DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old widowed Hispanic female who was transferred from the nursing home because of vomiting of coffee-ground emesis. The patient had been previously hospitalized recently and evaluated and felt to have benign disease. At that time, she had similar vomiting of dark-colored material. An endoscopy, which included an esophagogastroduodenoscopy, found very little abnormalities.
After transfer to the rehabilitation nursing home, the patient had recurrent vomiting, required intravenous fluids. This subsided but then recurred, and she was brought back to the hospital. The patient has had a long history of atrophic-appearing pancreas and has been taking supplementary pancreatic enzymes. The patient has a long history of somatization with chronic fatigue extending over a period of many decades.
PAST MEDICAL AND SURGICAL HISTORY: Past history indicated status post hysterectomy many years ago, occasional urinary incontinence, hyperlipidemia, and osteoarthritis.
A metastatic workup, including CT scans of the abdomen and pelvis during the previous hospitalization, proved to be negative.
HOSPITAL COURSE: On admission, the patient showed marked dehydration and electrolyte imbalance and required supplementary fluids and electrolyte solutions. This was rectified and studies showed that there appeared to be a relatively high small bowel obstruction. The patient was placed on nasogastric suctioning. Material was not coffee ground but had a high content of bilious material. The patient’s blood count was somewhat low, and she required some blood transfusions; although, there was no profound anemia.
The patient was again seen in gastrointestinal consultation by Dr. John Doe. At this time, he performed a study using a colonoscope instead of a gastroscope and found an obstruction in the third portion of the duodenum. The abdominal ultrasound showed dilated small bowel loops and sludge in the gallbladder. In view of the obstruction, the patient was seen in surgical consultation. The surgeon felt that this most likely represented a malignancy. The patient was subjected to surgery and exploration, and it was found that indeed there was an obstructing lesion in the third portion of the duodenum. A palliative gastrojejunostomy was performed.
The patient’s postoperative status was somewhat precarious, but the patient gradually improved. The patient required hyperalimentation with supplements until her status and diet returned. At the time of discharge, the hyperalimentation was stopped. She was on soft diet plus Ensure Plus twice a day.
ALLERGIES: The patient is allergic to codeine.
DISCHARGE MEDICATIONS: The patient was discharged on metoprolol 25 mg b.i.d. to control blood pressure and heart rate, acetaminophen 650 mg q.6 hours p.r.n., Pepcid 20 mg b.i.d., and eye drops Trusopt 2% one drop in left eye b.i.d., Timoptic 0.5% one drop in the left eye b.i.d., and pilocarpine 2% two drops in the left eye q.i.d.
FINAL DIAGNOSES:
1. Intestinal obstruction.
2. Adenocarcinoma, third portion of duodenum.
3. Dehydration and electrolyte imbalance.
4. Sludge in gallbladder.
PROCEDURES PERFORMED:
1. Exploratory laparotomy.
2. Gastrojejunostomy.
OTHER PROCEDURES:
1. Intravenous hyperalimentation.
2. Blood transfusion.
3. Abdominal ultrasound scan.
4. Esophagogastroduodenoscopy and colonoscopy by the gastrointestinal service.
