tokens: 145980160 FIH 6382196 94916/ly7e 289653 06/30/1993 12:00:00 AM PROSTATE CANCER . Unsigned DIS Report Status : Unsigned ADMISSION DATE : 06-30-93 DISCHARGE DATE : 07-06-93 PRINCIPAL DIAGNOSIS : Prostate cancer . SPECIAL PROCEDURES AND OPERATIONS : Radical retropubic prostatectomy , bilateral lymph node dissection . HISTORY OF PRESENT ILLNESS : The patient is a 67 year old white male with a recent history of urinary frequency Q2-3H , stranguria , nocturia x 3-4 per night . He was found on physical exam to have an asymmetric prostate with prominence on the left and a question of a nodule . Repeat exam one month later showed a firm left-sided lobe . Transrectal ultrasound showed a hypoechoic left-sided mass in the peripheral zone . A biopsy showed moderately to poorly differentiated Grade III-IV adenocarcinoma on the left . The right lobe was within normal limits . This was done on 05/05/93 at FIH . He also had a 3-4 year history of impotence . PAST MEDICAL HISTORY : Significant for non-insulin diabetes mellitus , for which he takes Diabeta , one QD ; right eye cataract , operated on three years ago . ALLERGIES : He is allergic to Motrin . MEDICATIONS ON ADMISSION : Diabeta , one QD . SOCIAL HISTORY : No smoking history . PHYSICAL EXAMINATION : He was a well developed , well nourished white male . HEENT : within normal limits . His neck was supple with no jugular venous distention or thyromegaly . Chest was clear to percussion and auscultation . Heart : regular rate and rhythm with normal S1 and S2 , no murmurs . The abdomen was soft and non-tender with no masses or organomegaly . No costovertebral angle tenderness . His genitourinary exam showed an uncircumcised male with normal scrotal contents . Rectal : There was a firm nodule in the left lobe of the prostate in the lateral aspect . Extremities : No clubbing , cyanosis or edema . Pulses 2+ . Neurological : Nonfocal . LABORATORY DATA : Sodium 141 , potassium 4.1 , chloride 104 , bicarbonate 28.8 , BUN 17 , creatinine 0.9 , glucose 118 . His white blood count was 7100 , hematocrit 35.9 , platelet count 258,000 . PT 9.4/10.3 , PTT 27 . His urinalysis showed marked occult blood and positive white blood cell screen but was otherwise negative . His chest X-ray was normal . EKG : normal sinus rhythm at 73 beats per minute . HOSPITAL COURSE : The patient was brought to the operating room on 06/30/93 after informed consent was obtained . A radical retropubic prostatectomy with bilateral lymph node dissection was done . He was afebrile postoperatively with vital signs stable . His potassium was 3.7 and his hematocrit 33 . His postoperative course was remarkable for a low grade temperature to 101.7 . His blood cultures and chest X-ray were negative . He had flatus on postoperative day # 3 . His Jackson-Pratt drained about 35-40 cc per day and was discontinued on postoperative day # 3 . His hematocrit on 07/03 was 28.1 . On that day he was slightly diaphoretic with some tachycardia to 100 . The remaining unit of autologous packed red blood cells was transfused . A cardiology consult was obtained for this episode of diaphoresis with tachycardia , as well as for an EKG being read as having anterolateral changes . He had no symptoms of chest pain or myocardial ischemia . A repeat EKG showed no changes . He subsequently did well , with a repeat hematocrit of 34.3 after the transfusion . His creatinine was 1.2 on postoperative day # 5 . On postoperative day # 6 his low grade temperature resolved . His vital signs were stable . He was discharged home on Percocet and Keflex . He was discharged in good condition . He will follow up with Dr. Iechalette Cancer in his office . SIE ROOM , M.D. DICTATING FOR : IECHALETTE ROOM , M.D. TR : btt / bmot DD : 07-07-93 TD : 07/08/93 CC : Dr. Na Dussmum