For this medical record abstracting assignment, first click the following link to access the medical record for a patient with a digestive system concern.

Medical Record Review for key diagnostic and therapeutic information

 

Directions:
For this medical record abstracting assignment, first click the following link to access the medical record for a patient with a digestive system concern.

When you have examined the entire medical record document, click the link below to download the list of questions related to that record. Save your answers in this document and submit them for this module’s assignment.

 

Service: Inpatient Hospital Admission

Disposition: Home

Discharge Summary

Patient is a 67-year-old male. He saw the doctor recently with abdominal pain and constipation. A barium enema showed diverticulosis and perhaps a stricture near the sigmoid and rectal junction. He was scoped by the doctor, who saw a stricture at that point and said he couldn’t rule out a carcinoma. Upper GI showed a hiatal hernia and duodenal diverticulum. Ultrasound showed gallstones. The patient had some bladder incontinence. He has had atrial fibrillation, diabetes, and takes Lanoxin. Otherwise, he is doing quite well. He has had a previous right total hip. At the time of admission, it was thought that he had a stricture, rule out carcinoma, diabetes mellitus, exogenous obesity, past history of atrial fibrillation, previous right total hip. His chest film showed some chronic blunting of the right costophrenic angle, but otherwise was negative. His admission EKG showed what was thought to be a normal sinus rhythm. His blood type was AB-positive. Urinalysis was negative.

Hemoglobin was 13.3, white blood cell count 7,600. PT 12, PTT was 23. The CEA, which came back several days later, was quite high at 856. Glucose is 127, albumin is 3.4. Other labs were normal. After mechanical and chemical bowel prep, he was taken to surgery. First, we laparoscoped to see if we could do this resection with the scope. When we found that it was adherent to loops of adjacent small bowel, he had an open resection. A large carcinoma of the rectosigmoid junction was found and resected with an end-to-end anastomosis. A segment of small bowel that was stuck to the tumor was also resected, and a functional end-to-end anastomosis was done. At least four separate liver metastases were noted. Needle biopsy of that was done as well. The pathology report showed moderate to poorly differentiated carcinoma, bases through the wall of the colon and into the perirectal fat. The small intestine was not involved. The liver metastases were also positive. The patient had a rather smooth postoperative course. He was thought to be ready for discharge on the sixth postoperative day. He was seen in consultation prior to surgery by the doctor, who managed his medical problems and diabetes and will arrange for appropriate medication at the time of discharge. He was sent home on Darvocet for pain. Ferrous Gluconate 324 mg three times a day for a month to restore his blood count. He is to resume his other previous medications. He is to restrict his activities for 2 months and to see me in the office in 8 days.

Final Diagnosis:

1. Invasive adenocarcinoma of the rectosigmoid, metastatic to the liver

2. Type II diabetes mellitus

3. Exogenous obesity

4. Atrial fibrillation

5. Previous right total hip replacement

Surgical Procedure: Resection of rectosigmoid with low pelvic anastomosis with an EEA, small bowel resection, liver biopsy.

History & Physical

Patient is a 67-year-old male. He has been in to see the doctor recently with abdominal pain and complains that he was unable to move his bowels. He was admitted and subsequently had endoscopy following a number of x-rays. The x-rays showed diverticulosis of the sigmoid and perhaps a stricture near the sigmoid rectal junction. This was difficult to delineate because of overlapping loops of bowel. The patient had an upper GI showing hiatal hernia and a duodenal diverticulum, and an ultrasound showing gallstones. The patient was subsequently seen by the doctor. A week ago today, the doctor performed upper GI endoscopy, which showed a little antral gastritis. A sigmoidoscopic examination showed, at about 25 cm, a narrowed area of the bowel with edema and stricture, and some blood oozing from above. Doctor said that he could not be sure whether this was strictly a diverticular stricture or whether there was a tumor above this point. The patient has otherwise been pretty healthy.

He had a previous fracture in the right hip. He had pulmonary embolus secondary to thrombophlebitis in his legs on two different occasions. He is not a smoker and seldom drinks. He has no known allergies. Both parents are deceased. He has had type II diabetes for about 5 years and takes Tolinase 150 mg two times a day. He has had atrial fibrillation in the past and takes Lanoxin 0.125 mg a day for that condition. He has never had hypertension, heart disease (other than the atrial fibrillation), or stroke. He has no chest pain or shortness of breath. He has had quite a bit of heartburn and indigestion, but this definitely has been improved by Zantac. He has some bladder incontinence

Physical Examination

He weighs 174. He is 5’ 61/2” tall. BP 152/84 on the right, 148/78 on the left. Pulse was 80. Examination of the HEENT was negative. The patient seemed extremely alert. Him has good carotid pulses without bruits. No goiter or nodes in the neck. The heart rate was regular. The heart was not enlarged. There was no murmur. The lungs were clear to auscultation and percussion. There was a low midline scar. No hepatosplenomegaly. There was a little left lower quadrant tenderness. Rectal exam was not repeated. He had good femoral, popliteal, and dorsalis pedis pulses. The ankles were quite thick. There was a scar on his right hip from previous surgery. Neurologic function is normal. His skin tended to be sweaty and clammy, which he says is the normal case for his.

