622086964
BH
8245338
356492
05/16/2004 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY NAME :
WIERSTUPH , NORNAME H
UNIT NUMBER :
370-15-25
ADMISSION DATE :
05/16/2004
DISCHARGE DATE :
05/26/2004
PRIMARY DIAGNOSIS :
Ovarian cancer .
ASSOCIATED DIAGNOSES :
Hypertension , asthma , obesity , history of heart murmur , hemorrhoids , whooping cough as a child .
OPERATIONS AND PROCEDURES :
Total abdominal hysterectomy , bilateral salpingooophorectomy , bilateral lymph node dissection , omentectomy , lysis of adhesions , removal of mass from surface of transverse colon .
HISTORY OF THE PRESENT ILLNESS AND REASON FOR HOSPITALIZATION :
64-year-old G5P5 postmenopausal for 10 years with a history of two months of progressive abdominal distention , crampy abdominal pain , urinary frequency and diarrhea .
The patient has not obtained gynecologic care for 32 years until April 2004 when an increase in abdominal GERD and urinary symptoms lead her to initial consultation with Dr. Lentny Farstnappsshee in Gobrew Street , Denlandcobridclevena , West Virginia 28880 .
At that time a pelvic ultrasound was performed showing extensive fluid and clear mass within the pelvi-abdominal cavity .
MRI showed a large fluid filled abdomen with a relatively small mass measuring about 5 to 6 cm in the right pelvis .
At this point she had an elevated CA 125 at 440 and came to Dr. Chabechird for further consultation .
PAST MEDICAL HISTORY :
Hypertension , asthma for 10 years , no hospitalizations , obesity , history of heart murmur , hemorrhoids and whooping cough as a child .
PAST SURGICAL HISTORY :
Tonsillectomy in 1947 , removal of a renal calculus in 1979 , cholecystectomy in 1986 .
OB-GYN HISTORY :
G5 , P5 normal Pap smears , sexual active without dyspareunia .
No regular breast self examination , has not had a mammogram .
MEDICATIONS AT HOME :
Included Prinzide 12.5 mg po daily , albuterol inhaler prn
ALLERGIES :
Demerol .
The patient developed ulceration after IM injection .
She also has food allergies to raw vegetables as well as some shortness of breath and throat constriction with shrimp .
FAMILY HISTORY :
Remarkable for colon cancer in her mother and maternal grandfather .
HOSPITAL COURSE :
The patient was admitted on 05/16/2004 for bowel preparation before the surgery .
On 05/17/2004 the patient underwent atotal abdominal hysterectomy , bilateral salpingooophorectomy , bilateral node dissection , omentectomy , lysis of adhesions , removal of mass from surface of transverse colon .
The report from the frozen section sent in the surgery came back with poorly differentiated adenocarcinoma , possibly serous carcinoma of the ovary .
In the postoperative recovery room the patient had a hematocrit of 29.2 with low urine output .
She was given 1 unit of packed red blood cell .
Her urine output subsequently increased .
The patient was transferred to the floor without any complications .
She had an uneventful night .
On postoperative day one , the patient 's urine culture came back with moderate E. coli .
She was started on Levofloxacin 500 mg po daily .
The patient was also started on a clear diet .
On postoperative day two , her Foley was discontinued .
The patient was out of bed .
She was tolerating liquids .
On postoperative day three , the patient had a port placed .
She also had one episode of shortness of breath .
Achest x-ray done at that time showed left pleural effusion and small right pleural effusion , not pulmonary edema and left lower lobe consolidations .
The patient was afebrile , her vital signs were stable and she maintained a good urine output .
She also had an episode of nausea with some emesis , after being treated with Zofran with no relief , a nasogastric tube was placed which drained 1200 cc of bilious fluid .
On postoperative day four , the patient continued to have nasogastric tube in place .
A repeat chest x-ray done for dyspnea showed persistent pleural effusion with atelectasis versus pneumonia .
Her levofloxacin was continued .
The patient tolerated nasogastric tube clamping trials with high residuals in the 600 cc range .
The patient did well on postoperative day five and six .
She was started on clear fluids with a nasogastric clamped .
On postoperative day seven the patient diet was slowly advanced as tolerated .
She was also started on Decadron in preparation for her chemotherapy .
On postoperative day eight which is Memorial Day the patient was started on Carboplatin-Taxolchemo therapy , which she tolerated without complication .
On postoperative nine , her JP drain was discontinued .
The patient was discharged home that afternoon in stable condition in the afternoon .
DISCHARGE MEDICATIONS :
Dilaudid 2 to 4 mg po q3h prn pain , Ativan 1 mg po q12h prn anxiety , Zofran 8 mg po q8h prn nausea , Compazine 10 mg po q6h prn nausea , Decadron 20 mg po q6h x 2 doses .
The patient was instructed to take 20 mg at 11 pm the night before her next chemotherapy and 8 am on the morning of chemotherapy .
Colace 100 mg po bid , Albuterol inhalers two puffs inhaled qid prn wheezing and asthma symptoms .
DISCHARGE INSTRUCTIONS :
The patient was instructed to follow up with Dr. Slaineaee Chabechird .
She was told to make an appointment two weeks after her surgery for removal of her retention sutures .
The patient was discharged home in stable condition .
NAUNGDAPHBERE T. BUMPSFOOKS , M.D.
DICTATING FOR :
Electronically Signed
SLAINEAEE S CHABECHIRD , JR , M.D.
06/04/2004 15:45
_____________________________ SLAINEAEE S CHABECHIRD , JR , M.D.
TR :
fk
DD :
05/26/2004
TD :
05/27/2004 4:01 A 356492
cc :
SLAINEAEE S CHABECHIRD , JR , M.D.