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Clinical Discharge Summary.docx
Summary
1537 Words
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Clinical Discharge Summary- Pancreatic surgery
Patient information- 63-year-old male
Primary problem- pancreatic cancer
Self: Submitted to Grand Canyon University
Potentially missing comma: 2021 2021,
Clinical Discharge Summary- Pancreatic cancer
September 7, 2021
Date of admission: 04 March 2021
Date of discharge: 09 March 2021
Hospital Course/ Summary
A 63 years old male patient was diagnosed with duodenal mass and neuroendocrine
carcinoma. In September 2020, it was poorly differentiated, and in March 2021, it was repaired
by a procedure of Whipple surgery. When the tumor is located in the head of the pancreas, the
Whipple procedure is performed as it is a type of surgery used to treat cancer of the pancreas.
The pylorus, the entire stomach, and several centimeters of the upper duodenum are preserved in
this modified resection. In contrast, in a classic Whipple procedure, all of the lower part of the
stomach, neck, head, and uncinated part of the pancreas is removed.
On his personal automotive patient arrived from his home to cancer hospital. At the time
of admission, the patient was alert and oriented, and all his vital signs were within a normal
range. The appearance of the patient was stable, and his wife was with him. The patient's past
surgical history reveals that he underwent partial left nephrectomy in 2014, resection in 2005,
cystoscopy, 20 years ago antrectomy and reconstruction; seven years ago, he went through left
leg stent and bilateral cataracts.
Diagnosis: ICD CODES
1. Gastrostomy status Z93.1
2. Type 2 Diabetes without gangrene and with diabetic peripheral angiopathy E11.51
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Spelling mistake: neuroendocrine
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type of (omit): type of
Redundant phrase: all of the all the
Spelling mistake: uncinated urinated
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Spelling mistake: nephrectomy refectory
Spelling mistake: cystoscopy
Spelling mistake: antrectomy mastectomy
Spelling mistake: Gastrostomy Gastronomy
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Spelling mistake: bupivacaine
Spelling mistake: Bupivacaine
Spelling mistake: epidurally epidural
Spelling mistake: Pancreaticoduodenectomy
Spelling mistake: Gastrostomy Gastronomy
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3. Malignant neoplasm of pancreas, unspecified C25.9
4. Chronic obstructive pulmonary disease J44.9.
5. History of nicotine dependence Z87.891
6. Peripheral vascular angioplasty status with grafts and implants Z95.820
List of procedures
1) 0.6% infusion of bupivacaine. 06 March 2021
Bupivacaine was administered epidurally to the patient as a local anesthetic to relieve pain.
2) Exploratory laparotomy. 06 March 2021
3) It was performed to open up the belly for the removal of pancreatic cancer.
4) Pancreaticoduodenectomy. 06 March 2021
It is also known as the Whipple procedure. It was performed to remove the head of the
pancreas where the cancer was present. The first part of the duodenum, bile duct, and gall
bladder was removed. Later on, the remaining organs were reattached for the normal flow
of food.
5) Gastrostomy. 07 March 2021
A tube was inserted to feed the abdomen and into the stomach until the patient is not
stable.
Complete List of Consult during Hospitalization
Anesthesia. 06 March 2021
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Surgery Consultation was Done, and the patient was considered for surgery as no nearby vessel
was not involved. The surgery was successful.
Doctor of medication. 07 March 2021
A doctor of medication was consulted to educate the patient about the complete regimen of drugs
for discharging him to home. So that patients obtain the right drug with an accurate dose at a
proper time with and adherence can be achieved.
PT and OT consulted on 08 March. 2021
The patient was given occupational and physical therapy for rehabilitative care. The
focus was that patient can improve strength, movements, and range of motion. It aims to improve
the patient's motor skills so that he can perform his daily tasks easily.
Dietitian consulted 07 March. 2021
The dietician was consulted to tell the patient when he needs to stop eating food and what
he can drink a night before surgery. After surgery, the dietician was consulted for soft foods,
small and high nutrient, and high protein diet.
The team was consulted for postoperative pain management: 06 March 2021
After consultation patient was recommended paracetamol 15mg/kg.
Patient's condition at discharge
The hospital course of the patient progressed as expected. A complex surgical procedure
associated with prolonged stay in the hospital and high morbidity is rapid as
pancreaticoduodenectomy (Fujii et al., 2018). It is the surgical removal of part of the pancreas.
The length of hospital stay for multiple types of operations and the complications are reduced
after surgical principles due to enhanced recovery. The patient's postoperative pain was managed
by multi-modal therapy in which medications were administered by mouth before the patient is
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discharged. When patients return to normal bowel functions, the nasogastric tube was removed,
and the patient was given tolerating diet. When the surgical output was acceptable, then the
surgical drain was removed. Before discharge, Jackson Pratt drainage was negative. Without
incident, the PICO dressing was removed. With assistance, the patient was able to move. At the
time of discharge, vitals and labs were stable. The overall condition of the patient is stable for
home discharge.
obtain (get): obtain get
accurate: accurate right
Spelling mistake: dietician dietitian
Spelling mistake: dietician dietitian
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Spelling mistake: pancreaticoduodenectomy
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Passive voice: pain was managed by
Passive voice: medications were administe...
Spelling mistake: nasogastric
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assist, assistance (help): assistance help
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Anesthesia consultation was done before performing surgery to check preoperative
fitness. The patient's condition, his lab reports, risks, and limitations were discussed in detail.
After the consultation, the patient was considered fit for surgery.