Impression

1. Stricture of the sigmoid seen on barium enema and colonoscopy, probably secondary to diverticular disease, causing obstructive symptoms, 2. Type II diabetes mellitus, 3. Exogenous obesity, 4. Past history of atrial fibrillation. Plan: Resection.

Surgical Consultation

It was a pleasure to see your patient, who is well known to me from my office. He is a pleasant 67-year-old white, obese male who, over the past 3 to 4 months, has had increasing amounts of difficulty with bowel movements. He has a complaint of small, pencil-thin bowel movements with some blood noted. The patient also had some difficulty

with upper GI indigestion, as well as gastritis. He has been evaluated per gastroenterology at the hospital and diagnosed with antral gastritis as well as diverticulosis, diverticulitis with narrowing of the sigmoid colon, approximately 25 cm via colonoscopy. The patient has had a workup that included an upper GI series and endoscopies that have shown the above problem, etiology yet to be determined. The patient has a rather strong family history of having similar type of etiologies. Apparently, his three sisters have had similar surgeries, surgery-like etiology secondary to narrowing of sigmoid colon, and difficulties with irritable bowel–type symptoms. The patient has had difficulty with his bowel movements for many years. However, during the past 3 months they have become somewhat bloodier, as well as worsened in types. The patient came to my office approximately 3 months ago with the above etiology. Workup was done then and is on previous chart for review.

His past medical history is consistent with type II diabetes mellitus. He is currently on Tolinase bid with fairly good control at home when the patient follows his diet. The patient does not have a history of smoking, nor does he drink. He currently lives alone. The patient had a hip replacement approximately a year or year and half ago with no sequelae. The patient has previous history of pulmonary embolus. However, he has had no difficulty with the previous surgery noted.

The medication protocol at home includes one-a-day aspirin and Tolinase bid basis. He is also taking Lanoxin 0.125 mg for previous history of atrial fibrillation, which has currently been controlled with normal sinus rhythm for the last 1-year period of time noted. The patient has been evaluated for urinary incontinence secondary to a low-lying bladder. The patient has been in fairly good health except for mild diabetes mellitus, which is controlled with diet as well as oral medications. Otherwise, he has done well and has been in fairly stable condition up to the recent history with his colon problems.

On physical examination, the patient’s general HEENT, eyes, ears, nose, and throat are basically clear. Neck does not show any cervical nodes. Neck is clear for adenopathy. Lungs are clear to auscultation; no rales, rhonchi, or friction rubs. No wheezing. The heart rate is regular rate and rhythm. Abdomen is soft, not overtly tender at this time. Extremities do not show any edema. Cranial nerves are grossly intact as tested. The patient’s EKG shows that of normal sinus rhythm, as evaluated by the consultant. The lab work shows a glucose of 127. BUN and creatinine are within normal limits, as are the electrolytes. Albumin is slightly low at 3.4, with a total protein of 6.0. The liver function profile, SGOT, alk. phos., and bilirubin are within normal limits, as well as triglycerides.

Diagnostic Impressions

1. Diverticulosis/diverticulitis with sigmoid constriction, etiology to be determined, rule out primary disease, that of diverticulosis or diverticulitis versus overt tumor

2. Diabetes mellitus

3. Atrial fibrillation by history, current normal sinus rhythm

4. Generalized obesity

Recommendations

1. Will put the patient on medication protocol, Lanoxin for control of atrial fibrillation, normal sinus rhythm.

2. Will start a sliding scale Insulin, with regular Humulin Iinsulin while he is undergoing surgery. Back on Tolinase postsurgery if control is indicated at that time.

Operative Report

Preoperative Diagnosis: Probable diverticular stricture of the sigmoid, rule out carcinoma

Postoperative Diagnosis: Carcinoma of the sigmoid invading into adjacent small bowel with metastases to the liver

Procedure: Attempted laparoscopic bowel removal, open exploration with resection of the sigmoid colon and end-to-end anastomosis with 28 mm EEA. Resection of segment of small bowel with direct extension of the tumor into that area with the functional end-to-end anastomosis, doing a side-to-side anastomosis, biopsy of liver metastases.

