DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSIS: Status post right hemicolectomy and repair of ventral hernia.
DISCHARGE MEDICATIONS:
1. Nexium 40 mg p.o. daily.
2. Claritin 10 mg p.o. daily.
3. Allopurinol 300 mg p.o. daily.
4. Maxzide 37.5 mg p.o. daily.
5. Tricor 145 mg p.o. daily.
6. Remeron 30 mg p.o. daily.
7. Aspirin 81 mg p.o. daily.
8. Trazodone p.r.n.
9. Viagra p.r.n.
10. Multivitamins.
11. Fish oil.
12. Garlic.
13. Monthly B12 shots.
14. Percocet 5/325 mg 1-2 p.o. q. 4-6 h. p.r.n. pain.
PROCEDURE: The patient underwent a right hemicolectomy for hepatic flexure cancer. He also underwent repair of a ventral hernia.
REASON FOR ADMISSION: The patient is a (XX)-year-old male who underwent a Billroth I gastric resection for a chronic refractory ulcer. The patient was sent to Dr. Jane Doe in order to have an upper endoscopy as well as colonoscopy. The upper GI was normal; however, on colonoscopy multiple polyps were seen, most of which were adenomatous. There was a large lesion at the hepatic flexure that was ulcerated and biopsy of this revealed carcinoma. He was referred to Dr. John Doe for surgical management. He was seen and on examination was noted to have a ventral hernia in the previous midline incision. It was recommended that he undergo surgical removal of the right colon as well as ventral hernia repair.
PAST MEDICAL HISTORY: Hypertension, gout, osteoarthritis, ankylosing spondylitis, chronic depression, chronic peptic ulcer disease requiring Billroth I resection. He has also had appendectomy and back fusion. He has been found to have some mild cirrhotic changes thought to be due to either alcohol or fatty infiltration.
FAMILY HISTORY: Significant for sister with ulcerative colitis and colon cancer. His father died at the age of 84 after multiple strokes. His mother died at age 74 from congestive heart failure and multiple sclerosis.
SOCIAL HISTORY: The patient is married, father of 4 children who lives alone. He denies smoking. He currently consumes 3-4 beers a day; however, drank more heavily in the past.
ALLERGIES: PENICILLIN.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished male, in no acute distress.
HEENT: Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae anicteric. Mucous membranes are moist. Uvula and tongue are midline.
NECK: No thyromegaly. No JVD or carotid bruits.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rhythm and rate. No S3 or murmur.
BACK: No CVA tenderness.
ABDOMEN: Well-healed incisions vertically in the midline and also in the right lower quadrant. A palpable defect is present in the vertical midline incision. There is no bulging noted. Positive bowel sounds are noted in all 4 quadrants. The abdomen is soft, nontender and nondistended without organomegaly.
EXTREMITIES: Peripheral pulses are 2+ bilaterally. Varicose veins are noted posteriorly on the calf and both legs. There is no cyanosis or edema.
MUSCULOSKELETAL: Limited range of motion in the back. Strength appropriate.
NEUROLOGIC: Alert and oriented x3. DTRs 2+ bilaterally. Cranial nerves II through XII are grossly intact.
LABORATORY DATA: On the day of admission, the patient was found to have a hematocrit of 39.
HOSPITAL COURSE: The patient was admitted after undergoing a right hemicolectomy and repair of a ventral hernia. His pain was well controlled with the use of morphine PCA as well as IV Toradol. On postop day #4, he began to pass flatus and eventually stool. His diet was advanced as tolerated and he was begun on his home medications. On postop day #6, he was tolerating a low-residue diet and ambulating without difficulty in the halls. He was having multiple daily bowel movements and it was felt that he was stable for discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: He will be discharged home without services.
