fluid / Position
Conclusion: Single fetus. Averaged age based on ultrasound measurement of 37 weeks and 4 days. Gestational age based on previous studies is 38 weeks and 4 days. There has been expected interval growth since our previous study. The Amniotic FluidIndex (AFI) is slightly below the mean. / 673
06/18/2011 / National Medical Center
Adrian Howard, M.D. / History & Physical:
HPI: Days Of Life (DOL) 2 infant born to 24 year old G3P0020 (with history of severe Ulcerative Colitis (UC) and Crohn’s, Gastro Esophageal Reflux (GER), depression) with negative serologies, Gestational Blood Sugar (GBS) negative, AB+ mother. Born via Spontaneous Vaginal Delivery (SVD) with APGAR’s of 9 and 9. Was found to have a murmur and echocardiogram performed and read by technologist was suspicious for bicuspid aortic valve, Aortic Stenosis (AS) and Aortic insufficiency (AI). There was also some question of a small Ventricular Septal Defect (VSD). Prior was tolerating PO feeding, active and vigorous; no cyanosis and no evidence of shock. Arterial Blood Gases (ABG) obtained showed 7.41/40/44/25/+1 - No sat difference, no BP gradient.
Cardiovascular diagnosis:Aortic insufficiency, Aortic stenosis, Pulmonic stenosis
Plan: Studies (Echocardiogram, EKG), Cardiology Consult. / 130-132
06/21/2011 / National Medical Center
Pranava Smita, M.D. / Operative Record:
Pre & Post-operative Diagnosis: Truncus arteriosus type 1 with moderate truncal valve regurgitation
Procedure Performed: Repair of Truncus Arteriosus, Ventricular septal defect repair with a Dacron patch, Truncal Valve repair, establishment of right ventricle to pulmonary artery with a 13mm valved segment of Femoral Vein homograft, PDA closure / 386-393
06/22/2011 / National Medical Center
Christopher Reddy, M.D. / Surgical Pathology Report:
Final Pathologic Diagnosis: Thymus, thymectomy; Thymus with stress reaction. / 55-56
06/25/2011 / National Medical Center
Ding Shang, M.D. / Operative Record:
Pre & Post-operative Diagnosis: Open chest status post Truncus arteriosus type 1 repair.
Procedure Performed: Delayed sternal closure. The patient remained stable throughout the procedure. / 397-398
07/08/2011 / National Medical Center
Kathleen Harrison, N.P. / Post-operative Evaluation:
Patient is accompanied by his mother and father, who report that he has done very well since discharge. They deny interval fever, congestion, and cough, increased work of breathing, diaphoresis, vomiting or diarrhea. They note that he is feeding very well and is taking 2.5-3 ounces every 2 hours with good urine output and regular stools.
On physical exam, he is afebrile. Heart rate is 126 beats per minute and his blood pressure is 85/34 in the right arm. Pulse Oximetry is 100% on room air. Heart rate and rhythm are regular with a normal S1 and single S2. There is a 3/6systolic murmur heard best at the left upper sternal border. Median sternotomy is with external sutures in place.
At today’s visit, an electrocardiogram was obtained which was unchanged from discharge and continued to reveal a normal sinus rhythm at a rate of 111 beats a minute with right atrial enlargement, left ventricular hypertrophy, and nonspecific ST abnormality. Chest X-Ray revealed a stable heart size and interval improvement in lung aeration and decreased evidence of edema since discharge.
Overall, the patient appears be doing very well following his recent discharge from the hospital. / 122-124

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