I will post here if somebody give your minutes to proof read my transcription and if posible fill in the blanks.
DISCHARG SUMMURY
PROBLEM LIST
1. Ascites
2. Diverticular disease
3. Peptic ulcer disease
4.Type 2 diabetes
5. _____Stroke
BRIEF HISTORY
A 91-year old white male was admitted to the hospital due to weakness, fatigue, anorexia and distended abdomen. The patient had a history of non peptic ulcer disease. He had been admitted in November with diverticulitis.
For several weeks the patients had been experiencing anorexia and mild nausea. For several days his abdomen appeared to be becoming increasingly more distended. Recent history he was brought to emergency room.
CT scan in the emergency room revealed a large amount of ascites. There was a left renal cyst. There was felt to be changes in the mesentery ("orbensitional") peritoneal carcinomatosis. There were multiple hypodensities in both kidneys felt to represent cysts. The peritoneal carcinomatosis was manifest as tiny nodules through-out the mesenteric fat. There was no evidence of an abdominal aortic aneurysm. The patient was admitted for further management.
PAST MEDICAL HISTORY
Patient was status post for tubal basilar stroke which left him with gait unsteadiness. He had a known history of peptic ulcer disease and diverticular disease.
MEDICATIONS
1. Protonix 40 mg daily
2. Avandia 4 mg daily
ALLERGIES
None known
PHYSICAL EXAMINATION
Physical exam revealed a frail appearing elderly man. Vital signs: Pulse 70 regular, blood pressure 140/82, temperature 96.7. Skin: No pallor. HEENT: No scleral icterus. Neck: With out goiter. No carotid bruits. Lungs clear. Heart: Systolic ejection murmur. Abdomen: Distended, positive fluid wave, no masses. Rectal was negative.
LABORATORY
Hemoglobin 13, hematocrit 39.2, WBC 8.1, platelets 330,000, Chemistry 7132, potassium 4.6, Chloride 98, CO2 30, Glucose 102, BUN 22, Creatine 1.1, albumin 2.5, cell count WAS 677,protein was 4.1, CEO was 2.5, TSH 2.77, alpha fetoprotein 2.3, acidic fluid was negative, CA 919 was 58.
Etilogy of ___________ felt that patient was too debilitated to be a candidate for chemotherapy. The patient did undergone MICT which did not show evidence of a definite pancreatic mass.
The patient did undergo proper ultrasound that has padding veins which showed no evidence of _____vein thrombosis .
The patient did receive thyroid replacement, and he started also on (magus). The family will preparation to patient to taken home from hospice home care and definitive diagnosis have not been made though the CAT scan has been highly suspicious of peritoneal carcinomatosis.
PLAN
The patient was discharge from the hospice home care and folowing medical regimen synthroid 25 mcg daily , protonix 40 ml daily ____30 cc b.id, Zoloft 25 ml daily. He was to see hospice home care services and supporting measures.
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