614746156
CTMC
48720920
513332
7/3/1999 12:00:00 AM
Discharge Summary
Signed
DIS
Admission Date :
07/03/1999
Report Status :
Signed
Discharge Date :
EHC9
HISTORY OF PRESENT ILLNESS :
The patient is a 71-year-old police chief who presents with painless jaundice x1 day .
The patient was generally in excellent health with a past medical history significant only for noninsulin dependent diabetes mellitus who was presented with painless jaundice x2 days .
He also noted a 23 pound weight loss in the past 11 months despite having an increased appetite .
The patient also complained of fatigue and " feeling down " .
His wife noted personality changes with increased irritability .
Patient denies night sweats in the past month .
The patient denies melena , hematochezia , nausea , and abdominal pain .
The patient states that he is occasionally constipated .
Also denies tenesmus .
On the day prior to admission , the patient 's family noted that " he looked yellow " and presented to the Lorough Medical Center 's Emergency Department this after noon .
PAST MEDICAL HISTORY :
1. Type II diabetes mellitus diagnosed 06/94 , well-controlled with last hemoglobin A1C 6.2
2. Vocal cord polyps
3. Question of history of AVN or osseous necrosis
4. History of hyperkalemia .
Question RTA type 4
MEDICATIONS :
Glucotrol 10 q.a.m. and vitamins
ALLERGIES :
The patient is allergic to MSG from which he gets hives .
SOCIAL HISTORY :
No ethanol use , remote pipe smoking use which he discontinued 20 years ago , no illicit drug use .
FAMILY HISTORY :
Noncontributory .
The patient 's father died at the age of 83 of CHF .
The patient 's mother is alive at the age of 114y .
The patient has six children and 10 grandchildren , all in excellent health .
HOSPITAL COURSE :
The patient presented to the Emergency Department with a complaint of painless jaundice , weight loss , and fatigue .
Abdominal CT while in the Emergency Department revealed likely primary colorectal adenocarcinoma with multiple liver metastases .
Hematocrit was 24 in the Emergency Department .
The patient received two units of packed red blood cells and the hematocrit rose to 30 the following day .
The patient was seen by both Gastroenterology and Oncology .
Biopsy was taken at colonoscopy on 7/5/99 .
Head CT was done with final results pending on discharge .
The patient was to follow-up with the Petersly Hospital And Medical Center as an outpatient for further treatment .
The patient is discharged to home .
His condition is stable and he was discharged with the following medications :
Iron 300 mg p.o. t.i.d. , Glucotrol , Acel 10 mg p.o. q.d. , and Bactrim SS 1 tablet p.o. b.i.d.
Dicatated By :
STEPH ALEA , M.D.
Attending :
BREANA G. CORNEA , M.D. IS68 ON208/5303
Batch :
31863
Index No. MIEQVK9Q4Z
D :
07/05/99
T :
07/05/99
CC :
1. BREANA G. CORNEA , M.D.* CONFORD GHACOLL HEALTHCARE