DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSIS: Metastatic colon cancer.
DISCHARGE DIAGNOSIS: Metastatic colon cancer.
BRIEF HISTORY AND HOSPITAL COURSE: The patient is a (XX)-year-old male who was admitted to the hospital with a diagnosis of metastatic colon cancer to two segments of his liver. He was admitted on MM/DD/YYYY and was taken to the operating room. In the operating room, he underwent low anterior resection to resect his colon cancer and then underwent a segment VIII resection as well as a segment VI wedge resection. The patient had epidural anesthesia administered by the anesthesiologist and was sent to the floor postoperatively. The patient did well postoperatively.
On postoperative day #1, he had not passed any gas nor had any bowel movements. However, we were able to discontinue his NG tube, as he did have a soft flat belly. On postoperative day #2, the patient seemed to be doing very well. No nausea and vomiting. He was tolerating some ice chips very well. The patient was able to get out of bed at this time and was ambulating on his own.
On hospital admission day #5, the patient continued to do well. He was passing gas at this time, and we were able to advance his diet. On hospital admission day #6, he continued to do well with no problems. His white count was normal, he had been afebrile, and it was decided to give him a regular diet. On the morning of hospital admission day #8, reevaluated the patient. This was now postoperative day #7. He began complaining of abdominal pain and had vomited two times. The night before, he refused his NG tube, and he had had a bowel movement. He said he started to feel pain after his bowel movement.
At that time, it was decided to do a CAT scan, as his white count had gone up and his symptoms were concerning, as well as he had developed a fever of 102.6. CAT scan showed a lot of intraperitoneal fluid with distended loops of bowel, and the patient had developed an acute abdomen. The CAT scan also showed free intraperitoneal air. By this point, it was decided to take him to the operating room and explore him.
We took the patient to the operating room. A large amount of liquid stool was found throughout the abdomen. The anastomosis of the lower anterior resection was evaluated and found to have an anastomotic perforation. At this time, we just irrigated the abdomen and descending loop colostomy that was stapled off on the distal end was brought up. The patient went to the ICU postop, still intubated. In the ICU, he did fairly well, except that he required persistent intubation, as he was unable to be extubated in the operating room. The patient was on broad-spectrum antibiotics, including Zosyn and gentamicin.
The patient had a triple-lumen catheter placed on hospital admission day #9 by the ICU team without any complications. He had two Jackson-Pratt drains in place at this time, and they were putting out a fair amount of fluid, in the 100 mL range. On hospital admission day #10, the patient had come from a PRVC mode to an IMV. However, the patient was extremely irritable, fighting the vent, and very restless, so it was decided to sedate the patient again and put him back on the PRVC mode. He underwent several trials of extubation, but the patient would not tolerate it. He kept getting agitated and required more sedation.
By hospital admission day #11, the Jackson-Pratt drainage had decreased into the 70s and 40s range. It was decided to start tube feeds on hospital admission day #11 through the NG tube when the patient started to have some bowel function through his ostomy. On hospital admission day #14, the patient was having better bowel function, and it was decided to increase his tube feeds and discontinue his TPN in the next 48 hours.
On hospital admission day #14, in the morning, it was noted that the patient’s midline wound looked like it was separating on the superior aspect. It was thoroughly inspected and found that he had had a dehiscence on the superior aspect of the wound. After evaluation with the primary surgeon as well as another attending surgeon, it was decided that the patient was not stable enough to go back to the operating room and that we would just put wet-to-dry dressings on the wound and keep the patient intubated.
Infectious disease consultation was obtained on hospital admission day #14. The patient had a CAT scan, and it showed a fluid collection in the pelvis. The patient was taken to Interventional Radiology and this was aspirated and there was no frank pus noted from there; however, there was some bloody ascites noted. On hospital admission day #15, the patient was now on broad-spectrum antibiotics from the infectious disease team, including Zyvox, meropenem, caspofungin, vancomycin, and Flagyl. He still had his JP drains in place, and now, he had an interventional radiology drain in place, and he now had a VAC dressing on his midline wound.
On the morning of hospital admission day #16, the patient was more awake and responsive without fighting the vent. It was decided to discharge the patient on CPAP. On hospital admission day #17, the patient was doing very well. He was tolerating CPAP. It was decided to attempt an extubation. On hospital admission day #18, the patient had a tremendous amount of improvement. He was alert and oriented, and he had been extubated and was tolerating a clear liquid diet. On hospital admission day #19, the patient was still in the ICU with his drains in place, which were draining minimal amounts of fluid. He was transferred to the floor on hospital admission day #19 with one JP out.
On hospital admission day #20, the second JP was removed, and on hospital admission day #21, the patient was tolerating a regular diet and had good bowel function. His percutaneous drain was taken out. However, the patient was having large amounts of ostomy output. We were concerned about C. diff, which was sent. However, the C. diff came back negative. He was empirically started on Flagyl in the interim before the results came back as negative. Again, the patient had another C. diff sent which was negative, and it was decided to start the patient on Lomotil on hospital admission day #22. The patient did well on the Lomotil, and his ostomy output decreased. He continued to have his VAC dressing in place. His white count had decreased, and all of his cultures were coming back negative. The patient continued to do well and was able to be discharged to a rehab facility on hospital admission day #23.
