779878634
TGCHO
9260099
612765
12/11/2003 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY
NAME :
A , REBAY J
UNIT NUMBER :
984-98-62
ADMISSION DATE :
12/11/2003
DISCHARGE DATE :
01/08/2004
The patient has a known history of pancreatic adenocarcinoma .
He is admitted at this time because of significant GI bleeding .
REVIEW OF SYSTEMS :
Significant for fatigue and increased abdominal discomfort .
MEDICATIONS AT THE TIME OF ADMISSION :
Insulin , Celexa , Protonix , Ambien and Pancreas .
PHYSICAL EXAMINATION :
Vital signs showed his blood pressure to be slightly decreased at 120/60 , pulse 64 , respirations 16 , temperature 98.8 , O2 sat 95 .
HEENT :
Evidence of anemia with being pale , but anicteric , no oral lesions .
Neck supple .
Lungs clear .
Back without CVA or spinal tenderness .
Heart regular rate and rhythm .
Abdomen :
Bowel sounds positive , soft , mildly tender in the epigastrium without hepatosplenomegaly , mass or tenderness .
Extremities :
Trace edema without cyanosis or clubbing .
His hematocrit at the time of admission was 20.5 , after having been 32 one week earlier .
ASSESSMENT :
The assessment was that he had a GI bleed .
He was transfused and then evaluated by GI .
Endoscopy showed multiple angio ectasias throughout the stomach .
He received multiple treatments for this over the succeeding weeks .
In addition , he was transfused .
His platelet count was maintained with platelet transfusion as necessary .
He was treated with Octreotide to try to slow down the bleeding .
Despite all these measures , his bleeding was never totally controlled .
He then had an angiogram with Gel foam to try to control his GI bleed .
Again , this was unsuccessful .
At that point he had a change in mental status and was no longer responsive .
Given this , the decision was made to make his care comfort measures only .
At this point , he was made comfort measures and expired comfortably .
The cause of death was a combination of GI bleeding felt to be ultimately related to his known metastatic pancreatic cancer .
TA KO FOSSA , M.D.
DICTATING FOR :
Electronically Signed TA KO FOSSA , M.D.
02/05/2004 17:03
_____________________________ TA KO FOSSA , M.D.
TR :
mb
DD :
01/23/2004
TD :
01/26/2004 2:16 A 612765
cc :
TA KO FOSSA , M.D.