Danita Moon
dkbookworm40@live.com
916-717-7387

DISCHARGE SUMMARY (6:45)

PROBLEM LIST
1. Metastatic ovarian cancer with ascites.
2. Gait disturbance.
3. Status post thyroidectomy for follicular carcinoma.
4. Depression.
5. Peptic ulcer disease.
6. Degenerative arthritis of the cervical lumbar spine.
7. Osteopenia of the spine and hip.

BRIEF HISTORY
A 92-year-old white female was admitted with abdominal swelling and suspected intra-abdominal bleeding. The patient had been followed in my practice. She had undergone a total thyroidectomy for follicular carcinoma. Fortunately, there had been no evidence of recurrent metastatic disease. She was found to have an ovarian cyst but elected not to pursue surgical treatment.

The patient suffered from depression. She had been on long term Zoloft 50 mg daily. She had become quite depressed after the death of her husband from myasthenia gravis.

For approximately a year and a half, she had suffered from a gait disturbance. She had been seen in consultation with what the gait disturbance would do to multiple factors, including degenerative joint disease and peripheral neuropathy. He also thought she had an element of Parkinson's disease. No specific medication was advised. During the preceding years she had suffered several falls. A fall 1 year ago had resulted in a right humeral fracture.

One week prior to admission, the patient saw a television program suggesting that Zoloft might have long-term adverse effects. She stopped the medication abruptly. Over the next week she became increasingly nervous, emotionally labile, and suffered from insomnia. Two days prior to admission, she fell in the bathroom. She did not recall specifically how she had landed. Since that time, however, she complained of lower abdominal discomfort. She also noted ecchymoses around her umbilicus.

The patient was brought to my office by her daughter on the day of admission. She appeared dehydrated and weakened. There were periumbilical ecchymoses and fullness in the left lower quadrant. It was feared that she had had an intra-abdominal hemorrhage and she was sent to the emergency room.

MEDICATIONS
Synthroid 112 mcg daily, Zoloft 50 mg daily, Nexium 40 mg daily, multivitamins 2 tablets daily.

PHYSICAL EXAMINATION
Physical exam revealed a sad, frail-appearing elderly woman. Pulse: 70, regular. Blood pressure: 130/70. Temperature: 98. Skin: periumbilical ecchymoses were present along with faint ecchymoses extending into the left lower quadrant. HEENT: Mild conjunctival pallor. Neck: Well-healed thyroidectomy scar. No masses. Lungs: No rales, wheezes or rhonchi. Heart: Grade 2/6 systolic ejection murmur along the lower left external border. Abdomen: No liver or spleen enlargement. There is definite fullness in the left lower quadrant with pain on firm palpation. Bowel sounds were present. Extremities were without edema. Arterial pulses were present. No calf tenderness.

LABORATORY
Hemoglobin 12.9, hematocrit 39.2, WBC 10.6, platelets 20-40,000, PTT 22.5. Chemistry: Sodium 144, potassium 3.5, chloride 108, CO2 28, glucose 112, BUN 21, creatinine 1.3. Alkaline phosphatase 117. Urinalysis was negative. EKG showed nonspecific T-wave abnormality. Chest x-ray is normal. A healed right proximal humeral fracture was present.

HOSPITAL COURSE
Patient was seen in consultation by the Gastroenterology Service. It was elected to proceed with a CT scan of the abdomen. The CT scan showed intraperitoneal free fluid. There was infiltration of the mesentery. There was mesenteric caking, raising a suspicion for a neoplasm. There was diverticular without evidence of diverticulitis.

Under ultrasound guidance the patient underwent paracentesis for removal of 3,500 cc's of thin, nonpurulent, ascitic fluid. Fluid analysis cytology was positive for adenocarcinoma. CA 125 was 589, CEA was 2.5. The patient was seen at consultation by the gynecological oncology service. The patient was offered the options of surgery or chemotherapy. She herself desired only comfort care. She was most concerned not to be a burden on her family.

Patient's hospital stay was trying to make her as comfortable as possible. She did undergo a second therapeutic paracentesis at which time more than four liters of fluid was removed. The patient was able to eat and then consume some nutritional supplements. She did have some minimal left side lower abdominal discomfort but this seemed to be manageable just by Tylenol.

The patient and her daughter met with Hospice home care and it was felt that the patient that she desired to go home with Hospice home care only. She would not wish to have surgery or chemotherapy but was interested in comfort care. She understood that she had a terminal illness. Current patient was discharged on Synthroid 112 mcg daily, Protonix 30 mg daily, Zoloft 50 mg daily. She was to be seen by Hospice home care and regiments would be made for hospice home services.

I noticed the last paragraph is not correct, but I'm unsure about the rest of it. Could anyone else offer any help on this transcript please?

Do you still need help with the discharge summary?