Patient is a 67-year-old male who presented with abdominal pain and constipation. Barium enema suggested diverticular stricture. Patient was seen in consultation by the doctor, who sigmoidoscoped the patient and found a stricture at about 25 cm. Doctor could not see above the stricture, so we could not rule out carcinoma. Patient understood the nature of the problem, the proposed surgical risk, and its possible complications, and consented to it. He was given a mechanical and chemical bowel prep.

Patient was brought to surgery and an NG tube was placed in the stomach and a Foley in the bladder. He was placed in the lithotomy position; routine prep and drape were done. We made a small incision in the right upper quadrant, directly into the peritoneal cavity and inserted the Hasson cannula, insufflated the peritoneal cavity with C02. Once we had a good tent, we examined the peritoneal cavity and could not really see the liver because we were so close to it. We then dissected out the sigmoid after we put in three other cannulas, a 12-mm in the right lower quadrant, a 10-mm in the left lower quadrant, and a 5-mm in the left upper quadrant. These were put in under direct vision. We then grasped the sigmoid and dissected it off the left pelvic gutter, and dissected down toward the bladder. We could not get the small bowel to easily come up out of the pelvis. We then put the colonoscope through the rectum and came up to 25 cm, where we saw not a diverticular stricture, but a carcinoma. We marked this point. When we were dissecting, we found the small bowel to be adherent at this time and we elected to open, so the trocars and instruments were all removed. We then made a midline incision and, on inspection, found a large mass in the pelvis. We had already freed up the left side of the sigmoid colon with laparoscope. We identified the ureter and pushed it away, opened the right pelvic peritoneum and identified the right ureter, and then transected the bowel above the junction of the sigmoid and descending colon with the GIA. We then divided the mesentery between Kelly clamps, including the inferior mesenteric terminal branch. These were all divided and ligated with heavy silks. We pulled the small bowel off the side, but it did look like there was some direct invasion there, and then further mobilized the tumor and the upper rectum. We divided all the mesentery between Kelly clamps and ligated with heavy silk.

We then transected the rectum through its middle and upper one thirds, with TA55 on the distal side and Kocher on the proximal side, and then removed the specimen. We brought the proximal end of the bowel out, cleaned it off of fat and mesentery, put a pursestring instrument on it, excised the bowel distal to the pursestring instrument, opened the pursestring instrument, and then incised it. The size was 28 mm. We then put the anvil of EEA in the proximal bowel and tightened it down with pursestring. We put the EEA instrument up through the rectum, pushed the trocar up through the suture line, then connected the anvil to the EEA instrument and tightened it down under direct vision, cut the bowel making the anastomosis and removed the EEA. We then filled the pelvis with saline, clamped the bowel proximally, and put in the colonoscope to obtain a good anastomosis with no bleeding and no leak of air.

We then aspirated the fluid in the pelvis. We resected the segment of the small bowel with GIA and did a functional end-to-end anastomosis and transected the bowel loop outside the anastomosis with a TA55. We actually had done this before we completed the rectal anastomosis, and when we went back we found a hematoma in the mesentery.

We dissected through the hematoma to get it controlled, ligated the bleeders with heavy silk, but then we had to resect another 10 cm of small bowel and then did another functional end-to-end anastomosis and closed the enterotomy with TA55 and the mesentery with fine silks. This gave us a nice anastomosis with good pink bowel, pretty close to the cecum.

We then noted there to be at least three, maybe four, metastases scattered over different areas of the right lobe of the liver. One was biopsied with a Tru-cut needle and the biopsy site cauterized. We then had a correct sponge, instrument, and needle count. We closed the fascia of the right upper quadrant puncture wound with some interrupted silk Vicryls and closed the muscles with interrupted Vicryls. The other smaller ports were closed by skin clips. We then closed the fascia of the peritoneum of the midline wound with running suture of #l Vicryl and the fascia with interrupted figure 8 #l Vicryl, closed the skin with clips, and applied sterile dressings. Sponge, instruments, and sharp counts were again correct. The patient tolerated the procedure well and we trust he will do well.

Pathology Report

Specimen—Origin:

I. Small bowel sigmoid colon

II. Liver biopsy

Pathologic Diagnosis:

I. Segments of small bowel: Serosal adhesions

Colon: Invasive adenocarcinoma, moderate to poorly differentiated, extending into pericolic adipose

Lymph nodes, small bowel mesentery: Negative for metastasis (0/6 nodes)

Lymph nodes, pericolic: Negative for metastasis (0/6)

Pericolic adipose: Metastatic adenocarcinoma

II. Liver (needle biopsy): Metastatic adenocarcinoma

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