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None of this copy has been proofed for typos (1-8-2000)

Admitted: 17 Dec 99
Discharged: 27 Dec 99

CHIEF COMPLAINT: Anemia.

HISTORY OF PRESENT ILLNESS: The patient is a 51 year-old white female with complaint of "loss of strength" over the last several months. The patient finally sought medical attention approximately one week prior to admission to this facility, at which time she was noted to have a hematocrit of 11. It was recommended that the patient be admitted at that time for evaluation and transfusion; patient refused,

(my only request of the private practice doctor was to run blood tests to see what might be wrong as he stated that he had not dealt with military medical patients in over a year, I had no confidence or desire to be hit with a medical bill I might not be able to pay ... so I told his office that I was going to check with military ... also, the only hospital where this doctor had privileges was a small hospital where my husband had been pronounced dead and I had NO desire to go there for any reason, whatsoever, as I had billing from them already that was incorrect, and also an inflated billing from this doctor even when I had thoroughly discussed what my billing was to be before I came to his office ... so I stated that I would seek other care from the military ... I have since come to be very glad I made this decision)

stating that she wished to be seen at a military facility. The patient was unable to get transportation to this facility until approximately one week later, at which time she presented to the Emergency Room. At the time of presentation, the patient denies any abdominal pain, nausea, vomiting, diarrhea, constipation, change in her bowel habits, melena, hematochezia, hematemesis. No history of hepatitis. No history of jaundice. She does have a positive history of a cecal polyp. Steady weight loss over the last year following a bout of pneumonia.

PHYSICAL EXAMINATION: General: She is a well-developed, well-nourished slender pale white female in no acute distress. HEENT: Unremarkable except for an unhealed scratch in the previous squamous cell cancer of the face. Neck: Supple, witout bruits. Thyroid was smooth and without masses. Heart: Regular rate and rhythm with a systolic murmur. Lungs: Clear to auscultation, without rales, honchi, wheezes. Abdomen: Positive bowel sounds, soft, nontender. The patient was noted to have the pelvic presence of fullness in the right lower quadrant, just above the pelvic bris. GU: External normal female and otherwise unremarkable. Rectal: Good tone, gusiac negative from below. Back: Straight, nontender. Extremities: Without clubbing, cysnosis, or edema.

LABORATORY AND X-RAY DATA: EKG revealed normal sinus rhythm with a rate of 81.

ASSESSMENT AT THE TIME OF ADMISSION:
1) Anemia. 2) Previously undocumented heart murmur with a questionable history of heart enlargement and questionable cardiac response to a hematocrit of 11. 3) Right lower quadrant abdominal fullness.

HOSPITAL COURSE: Hematocrit at the time of admission was noted to be 14.5 with hemoglobin of 3.6, white count of 5.42, and platelet count of 481,000. Her chem-7 was within normal limits with the exception of glucose of 135 and her liver function tests were abnormal for a total protein of 5.7 and an albumin of 3.2; otherwise, liver function tests were within normal limits.

Because of the patient's unexpected response to a low hematocrit of 11 and question of her cardiac status, a consultation to Internal Medicine was obtained with recommendations from Internal Medicine to evaluate the patient for hypothyroidism and also to get a persantine thallium to rule out any cardiac problems.

The patient was transfused with two units of packed red blood cells with improvement of her hematocrit. Her thyroid function tests returned normal. While awaiting for confirmation of cardiac clearance, a CT scan of the abdomen and pelvis was performed which revealed an abnormality with circumferential wall thickening of the terminal ileum with a mass extending into the decum. Also noted was a questionable porta hepatis adenopathy. This could not be adequately evaluated secondary to the patient's severe reaction to IVP dye. It was recommended that further evaluation be performed to include MRI and ultrasound.

