320422564
CTMC
09300549
340424
06/16/1997 12:00:00 AM
BILIARY OBSTRUCTION
Signed
DIS
Admission Date :
06/16/1997
Report Status :
Signed
Discharge Date :
06/18/1997
PROBLEM LIST :
1. RECTAL CARCINOMA , STATUS POST PARTIAL COLECTOMY .
2. METASTATIC COLON CARCINOMA .
3. HYPERTENSION .
4. AORTIC STENOSIS WITH PORCINE VALVE .
5. URINARY TRACT INFECTION .
6. CHOLANGITIS .
7. ANEMIA .
HISTORY OF PRESENT ILLNESS :
This is a 70 year old gentleman with metastatic rectal cancer who presented with biliary obstruction .
In the past , he had biliary stents placed which clotted off .
The patient was admitted to the Short Stay Unit for further evaluation .
The day prior , the patient had endoscopic retrograde cholangiopancreatography done with dilated ducts times two and eventually had interventional radiology attempt to place percutaneous drains to decompress his biliary tree .
The patient had two drains placed after a prolonged course and difficult procedure .
After being transferred from the interventional radiology table to the stretcher , one of his lateral percutaneous drains had been pulled out inadvertently .
He was admitted to the Short Stay Unit , given Ancef and Gentamicin per the team for antibiotic prophylaxis and observed overnight .
PAST MEDICAL HISTORY :
As above .
ALLERGIES :
None .
MEDICATIONS ON ADMISSION :
Cipro 500 mg p.o. b.i.d. , Vasotec 10 mg q.d.
SOCIAL HISTORY :
The patient denies any alcohol or tobacco .
FAMILY HISTORY :
Significant for colon carcinoma .
REVIEW OF SYSTEMS :
Unremarkable .
PHYSICAL EXAMINATION :
Temperature was 99.1 , blood pressure 132/74 , heart rate 80 , respirations 18 , 02 sat 99% on room air .
The patient was an alert , jaundiced gentleman in no acute distress .
LUNGS :
were clear to auscultation .
HEART :
had a regular rate and rhythm with a II / VI systolic murmur at the right sternal border .
ABDOMEN :
was soft , nontender , with good bowel sounds .
He had midline catheter that was still in place and was draining bile .
EXTREMITIES :
were without edema .
NEUROLOGICAL :
exam within normal limits .
LABORATORY :
White count was 8.2 , hematocrit 35 .
AST was 175 , ALT 76 , LDH 454 .
Total bilirubin was 12 and direct bilirubin 8 .
Alkaline phosphatase was 372 .
HOSPITAL COURSE :
The patient was admitted to the Short Stay Unit and continued to receive antibiotics overnight .
The next morning , he was doing well with the intact drain draining bilious material without any difficulty .
The patient was doing well with minimal to no belly pain and no nausea or vomiting .
The patient was taken back to surgery by the interventional radiology team and had a second drain placed without any difficulty and was transferred back to the Short Stay Unit .
The patient was observed overnight without any problems .
He was tolerating p.o. and feeling back to his baseline .
He was discharged in stable condition .
DISCHARGE MEDICATIONS :
Same as admission .
He will continue Cipro p.o. for prophylaxis .
FOLLOW-UP :
Follow-up with Dr. Loydsadd in one to two weeks .
He is also to have AH for his home stent care .
Dictated By :
Attending :
LILLBI FYFEBREUN , M.D. KE15 TB326/0625
Batch :
56777
Index No. M2ZRS51Y3Q
D :
06/18/97
T :
06/21/97