Malignant neoplasm of pancreatic duct Secondary malignant neoplasm of other specified sites Nonalcoholic steatohepatitis (NASH) Personal history of antineoplastic chemotherapy Adverse effect of antineoplastic and immunosuppressive drugs initial encounter Unspecified place in single-family (private) house as the place of occurrence of the external cause Autoimmune thyroiditis Hypothyroidism unspecified Major depressive disorder single episode unspecified Hyperlipidemia unspecified Personal history of urinary calculi Personal history of nicotine dependence
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
tetracycline
 
Attending: ___.
 
Chief Complaint:
Pancreatic cancer
 
Major Surgical or Invasive Procedure:
___:
1. Exploratory laparoscopy.
2. Radical pancreaticoduodenectomy with distal gastrectomy.
3. En bloc resection of main portal vein and replace right 
hepatic artery.
4. Cholecystectomy.
5. End-to-end primary repair of portal vein.
6. Placement of gold fiducials.
7. End-to-side duct to mucosa pancreaticojejunostomy.
8. End-to-side hepaticojejunostomy.
9. Antecolic ___ gastrojejunostomy.
10.Transgastric feeding jejunostomy.

 
History of Present Illness:
Mrs. ___ is a ___ woman who has completed 
preoperative chemotherapy and radiation for borderline 
resectable pancreatic ductal carcinoma characterized by main 
portal vein involvement and encasement of the very large 
replaced right hepatic artery. She has completed chemoradiation 
as well as preoperative plugged occlusion of the replaced right 
hepatic artery with
development of adequate arterial collaterals to the right liver. 
 She is now taken to the operating room for definitive surgical 
resection and vascular reconstruction.  The risks and benefits 
of surgery have been discussed with the patient in great detail 
and are documented in a separate note.

 
Past Medical History:
Hypothyroidism - ___'s
Depression
Hyperlipidema (although not on statin currently)
Nephrolithiasis (long time ago, passed a kidney stone)

Past Surgical History: 
-prior eye surgery many years ago to correct a strabismus when 
she was a child

 
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at ___ or 
___ years, was diagnosed with colon cancer at age ___, and died 6 
months later. Grandmother died from "septicemia," abdominal 
causes. She is ___ of five children, all in good health. Sister 
with ___ disease. 
 
Physical Exam:
Prior to Discharge:
VS: 98.5, 80, 161/87, 18, 96% RA
GEN: NAD
CV: RRR, no m/r/g
PULM: CTAB
ABD: Trapdoor incision open to air with steri strips and c/d/I. 
RLQ 2 old JP sites with dsd and c/d/i
EXTR: Warm, no c/c/e
 
Pertinent Results:
___ 07:00AM BLOOD WBC-6.2# RBC-2.36* Hgb-8.0* Hct-24.3* 
MCV-103*# MCH-33.9* MCHC-32.9 RDW-13.7 RDWSD-51.2* Plt ___
___ 07:00AM BLOOD Glucose-90 UreaN-8 Creat-0.5 Na-134 K-3.4 
Cl-100 HCO3-23 AnGap-14
___ 04:11AM BLOOD ALT-56* AST-76* AlkPhos-55 TotBili-0.3
___ 07:00AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.6
___ 06:44PM ASCITES Amylase-11
___ 06:45PM ASCITES Amylase-8

PATHOLOGY: Pancreatic adenocarcinoma 
 
Brief Hospital Course:
The patient with pancreatic ca s/p neoadjuvant therapy was 
admitted to the HPB Surgical Service for elective Whipple. On 
___, the patient underwent pancreaticoduodenectomy 
(Whipple), open cholecystectomy and portal vein reconstruction, 
which went well without complication (reader referred to the 
Operative Note for details). After a brief, uneventful stay in 
the PACU, the patient arrived on the floor NPO with an NG tube, 
on IV fluids, with a foley catheter and a JP drain in place, and 
epidural catheter for pain control.  The patient was 
hemodynamically stable.
The ___ hospital course was uneventful and followed the 
___ Clinical Pathway without deviation.  Post-operative pain 
was initially well controlled with epidural and PCA, which was 
converted to oral pain medication when tolerating clear liquids. 
The NG tube was discontinued on POD#3, and the foley catheter 
discontinued at midnight of POD#4. The patient subsequently 
voided without problem. The patient was started on sips of 
clears on POD#4, which was progressively advanced as tolerated 
to a regular diet by POD#7.  JP amylase was sent in the evening 
of  POD#6; the JP was discontinued on POD#7 as the output and 
amylase level were low.
During this hospitalization, the patient ambulated early and 
frequently, was adherent with respiratory toilet and incentive 
spirrometry, and actively participated in the plan of care. The 
patient received subcutaneous heparin and venodyne boots were 
used during this stay. The patient's blood sugar was monitored 
regularly throughout the stay; sliding scale  insulin was 
administered when indicated. 
At the time of discharge on ___, the patient was doing well, 
afebrile with stable vital signs.  The patient was tolerating a 
regular diet, ambulating, voiding without assistance, and pain 
was well controlled.  Staples were removed, and steri-strips 
placed. The patient was discharged home without services. The 
patient received discharge teaching and follow-up instructions 
with understanding verbalized and agreement with the discharge 
plan.