The patient also underwent an adenosine thallium which returned normal and she was cleared for further evaluation. On 20 Dec 99, the patient underwent a colonoscopy which revealed a polypoid lesion in the cecal cap which appeared to come from the ilenocecal valve region. Also noted was an 8 mm polyp at approximately 30 cm. Both of these areas were biopsied. The biopsy on the colonic polyp at 30 came back consistent with tubular adenoma with some dysplasia but no invasion of submucosa was noted and this polyp had been totally removed. The polypoid lesion in the cecum came back consistent with poorly differentiated adenocarcineoma.

The patient also, on 20 Dec 99, underwent MRI which revealed that the pancreas was within normal limits. There was noa bnormality in the porta hepatis. Given that the patient's pancreas was clear, there was no evidence of adenopathy based on MRI and that this mass appeared to be confined to the ileocecal valve region. The patient was counseled for a right hemicolectomy.

Prior to the patient's surgery she was tranfused an additional unit of packed red blood cells to raise her hematocrit prior to her surgery. On 21 Dec 99, the patient underwent a right hemicolectomy, at which time the patient was noted to have a large cecal mass at the ileocecal valve with a tumor adherent to the right pelvic side wall. During the operation, a portion of the tumor had to be finger fractured to allow exposure away from the right pelvic side wall and the area where the tumor was adherent to the right pelvic side wall was excised and marked with surgical clips. A right hemicolectomy with ileocecectomy was performed.

Postoperatively, the patient did well. On postoperative day #1 her hematocrit was noted to be 26.9. DEA at that time was noted to be 1.9. Postoperative day#2, the patient was doing well, had brisk urine output, and at that time her intravenous fluid rates were decreased and her Foley was disocntinued. The patient was complaining of some sinus fullness and a sinus series was obtained which was otherwise unremarkable. Postoperative day #3, the patient continued to do well. Hematocrit at that time was 25.7. Postoperative day #4, the patient was advanced to a clear liquid diet. Postoperative day #5, the patient had positive flatus and a bowel movement and she was advanced to a regular diet, which she tolerated well. On postoperative day #6, the patient was discharged to home after her surgical skin staples were removed and Steri-Strips were wer placed.

DISCHARGE DIAGNOSES:

1) Poorly differentiated adenocarconoma of the cecum.
2) Tubular adenoma of the sigmoid colon; removed by colonscopy.
3) Anemia, secondary to colon cancer.

PROCEDURES PERFORMED:
1) CT scan of the abdomen.
2) Adenosine thallium.
3) MRI of the pancreas.
4) Conoscopy with biopsy.
5) Exploratory laparotomy with right hemicolectomy and ileocecectomy.

DISCHARGE MEDICATIONS: 1) Tylox one to two q4-6h prn pain.
2) Ferrous sulfate 325 mg po tid.
3) Colace 100 mg po bid.

FOLLOW-UP INSTRUCTIONS:
1) The patient is to follow-up in the General Surgery Clinic in approximately one week for follow-up.
2) The patient was given consults for Oncology and Radiation Therapy for further evaluation for potential radiation and chemotherapy treatments.

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PREOPERATIVE DIAGNOSIS: Poorly differentiated adenocarcinoma of the cecum.

POSTOPERATIVE DIAGNOSIS: Poorly differentiated adenocarcinoma of the cecum.

PRODECURE PERFORMED: Exploratory laparotomy and right hemicolectomy. SURGEON: Dr. Derrick Galapon
Assistant: Dr. Gott

