989519730 WGH
4708487
265076
4927849
05/09/2004 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY
NAME :
GINSLENT , A L
UNIT NUMBER :
537-43-35
ADMISSION DATE :
05/09/2004
DISCHARGE DATE :
05/16/2004
PRINCIPAL DIAGNOSIS :
Colon cancer .
ASSOCIATED DIAGNOSES :
History of diverticulitis , status post cholecystectomy , status post appendectomy , and hypertension .
PRINCIPAL PROCEDURE :
Transverse colectomy for tumor .
ASSOCIATED PROCEDURES :
None .
HISTORY OF PRESENT ILLNESS :
The patient is an 84-year-old woman with a history of diverticulitis who was found to have colon cancer on colonoscopy , which was performed in March of 2004 .
An invasive moderately differentiated adenocarcinoma was noted in the transverse colon at 80 cm .
The patient reports a history of bloating and flatulence as well as increased fatigue .
She has also had some discomfort in her left lower abdomen and notes diarrhea every 4-5 days .
She says that her appetite is good and has noted no weight loss .
PAST MEDICAL HISTORY :
Cholecystectomy in 1994 , colonoscopy 2004 , status post tonsillectomy , status post appendectomy , status post ORIF of left wrist , status post left ear surgery , NSVD x5 , and hypertension .
MEDICATIONS :
Premarin vaginal once a month , enalapril , Tylenol , vitamins , and Halcion at night .
ALLERGIES :
No known drug allergies .
SOCIAL HISTORY :
She is married and lives in an assisted living facility with her husband .
She has five grown children .
PHYSICAL EXAMINATION :
On exam she is afebrile .
Her vital signs are stable .
Baseline blood pressure of 144/61 , heart rate of 73 , and oxygen saturation of 96% on room air .
She is a pleasant well appearing elderly woman in no acute distress .
Lungs are clear to auscultation bilaterally .
Heart is regular without murmurs , rubs , or gallops .
Abdomen is soft , nontender , and nondistended .
Her extremities are without edema and are warm .
HOSPITAL COURSE :
The patient was consented for surgery and on the day of admission was taken to the operating room for transverse colectomy for tumor .
The patient tolerated the procedure well and there are no complications .
Her postoperative course was unremarkable .
She was maintained on an epidural and PCA for pain control .
She was kept NPO initially and her diet was slowly advanced as tolerated .
When she was taking clear liquids , her pain medication was switched to p.o. pain regimen with good affect .
For blood pressure control she was maintained on metoprolol at the request of her primary care physician and enalapril was discontinued .
With the help of physical therapy the patient was ambulated and on postoperative seven , with the patient tolerating a post surgical soft diet and with pain well controlled on oral pain medications , she was discharged to rehabilitation facility .
DISCHARGE MEDICATIONS :
1. Tylenol 650 mg p.o. q.4.h. p.r.n. pain .
2. Metoprolol 25 mg p.o. b.i.d.
3. Motrin 400 mg p.o. b.i.d. p.r.n. pain .
4. Halcion 0.25 mg p.o. at night .
5. Dulcolax 10 to 20 mg PR b.i.d. p.r.n. constipation .
6. Senna 2 tablets p.o. b.i.d.
DISCHARGE INSTRUCTIONS :
Consume a diet as tolerated avoiding carbonated beverages .
Her activity level is as tolerated .
She is to contact Dr. Warm 's office to schedule a follow up appointment .
She is to also call the office if she has any fever greater than 101 , bleeding from the surgical wounds , or pus from the wounds .
She is to be maintained on metoprolol for blood pressure control and the restarting of her ACE inhibitor is to be decided by her primary care physician .
ALEN L CREDKOTE , M.D.
DICTATING FOR :
Electronically Signed OIE LIMOR WARM , M.D. 05/18/2004 11:28
_____________________________ OIE LIMOR WARM , M.D.
TR :
ep
DD :
05/16/2004
TD :
05/16/2004 7:28 A 265076
cc :
OIE LIMOR WARM , M.D. CH GILD WARM , M.D.