Surgery. 06 March 2021
Complete physical exam at discharge
Subjective
The patient can move, and there is no pus at the site of the wound. No cyanosis was
observed. At the time of admission, the patient was oriented and alert. The nervous system was
normal. no palpitation and nor murmur sound. The genitourinary system was normal.
Objective
Vitals
Temp: 98.6
BP: 125/75;
HR: 81;
Pulse: 76bpm
RR: 16;
O2 Saturation: 97%;
Physical Examination
General: The patient was alert and oriented in time and place.
HEENT: no throat infection, the sclera is white, and no blur vision.
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Spelling mistake: cyanosis hypnosis
Checks that a sentence starts with ...: no No
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Spelling mistake: sclera clear
Passive voice: was noted to be
Spelling mistake: dietician dietitian
Spelling mistake: cyanosis hypnosis
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assist, assistance (help): assistance help
Spelling mistake: Enoxaparin
Spelling mistake: Lidocaine Cocaine
Spelling mistake: prilocaine procaine
Spelling mistake: Omeprazole
Spelling mistake: Hydromorphone Hydrophone
Respiratory: Breathing rate is normal. No congestion. The patient had a little
postoperative cough.
CVS (Cardiovascular system) : The patient has a normal pulse rate. The Blood pressure
of the patient is 125/75. No murmur sound was noted.
GIT (Gastrointestinal Tract): The patient's abdomen was normal, with no tenderness
and no puss in the surgical cut. The span of the liver was noted to be normal on palpation. The
size of both kidneys was equal, and both were non-tender. No leakage was observed from the
pancreas and bile duct. The patient was still on a soft diet prescribed by the dietician for almost
the next two weeks.
Genitourinary: The genitourinary system was normal
Psychiatric: No signs of stress, anxiety, and depression. The mood was normal.
Extremities: No cyanosis, no clubbing.
Musculoskeletal: Musculoskeletal system was normal. There were no signs of paralysis.
The patient was able to move slightly with assistance.
Neurological: No dizziness and vertigo.
Complete list of medication at the time of discharge
• Enoxaparin sodium (prophylactic approach to prevent DVT)
• Lidocaine prilocaine 2.5% cream. Apply topically once daily.
• Creon capsule 36000 units, three times a day.
• Omeprazole 40 mg daily 20 minutes before food.
• Hydromorphone 8mg, as per need.
• Multivitamin 1 tablet orally once daily.
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Summary
A 63-year-old male was admitted to the hospital with chronic pancreatic pain on 04
March 2021 and was discharged on 09 March 2021. His surgery was performed on 06 March.
Before an experienced surgeon checked the surgery patient. The surgery was successful. The
patient returned from anesthesia after 20 minutes. After surgery, the vitals of the patient was
normal. For cancer pain, he was given hydromorphone. For surgical pain, he was given
paracetamol. He was advised to move gradually.
Overall Assessment
Health Promotion/Education
as per (as, in ac...: as per in accordance wi...
Spelling mistake: Ondansetron
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assist, assistance (help): assistance help
Word repetition: Care Care Care
Spelling mistake: Kielo Kiel
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Punctuation error, sentence looks...: Before
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Spelling mistake: hydromorphone hydrophone
be advised: was advised
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• Polyethylene glycol powder 17 mg once daily
• Ondansetron 8mg tablet PRN
Pending test results for follow-up
The patient will return to the clinic on Monday. At that time, lab draws 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
(Munro & Beck, 2021).
Complete list of discharge instructions:
• Take a soft diet for seven days
• Take care of wounds and stitches.
• Take medications as prescribed.
• Try to maintain mobility with assistance for quick wound relief.
• Take care of personal hygiene to avoid chances of infections.
• Take antibiotics without a skip as prescribed to prevent the infection
inside the abdomen and incision areas.
Wound Care
Care of the wound should be taken by the patient itself and by the care provider. The care
provider should clean the surgical stitches with antiseptic and normal saline until the wound
heals completely (Kielo et al., 2019) . The patient should avoid complete bed rest so that
infections and sores in the wound can be prevented. Increase mobility gradually.
Complete list of discharge follow-ups
The patient will come to the clinic again after five days of discharge for CMP,
magnesium, CBC, albumin level, platelet count, and phosphate tests. The results of all these tests
will be compared and evaluated with the results of tests taken before surgery.
To manage post-surgical complications patient is given health education. Health
promotional activities empower individuals to prevent their medical complications.
Ethical Considerations
The moral arrangement applied during therapy gives education, self-governance, willful
cooperation, privacy, and dynamic force to the patient regarding certain clinical mediations.
Expected Outcomes
It is expected that the patient's condition will improve and do not get surgical
complications.
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References
Fujii, M. H., Hodges, A. C., Russell, R. L., Roensch, K., Beynnon, B., Ahern, T. P., Holoch, P.,
Moore, J. S., Ames, S. E., & MacLean, C. D. (2018). Post-discharge opioid prescribing and
use after common surgical procedure. Journal of the American College of Surgeons, 226(6),
1004–1012.
Kielo, E., Suhonen, R., Salminen, L., & Stolt, M. (2019). Competence areas for registered nurses
and podiatrists in chronic wound care and their role in wound care practice. Journal of
Clinical Nursing, 28(21–22), 4021–4034.
Munro, J. A., & Beck, A. D. (2021). The effect of UK nursing policy on higher education wound
care provision and practice: a critical discourse analysis. Policy, Politics, & Nursing
Practice, 22(2), 134–145.
Spelling mistake: mediations medications
Passive voice: It is expected that