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine 75 mg PO DAILY 
2. Levothyroxine Sodium 75 mcg PO DAILY 
3. Creon ___ CAP PO TID W/MEALS 
4. LORazepam 0.5-1 mg PO Q6H:PRN anxiety 
5. Prochlorperazine 10 mg PO Q6H:PRN nausea 
6. Docusate Sodium 100 mg PO BID 
7. Loratadine 10 mg PO DAILY 
8. Multivitamins 1 TAB PO DAILY 
9. Fish Oil (Omega 3) 90 mg PO DAILY 
10. Polyethylene Glycol 17 g PO DAILY 

 
Discharge Medications:
1. Docusate Sodium 100 mg PO BID 
2. Levothyroxine Sodium 75 mcg PO DAILY 
3. LORazepam 0.5-1 mg PO Q6H:PRN anxiety 
4. Venlafaxine XR 150 mg PO DAILY 
5. Acetaminophen 1000 mg PO Q8H 
do not exceed more then 3000 mg/day 
6. Aspirin 81 mg PO DAILY 
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 
Tablet Refills:*5
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) 
hours Disp #*80 Tablet Refills:*0
8. Metoclopramide 10 mg PO QIDACHS 
RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56 
Tablet Refills:*0
9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 
10. Pantoprazole 40 mg PO Q12H 
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) 
hours Disp #*60 Tablet Refills:*5
11. Senna 8.6 mg PO BID 
12. Fish Oil (Omega 3) 90 mg PO DAILY 
13. Loratadine 10 mg PO DAILY 
14. Multivitamins 1 TAB PO DAILY 
15. Polyethylene Glycol 17 g PO DAILY 
16. Prochlorperazine 10 mg PO Q6H:PRN nausea 
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea 
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every 
eight (8) hours Disp #*30 Tablet Refills:*0
18. Creon ___ CAP PO TID W/MEALS 
19. Enoxaparin Sodium 40 mg SC DAILY 
Start: Today - ___, First Dose: Next Routine Administration 
Time 

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Pancreatic adenocarcinoma 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were admitted to the surgery service at ___ for surgical 
resection of your pancreatic mass. You have done well in the 
post operative period and are now safe to return home to 
complete your recovery with the following instructions:
.
Please call Dr. ___ office at ___ or ___ 
___, RN at ___ if you have any questions or 
concerns. 
.
Please resume all regular home medications , unless specifically 
advised not to take a particular medication.  Also, please take 
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times 
per day, and drink adequate amounts of fluids.  Avoid lifting 
weights greater than ___ lbs until you follow-up with your 
surgeon, who will instruct you further regarding activity 
restrictions.
Avoid driving or operating heavy machinery while taking pain 
medications.
Please follow-up with your surgeon and Primary Care Provider 
(PCP) as advised.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have 
increased pain, swelling, redness, or drainage from the incision 
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap 
and warm water.  Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.  
Please remove any remaining strips ___ days after surgery.
.
G/J-tube: Capped.

 
 

 
Followup Instructions:
___

{'Pancreatic adenocarcinoma': ['Malignant neoplasm of pancreatic duct'], 'Hypothyroidism': ['Hypothyroidism'], 'Depression': ['Major depressive disorder', 'single episode', 'unspecified'], 'Hyperlipidemia': ['Hyperlipidemia', 'unspecified'], 'Nephrolithiasis': ['Personal history of urinary calculi']}