DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
PRINCIPAL DIAGNOSIS: Partially obstructing transverse colon cancer.
SECONDARY DIAGNOSES:
1. History of hypothyroidism.
2. Depression.
3. Kidney stones.
4. Duodenal ulcer, status post knee arthroscopy.
PRINCIPAL PROCEDURES:
1. Extended right colectomy.
2. CAT scan of the abdomen and pelvis.
3. Water-soluble enema.
4. NG tube placement.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a 24-hour history of abdominal pain, mainly in the right lower quadrant. He describes it as band-like, and it has gradually increased in severity. The pain is accompanied by nausea and vomiting. Recent stools have been dark and loose. He has been able to pass flatus. His normal bowel pattern is to have two bowel movements per day, but he has been having increasing diarrhea in the last several weeks. The patient has been more fatigued than usual. His weight is stable. He has had a sigmoidoscopy in the past. The patient has not had a complete colon evaluation.
PAST MEDICAL HISTORY: As previously related.
ALLERGIES: No known drug allergies.
MEDICATIONS: Zoloft 50 mg p.o. every day and Synthroid 50 mcg p.o. every day.
SOCIAL HISTORY: Married. Denies smoking. Has rare alcohol intake.
PHYSICAL EXAMINATION: Temperature 98.4, pulse 92, blood pressure 124/62. The patient is a well-developed, well-nourished male, in no acute distress. HEENT within normal limits. Sclerae are anicteric. Heart is regular. S1, S2 normal. Lungs are clear. Abdomen is soft with mild tenderness on the right side of the abdomen to deep palpation. No guarding or rebound. Positive tympany, especially on the right. No masses. No inguinal hernias. Femoral and popliteal pulses 2+ bilaterally. Extremities are without edema.
ADMISSION LABORATORIES: White blood count 11.6, hematocrit 43.2, platelets 321, 81 polys and 1 band. Potassium 5, bicarb 24, creatinine 1, glucose 140, albumin 3.6, troponin less than 0.1. INR 1.2. KUB: Suspected bowel obstruction. Obtain CAT scan for further evaluation. EKG: Normal sinus rhythm, nonspecific ST and T-wave abnormality.
HOSPITAL COURSE: The patient was admitted with symptoms of abdominal pain and a CAT scan showing a transverse colon lesion, likely a cancer. The CAT scan did not note any liver metastases. There was some proximal dilatation to the bowel. A water-soluble enema was done to further illustrate the transverse colon and a large apple-core lesion was seen there. He was started on Levaquin and Flagyl and heparin subcutaneously as a prophylactic for deep venous thrombosis. Troponins and CKs returned as negative. The following day, he was taken to the operating room for a right colectomy. His postoperative course was punctuated by a low urine output and finally a postoperative ileus was diagnosed and a NG tube placed. The NG tube stayed in place for four days, after which it was removed. His diet was advanced to a regular diet. We removed his Foley catheter that day. The following day, we took out his staples and sent him home with a followup appointment in four weeks with Dr. John Doe. His pathology report indicated a moderately differentiated adenocarcinoma with 0/23 nodes positive. There was no vessel invasion. Ultrasound on the specimen was a tubulovillous adenoma with high-grade dysplasia and several tubular adenomas. The lesion was characterized as a T3N0.
DISCHARGE DIAGNOSIS: Status post extended right colectomy for a T3N0 transverse colon cancer.
DISCHARGE MEDICATIONS: As prior to admission plus Percocet 1 to 2 tablets p.o. q. 4-6 h. p.r.n. pain.
DISCHARGE DIET: Regular.
DISCHARGE CONDITION: Stable and improved.
DISCHARGE STATUS: Home on self care.
FOLLOWUP: Arranged in one month with Dr. John Doe.
