Health Record Face Sheet

Age: 67

Gender: Male

Length of Stay: 3 days

Service: Inpatient Hospital Admission

Disposition: Home

Discharge Summary

Patient is a 67-year-old male. He saw the doctor recently with abdominal pain and constipation. A barium enema showed diverticulosis and perhaps a stricture near the sigmoid and rectal junction. He was scoped by the doctor, who saw a stricture at that point and said he couldn’t rule out a carcinoma. Upper GI showed a hiatal hernia and duodenal diverticulum. Ultrasound showed gallstones. The patient had some bladder incontinence. He has had atrial fibrillation, diabetes, and takes Lanoxin. Otherwise, he is doing quite well. He has had a previous right total hip. At the time of admission, it was thought that he had a stricture, rule out carcinoma, diabetes mellitus, exogenous obesity, past history of atrial fibrillation, previous right total hip. His chest film showed some chronic blunting of the right costophrenic angle, but otherwise was negative. His admission EKG showed what was thought to be a normal sinus rhythm. His blood type was AB-positive. Urinalysis was negative.

Hemoglobin was 13.3, white blood cell count 7,600. PT 12, PTT was 23. The CEA, which came back several days later, was quite high at 856. Glucose is 127, albumin is 3.4. Other labs were normal. After mechanical and chemical bowel prep, he was taken to surgery. First, we laparoscoped to see if we could do this resection with the scope. When we found that it was adherent to loops of adjacent small bowel, he had an open resection. A large carcinoma of the rectosigmoid junction was found and resected with an end-to-end anastomosis. A segment of small bowel that was stuck to the tumor was also resected, and a functional end-to-end anastomosis was done. At least four separate liver metastases were noted. Needle biopsy of that was done as well. The pathology report showed moderate to poorly differentiated carcinoma, bases through the wall of the colon and into the perirectal fat. The small intestine was not involved. The liver metastases were also positive. The patient had a rather smooth postoperative course. He was thought to be ready for discharge on the sixth postoperative day. He was seen in consultation prior to surgery by the doctor, who managed his medical problems and diabetes and will arrange for appropriate medication at the time of discharge. He was sent home on Darvocet for pain. Ferrous Gluconate 324 mg three times a day for a month to restore his blood count. He is to resume his other previous medications. He is to restrict his activities for 2 months and to see me in the office in 8 days.

Final Diagnosis:

1. Invasive adenocarcinoma of the rectosigmoid, metastatic to the liver

2. Type II diabetes mellitus

3. Exogenous obesity

4. Atrial fibrillation

5. Previous right total hip replacement

Surgical Procedure: Resection of rectosigmoid with low pelvic anastomosis with an EEA, small bowel resection, liver biopsy.

History & Physical

Patient is a 67-year-old male. He has been in to see the doctor recently with abdominal pain and complains that he was unable to move his bowels. He was admitted and subsequently had endoscopy following a number of x-rays. The x-rays showed diverticulosis of the sigmoid and perhaps a stricture near the sigmoid rectal junction. This was difficult to delineate because of overlapping loops of bowel. The patient had an upper GI showing hiatal hernia and a duodenal diverticulum, and an ultrasound showing gallstones. The patient was subsequently seen by the doctor. A week ago today, the doctor performed upper GI endoscopy, which showed a little antral gastritis. A sigmoidoscopic examination showed, at about 25 cm, a narrowed area of the bowel with edema and stricture, and some blood oozing from above. Doctor said that he could not be sure whether this was strictly a diverticular stricture or whether there was a tumor above this point. The patient has otherwise been pretty healthy.

He had a previous fracture in the right hip. He had pulmonary embolus secondary to thrombophlebitis in his legs on two different occasions. He is not a smoker and seldom drinks. He has no known allergies. Both parents are deceased. He has had type II diabetes for about 5 years and takes Tolinase 150 mg two times a day. He has had atrial fibrillation in the past and takes Lanoxin 0.125 mg a day for that condition. He has never had hypertension, heart disease (other than the atrial fibrillation), or stroke. He has no chest pain or shortness of breath. He has had quite a bit of heartburn and indigestion, but this definitely has been improved by Zantac. He has some bladder incontinence