Malignant neoplasm of ascending colon Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Urinary tract infection site not specified Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Right colon cancer
 
Major Surgical or Invasive Procedure:
lap R colectomy 

 
History of Present Illness:
___ healthy male initially presenting with history of abdominal 
pain. Incidental findings on CT of a large mass 6.2 x 4.9 x 6.0 
(TV x AP x CC) cm mass within the mid ascending colon consistent 
with malignancy. Colonoscopy workup also confirming 
adenocarcinoma. He presents for elective resection of his 
cancer. 

 
Past Medical History:
None
 
Social History:
___
Family History:
One brother died of leukemia.

 
Physical Exam:
Vital Signs: Blood Pressure: 100/70, Heart Rate: 61, Weight: 202 
Lbs, Height:
71 Inches, BMI: 28.2 kg/m2.
HEENT: Anicteric. OP clear.  TM's normal bilaterally.
___: Negative.
COR: Regular, without concerning murmurs, ___, or rubs.
LUNGS: Clear bilaterally without rales, ronchi, or wheezes.
AB: Soft. No masses. No organomegaly.
VASCULAR:  DP pulses palpable bilaterally.  No bruits. No JVP.
SKIN: No concerning nevi noted.  No concerning rash noted.
NEURO: The cranial nerves are intact. Grossly non-focal.
GU: Testes descended bilaterally.  No nodules. No ___. 

 
Pertinent Results:
___ 07:46PM URINE RBC-187* WBC-29* Bacteri-NONE Yeast-NONE 
Epi-<1

   URINE CULTURE (Final ___: 
      Culture workup discontinued. Further incubation showed 
contamination
      with mixed fecal flora. Clinical significance of 
isolate(s)
      uncertain. Interpret with caution. 
      PROTEUS MIRABILIS.    >100,000 ORGANISMS/ML.. 
         PRESUMPTIVE IDENTIFICATION. 

___ 07:05AM BLOOD WBC-10.8# RBC-3.97* Hgb-11.5* Hct-34.7* 
MCV-87 MCH-28.8 MCHC-33.0 RDW-12.9 Plt ___

___ 01:00PM BLOOD CEA-1.9
 
Brief Hospital Course:
Patient was admitted to Dr. ___ service on ___. 
He was taken to the operating room for a laparoscopic right 
colectomy. Patient tolerated the procedure without complications 
and taken to the PACU for monitoring. He was transferred to the 
floor for further recovery. 

His hospital course could be summarized as following:

Neuro: Patient had sufficient pain control with Vicodin.
Resp: No respiratory issues.
Cardio: No hemodynamic issues. 
GI: Patient was kept NPO after his procedure with IVF. He was 
advanced to sips POD1. Diet was eventually advanced to regular 
on POD3 with return of bowel function. He will be discharged 
with a stool softener to be taken with narcotics. 
GU/FEN/Renal: Patient's urine output was monitored closely. His 
IV fluids were discontinued as he tolerated enough of his oral 
intake. 
ID: Patient with fever POD2 of 101.3. UA/UCx confirming UTI with 
proteus. Patient will be kept on a 5 day course of 
ciprofloxacin. Moreover, some erythema to surgical incision. 
Will discharge him with a 7 day course of cefadroxil for empiric 
coverage. 
Heme: Patient with subcutaneous heparin for DVT prophylaxis
Dispo: Patient ambulating without any difficulty. He will be 
discharged home. 

 
Medications on Admission:
None
 
Discharge Medications:
1. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q4-6H () as needed for pain for 2 weeks: Please do not take more 
than 4000mg of acetainophen in 24 hrs. Do not exceed 8 in 24 
hrs.
Disp:*45 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: 
for constipation while on narcotics.
Disp:*60 Capsule(s)* Refills:*2*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H 
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Duricef 1 gram Tablet Sig: One (1) Tablet PO once a day for 7 
days.
Disp:*7 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary: Right colon Cancer

 
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications. 

 
Discharge Instructions:
Please call your doctor or return to the ER for any of the 
following:
* If you are vomiting and cannot keep in fluids or your 
medications.
* You are getting dehydrated due to continued vomiting, 
diarrhea or other reasons. Signs of dehydration include dry 
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a 
bowel movement.
* Your pain is not improving within ___ hours or not gone 
within 24 hours. Call or return immediately if your pain is 
getting worse or is changing location or moving to your chest or 

back.
*Avoid lifting objects > 5lbs until your follow-up appointment 
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain 
medications.
* You have shaking chills, or a fever greater than 101.5 (F) 
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that 
concern you. 
* Please resume all regular home medications and take any new 
meds 
as ordered. 
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any 
remaining strips ___ days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling, 
redness, or drainage from the incision sites.

 
Followup Instructions:
___

{'abdominal pain': ['Malignant neoplasm of ascending colon'], 'mass within the mid ascending colon': ['Malignant neoplasm of ascending colon'], 'adenocarcinoma': ['Malignant neoplasm of ascending colon'], 'fever': ['Urinary tract infection'], 'erythema to surgical incision': ['Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site']}