FOLLOWUP INSTRUCTIONS: The patient was advised initially to follow a low-residue diet for the first week postop and slowly introduce high-fiber foods. He should not drive for 1-2 weeks while taking narcotic pain medication. He should not lift more than 20 pounds nor engage in strenuous activity for 4-6 weeks. He can gradually resume his normal activities and get mild daily exercise. The patient can shower but should not bathe or submerge his incision in water. He will be discharged with staples in place and will return in 3 days to the Colorectal Clinic for removal of his staples. He will follow up in 4 weeks with Dr. John Doe. He will be discharged on Percocet for management of his pain. He should call the physician if he develops a temperature greater than 101 degrees Fahrenheit, if he has pain that is increasing and not relieved by Percocet or if his incision has purulent drainage or any signs of infection.
********************************************************
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Community-acquired pneumonia.
2. Anemia, status post transfusion with 1 unit of packed red blood cells.
MEDICATIONS AT DISCHARGE:
1. Levaquin 750 mg p.o. daily for 5 days.
2. Home oxygen 2 liters of nasal cannula.
3. Glucotrol 10 mg p.o. daily.
4. Lisinopril 20 mg p.o. daily.
5. Metformin 500 mg p.o. b.i.d.
6. Albuterol 2 puffs t.i.d.
7. Combivent 2 puffs t.i.d.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old male with history of COPD, type 2 diabetes, transfusion-dependent anemia and colon cancer status post right hemicolectomy, who presents with overall weakness and dyspnea on exertion. He states that he knows when he needs transfusion and he felt that his hematocrit was low at the time of presentation. He also noted that he has been short of breath and had been producing orange-colored sputum over the last couple of days. He did not notice any fevers at home; although, when he arrived in the emergency room, his temperature was 102.4.
REVIEW OF SYSTEMS: Negative.
PAST MEDICAL HISTORY:
1. Diabetes type 2.
2. Colon cancer status post hemicolectomy.
3. Transfusion-dependent anemia with ring sideroblasts.
4. Bone marrow failure.
5. COPD.
6. Gastric ulcers.
7. Hypertension.
8. TIA.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Glucotrol.
2. Lisinopril.
3. Metformin.
4. Albuterol.
5. Combivent.
SOCIAL HISTORY: The patient lives with his wife and he has a primary caretaker in his wife. He is independent for all his ADLs. No alcohol. Remote tobacco history.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION:
VITAL SIGNS: On arrival, his temperature was 102.4, pulse 86, blood pressure 142/80, 92% on room air.
GENERAL: The patient is a very pleasant male, alert and oriented x3.
HEENT: Pupils equal, round and reactive to light. Extraocular movements are intact.
NECK: No JVD.
CARDIOVASCULAR: Regular rate and rhythm. Soft systolic murmur.
LUNGS: Crackles, both bases, left greater than right.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY DATA: WBC 9.6 with 73 polys and 9 bands. Hematocrit 25.4 and platelets of 450. Sodium 138, potassium 4.4, chloride 104, bicarb 28, BUN 16, creatinine 0.8, and calcium 9.0.
Chest x-ray showing multifocal infiltrates in the left upper lobe, left lower lobe, right lower lobe and lingula.
HOSPITAL COURSE: The patient was admitted for treatment of his community-acquired pneumonia and hypoxia. He was started on Levaquin p.o. The morning after his admission, he felt much improved and was afebrile. He was transfused 1 unit of packed red blood cells during his admission for his hematocrit of 25.4. His posttransfusion hematocrit is 28.6. He has an upcoming appointment with Dr. John Doe in hematology in 4 days and he may get another transfusion at that point. The patient said that he had to get home to take care of his wife, and although it would be ideal for the patient to stay longer for treatment of his pneumonia, as he felt much improved on p.o. Levaquin, we have agreed to discharge him to home with home oxygen and high dose of p.o. Levaquin at this time.
DISCHARGE CONDITION: Stable.
DISCHARGE INSTRUCTIONS:
1. Discharged home with VNA and home O2.
2. Follow up with Dr. John Doe in 1 week with a chest x-ray.