ANESTHESIA PROVIDER: Terner

TYPE OF ANESTHESIA: General endotracheal

MATERIAL TO LABORATORY: Right colon

DATE OF OPERATION: 21 DEC 99

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the operating room table where general endotracheal anesthesia was obtained. The patient had a Foley catheter placed to decompress the bladder. The abdomen was prepped and draped in usual serile fashion. A lower midline incision was made using a scalpel blade. Hemostasis was obtained by electrocautery. The dissection was carried down to the underlining fascia and the fascia was opened in the midline. The peritoneum was identified and opened using a pair of Metzenbaum scissors and was oepened the entire length of the incision. To provide better exposure, the incision was made larger, extending it above the umbilicus. Upon entering the abdomen, a quick survey of the abdomen was conducted, at which time the patient was noted to have a large, approximately orange sized mass in the right lower quadrant, which was adherent to the right pelvic side wall. Bookwalter retractors were placed to provide better exposure. The right colon was mobilized by taking down the while line of Toldt using right ankle clamp and Bovie. In this manner, the right colon was movilized down to the cecal mass, which was adherent to the pelvic side wall. The mass was mobilized from the right pelvic side wall. During this mobilization, a portion of tumor was left on the right pelvic side wall. The hepatic flexure was dissected out, again using Bovie and Metzenbaum scissors. The patient was noted to have multiple adhesions to the inferior edge of the liver. The liver itself appeared grossly normal. On palpation, it appeared grossly normal. To mobilize the mass further for planned excision, the portion of the small bowel, which was adherent into the pelvis, most likely secondary to the patient's previous hysterectomy, had to be mobilized. This was taken down again sharply using a pair of Metzenbaum scissors and/or the Bovie. In this manner, the reight cecal mass was mobilized. The planned transection sites were ascertained by examining the right colon. The mesentery was dissected away from the colonic wall in the region of the transverse colon, just distal to the hepatic flexure. This area was divided using a GIA stapler. An area proximal to the ileocecal valve was identified where the small bowel was grossly normal. Again, the mesentery was cleaned away from the small bowel wall of the terminal ileum. A GIA stapler was sued to divide this area.

The mesentery was scored using the Bovie and then using Kelly clamps the mesentery of the right colon was taken down between clamps and tied using free ties. The right colic artery, once it was identified, was taken in similar fashion and a suture ligature was placed on it to provide better hemostasis. The specimen was passed off the field where it was opened by the circulating nurse and again, identifying a large cecal mass in the region of the ileocecal valve. Attention was then turned to the right pelvic side wall. and the right pelvic side wall was dissected out. The ureter was identified and was dissected out partially to ensure that it course did not go into the area where the tumor had been adherent to the pelvic side wall. The iliac vessels were identified and were partially dissected out to ensure that their course also did not go near the tumor in the right pelvic side wall. The peritoneum of the right pelvic side was was scored using the Bovie and then, using a right angle clamp and sharp dissection using the Bovie, the adherent tumor to the right pelvic side wall was excised and passed off the field as surgical specimen. Surgical clips were placed on te cut edges of the peritoneum, as well as placing a single clip in the middle of the surgical site where the tumor had been adherent. Attention was turned to performing the anastomosis.

Allis clamps were placed on the stapled corners of the large and small bowel. A 3-0 GI silk was used to tack the large and small bowel together on their antimesenteric borders. The corner of the staple line was removed using a pair of Mayo scissors. A 75 mm GIA was brought up on the field and used to perform a stapled side-to side functional en-to-end anastomosis. After this 75 mm stapler was fired, the staple line was examined for any bleeding points and none were noted at that time. Allis clamps were used to clamp across the open end of the large and small blwel, ensuring that the staple line was staggered and then a TA 55 was used to staple across the open bowel edge. A scaplpel blade was used to remove the excess tissue, distal to the staple line. The staple line was examined and there was one small bleeding point, which was addressed using a figure-of-eight stuture of 3-0 GI silk. The mesentery of the large and small bowel were reapproximated using a running suture of 3-0 Vicryl to close the mesenteric defect. The abdomen was copiously irrigated. After irrigating the abdomen, the liver again was examined and palpated bimanually. No gross abnormalities were noted in the liver. Attention was also turned to examining at least the head of the pancreas. The duodenum, which had previously been exposed during the dissection, was examined. It was already partially kocherized and at that time, using palpation, the head of the pancreas was examined by othe the operating and the assistant surgeon and no gross abnormalities were palpated. The abdomen was copiously irrigated. The irrigation was aspirated from the abdomen until clear. The surgical incision was closed by reapproximating the fascia using a running suture of #1 looped PDS. The incision was copiously irrigated. The skin was closed using surgical staples. A clean and sterile dressing was placed over the wound.

The patient was awakened, extubated, and transported to the recovery room having tolerated the procedure well.