Malignant neoplasm of liver secondary Personal history of malignant neoplasm of large intestine Unspecified essential hypertension
 
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:
Metastatic adenocarcinoma of the
colon to the liver.

 
Major Surgical or Invasive Procedure:
___ left lateral segmentectomy and port placement 

 
History of Present Illness:
Per Dr. ___ report, Mr. ___ is a ___ male 
who underwent a laparoscopic extended right hemicolectomy on 
___ for stage II transverse colon cancer.  He 
developed a rising CEA, and a CT scan in ___
demonstrated a low-density lesion in the left lobe of the
liver suspicious for metastatic disease.  His most recent CEA
was 19.  A follow-up CT scan on ___
demonstrated a 2.0 x 2.0 cm lesion in the left lateral
segment.  He is, therefore, brought to the operating room for
left lateral segmentectomy after informed consent was
obtained.  I should note that chest CT was negative for
metastatic disease.

 
Brief Hospital Course:
On ___ he underwent left lateral segmentectomy with 
intraoperative ultrasound and left double-lumen port placement 
for metastatic adenocarcinoma of the
colon to the liver. Surgeon was Dr. ___. Please 
refer to operative report for complete details. Operative 
findings per Dr. ___ were: a solitary lesion in the 
left lateral segment was found.  No other lesions were found 
grossly or by intraoperative ultrasound.  No extrahepatic 
disease was noted.

Postop, he did well. LFTs initially increased slightly, but then 
started trending down. Diet was advanced and tolerated. The 
abdominal incision was clean, dry and intact. Vital signs 
remained stable and he was transitioned to po pain medication 
once the epidural was removed on ___. He was ambulatory.

Pathology results were pending at time of discharge. 

 
 
Medications on Admission:
Lisinopril 10', Verapamil SR 240' 
 
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet 
Sustained Release PO Q24H (every 24 hours).  
3. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) 
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
metastatic colon CA to liver

 
Discharge Condition:
good

 
Discharge Instructions:
Please call Dr. ___ ___ if fever, chills, 
nausea, vomiting, worsening abdominal pain, incision 
redness/bleeding/drainage or any concerns
may shower
No driving while taking pain medication
No heavy lifting
 
Followup Instructions:
___

{'Metastatic adenocarcinoma of the colon to the liver': ['Malignant neoplasm of liver', 'secondary'], 'Rising CEA': ['Malignant neoplasm of liver', 'secondary'], 'Low-density lesion in the left lobe of the liver suspicious for metastatic disease': ['Malignant neoplasm of liver', 'secondary'], 'Solitary lesion in the left lateral segment': ['Malignant neoplasm of liver', 'secondary'], 'No other lesions were found grossly or by intraoperative ultrasound': [], 'No extrahepatic disease was noted': []}