145980160
FIH
6382196
94916/ly7e
289653
06/30/1993 12:00:00 AM
PROSTATE CANCER .
Unsigned
DIS
Report Status :
Unsigned
ADMISSION DATE :
06-30-93
DISCHARGE DATE :
07-06-93
PRINCIPAL DIAGNOSIS :
Prostate cancer .
SPECIAL PROCEDURES AND OPERATIONS :
Radical retropubic prostatectomy , bilateral lymph node dissection .
HISTORY OF PRESENT ILLNESS :
The patient is a 67 year old white male with a recent history of urinary frequency Q2-3H , stranguria , nocturia x 3-4 per night .
He was found on physical exam to have an asymmetric prostate with prominence on the left and a question of a nodule .
Repeat exam one month later showed a firm left-sided lobe .
Transrectal ultrasound showed a hypoechoic left-sided mass in the peripheral zone .
A biopsy showed moderately to poorly differentiated Grade III-IV adenocarcinoma on the left .
The right lobe was within normal limits .
This was done on 05/05/93 at FIH .
He also had a 3-4 year history of impotence .
PAST MEDICAL HISTORY :
Significant for non-insulin diabetes mellitus , for which he takes Diabeta , one QD ; right eye cataract , operated on three years ago .
ALLERGIES :
He is allergic to Motrin .
MEDICATIONS ON ADMISSION :
Diabeta , one QD .
SOCIAL HISTORY :
No smoking history .
PHYSICAL EXAMINATION :
He was a well developed , well nourished white male .
HEENT :
within normal limits .
His neck was supple with no jugular venous distention or thyromegaly .
Chest was clear to percussion and auscultation .
Heart :
regular rate and rhythm with normal S1 and S2 , no murmurs .
The abdomen was soft and non-tender with no masses or organomegaly .
No costovertebral angle tenderness .
His genitourinary exam showed an uncircumcised male with normal scrotal contents .
Rectal :
There was a firm nodule in the left lobe of the prostate in the lateral aspect .
Extremities :
No clubbing , cyanosis or edema .
Pulses 2+ .
Neurological :
Nonfocal .
LABORATORY DATA :
Sodium 141 , potassium 4.1 , chloride 104 , bicarbonate 28.8 , BUN 17 , creatinine 0.9 , glucose 118 .
His white blood count was 7100 , hematocrit 35.9 , platelet count 258,000 .
PT 9.4/10.3 , PTT 27 .
His urinalysis showed marked occult blood and positive white blood cell screen but was otherwise negative .
His chest X-ray was normal .
EKG :
normal sinus rhythm at 73 beats per minute .
HOSPITAL COURSE :
The patient was brought to the operating room on 06/30/93 after informed consent was obtained .
A radical retropubic prostatectomy with bilateral lymph node dissection was done .
He was afebrile postoperatively with vital signs stable .
His potassium was 3.7 and his hematocrit 33 .
His postoperative course was remarkable for a low grade temperature to 101.7 .
His blood cultures and chest X-ray were negative .
He had flatus on postoperative day # 3 .
His Jackson-Pratt drained about 35-40 cc per day and was discontinued on postoperative day # 3 .
His hematocrit on 07/03 was 28.1 .
On that day he was slightly diaphoretic with some tachycardia to 100 .
The remaining unit of autologous packed red blood cells was transfused .
A cardiology consult was obtained for this episode of diaphoresis with tachycardia , as well as for an EKG being read as having anterolateral changes .
He had no symptoms of chest pain or myocardial ischemia .
A repeat EKG showed no changes .
He subsequently did well , with a repeat hematocrit of 34.3 after the transfusion .
His creatinine was 1.2 on postoperative day # 5 .
On postoperative day # 6 his low grade temperature resolved .
His vital signs were stable .
He was discharged home on Percocet and Keflex .
He was discharged in good condition .
He will follow up with Dr. Iechalette Cancer in his office .
SIE ROOM , M.D.
DICTATING FOR :
IECHALETTE ROOM , M.D.
TR :
btt / bmot
DD :
07-07-93
TD :
07/08/93
CC :
Dr. Na Dussmum