105732749
FIH
7017973
715894
55714
9/10/1999 12:00:00 AM
Discharge Summary
Unsigned
DIS
Report Status :
Unsigned
DISCHARGE SUMMARY NAME :
STERPKOTENEISH , LYDELL A
UNIT NUMBER :
712-67-96
ADMISSION DATE :
09/10/1999
DISCHARGE DATE :
09/14/1999
PRINCIPAL DIAGNOSIS :
Pancreatic carcinoma .
PRINCIPAL PROCEDURE :
Laparoscopy with biopsy for diagnosis .
HISTORY OF PRESENT ILLNESS :
Ms. Sterpkoteneish is a 69-year-old woman , who over the past six months has noted increasing pain in her left upper quadrant radiating to the back .
She described the pain as being exacerbated by eating and described an associated weight loss .
She presented to her primary care physician , Dr. Tlandtaze , in Aersing Rocuch Sun , who obtained a CT scan , which demonstrated a mass in the tail of the pancreas .
She was then referred to the Fairm of Ijordcompmac Hospital under the El Memorial and was seen by Dr. Blinjesc , who scheduled her for an exploratory laparoscopy .
PAST MEDICAL HISTORY :
Is significant for spinal stenosis and a series of operations including repair of a ureteral stricture ; cataract implants ; two partial hysterectomies ; and an appendectomy .
MEDICATIONS ON ADMISSION :
Oxycontin 10 mg PO q.day .
Darvocet .
Estratab .
Aspirin 325 mg PO q.day .
ALLERGIES :
No known drug allergies .
PHYSICAL EXAMINATION :
The blood pressure was 150/86 ; pulse 82 ; respirations 16 .
Lungs were clear to auscultation bilaterally .
Heart :
regular S1 and S2 ; no murmurs .
Abdomen :
soft ; nontender ; no palpable masses .
HOSPITAL COURSE AND TREATMENT :
The patient was admitted through same day surgery and taken to the operating room where Dr. Blinjesc , assisted by Dr. Zockbeathe , performed a diagnostic laparoscopy with peritoneal washings .
Findings included no gross evidence seating in the abdominal wall ; one nodule on the posterior surface of the right lobe of the liver ; one nodule in the inferior edge of the falciform ligament .
Specimens sent to pathology included peritoneal washings and permanent specimens from the liver and falciform nodules .
There were no complications , and the patient tolerated the procedure well .
Postoperatively , the patient had some abdominal bloating with evidence of subcutaneous emphysema over the abdomen .
She was uncomfortable and slow to have bowel movements , although she did have flatus .
She tolerated a full diet well , but continued to have abdominal cramping and a mild ileus for the following three days .
She was treated with repeated Fleet 's enemas , and on postoperative day three , she had a number of bowel movements , was considerably more comfortable , and deemed ready for discharge .
CONDITION ON DISCHARGE :
Was excellent .
MEDICATIONS ON DISCHARGE :
Included aspirin 325 mg PO q.day .
Percocet one to two whenever necessary q. four to six hours for pain .
Estratab one PO q.day .
At the time of discharge , cytopathology specimens had been negative , and surgical pathology specimens were still pending .
She was instructed to call Dr. Blinjesc for the results of these tests and to follow up with him for further management if necessary .
STA BODEJOVE , M.D.
DICTATING FOR :
______________________________ LONSHI OCK , M.D.
TR :
hjr
DD :
09/14/1999
TD :
09/17/1999 2:26 P
cc :
LONSHI OCK , M.D.
cc :
Telshey K. Swatlleebtik , M.D. Rinime Hawnspantkote Arkansas