Clinical Discharge

Clinical Discharge Summary Note

Reason for admission:

Patient is a 75-year-old male diagnosed with duodenal mass, neuroendocrine carcinoma, poorly differentiated in November 2018 that was repaired by completing a whipple surgical procedure on September 2019. The patient arrival from home via personal automotive to the Moffitt Cancer alert and oriented, vital sign with in normal limit, stable appearance, and with wife by his side. “A Whipple procedure is a type of surgery used to treat pancreatic cancer when the tumor is located in the head of the pancreas. Unlike a "classic" Whipple procedure in which the lower part of the stomach, all of the duodenum and the head, neck and uncinated process of the pancreas are removed, this modified resection preserves the entire stomach, the pylorus and several centimeters of the upper duodenum (Gastroenterology Week., 2007)”. This patient past surgical history revealed s/p cystoscopy and resection in 1995; s/p partial left nephrectomy in 2016; s/p antrectomy and reconstruction 30 years ago; bilateral cataracts; and left leg stent times two 9 year ago.

ICD-10 Diagnosis

1. Malignant neoplasm of pancreas, unspecified- C25.9.

2. Type 2 Diabetes w/ diabetic peripheral angiopathy w/o gangrene- E11.51.

3. Chronic obstructive pulmonary disease- J44.9.

4. Gastrostomy status- Z93.1.

5. Peripheral vascular angioplasty status w/ implants and grafts –Z95.820.

6. Personal history of nicotine dependence- “Z87.891 (www.icdcodelookup.com. 2019)”.

List of all procedures:

1. Epidural, infusion of bupivavaine 0.625%

2. Exploratory laparotomy

3. Pancreaticoduodenectomy (whipple).

4. Gastrostomy or jejunostomy +/- vein resection/reconstruction.

Complete list of consults during hospitalization:

1. DM Educator consulted for discharge home medication regiment

2. PT/OT consulted

3. Dietitian consulted for GI soft/ high protein diet

4. Consulted acute post-surgical pain team

5. 2unit of PRBC given for HGB 7.6

6. Home health ordered for walker

Patient's condition at discharge:

“Pancreaticoduodenectomy is a complex surgical procedure associated with high morbidity and prolonged length of stay. Enhanced recovery after surgery principles have reduced complications rate and length of stay for multiple types of operations (Daniel, S. K., 2018)”. This patient hospital course progressed as expected. Postoperatively, pain was controlled by multimodal therapy and transitioned to by mouth medications prior to discharge. Both NGT removed and the patient tolerating diet with return of bowel function. UOP satisfactory. Surgical drain removed without incident after acceptable output noted times two. Jackson Pratt drainage was negative times two prior to d/c. PICO dressing removed without incident. PT/OT consulted. Ambulated well with assistance and able to perform ADLs with assistance. Home health is ordered for walker, PT/OT. Labs and VS stable at discharge. Patient is appropriate for discharge home.

Complete list of discharge medications:

1. Aspirin 81mg, 1 tablet daily

2. Lovenox prophylactically

3. Creon 36,000 unit, 1 capsule, 3 times a day

4. Hydromorphone 8MG, 1 to 2 tablet as needed

5. Metoprolol 25mg, 1 tablet, 2 times a day

6. Lidocaine prilocaine topical 2.5%, 1 application daily

7. Metformin 500mg, 1 table, 2 times daily

8. Multivitamin oral, 1 tablet daily

9. Ondansetron 8mg, 1 tablet, PRN

10. Pantoprazole 40mg, 1 tablet daily

11. Polyethylene glycol 3350 oral 17mg, oral powder daily

Pending test results for follow up

Patient will return to clinic on Monday and at that time lab draw for CBC, CMP, magnesium, phosphate will be drawn and evaluated due to previous lab draw revealed a low RBC, H/H, platelet count, sodium, potassium, chloride, calcium, total protein, and albumin level.

Complete list of discharge follow-ups:

1. Follow up with PCP on Friday/ Monday for hypertension

2. Plavix with be started after follow up appointment

3. Follow up with GI clinic on Friday/ Monday status post discharge

4. Home health skilled nursing service on Monday (wound care)

5. DM Educator appointment on Monday

References

Daniel, S. K., ⨯ Lucas, W. T., Mann, G. N., Park, J. O., & Pillarisetty, V. G. (2018). Standardization of perioperative care facilitates safe discharge by postoperative day five after pancreaticoduodenectomy. PLoS One, 13(12) doi:http://dx.doi.org.lopes.idm.oclc.org/10.1371/journal.pone.0209608

Pancreatic cancer; whipple webcast highlights innovative surgical treatment for pancreatic cancer. (2007, Sep 10). Gastroenterology Week Retrieved from https://lopes.idm.oclc.org/login?url=https://search-proquest-com.lopes.idm.oclc.org/docview/237340908?accountid=7374

10 Code Lookup. (2019). Retrieved from https://icdcodelookup.com/icd-10/codes/malignant neoplasm of pancreas.