tokens: 320422564 CTMC 09300549 340424 06/16/1997 12:00:00 AM BILIARY OBSTRUCTION Signed DIS Admission Date : 06/16/1997 Report Status : Signed Discharge Date : 06/18/1997 PROBLEM LIST : 1. RECTAL CARCINOMA , STATUS POST PARTIAL COLECTOMY . 2. METASTATIC COLON CARCINOMA . 3. HYPERTENSION . 4. AORTIC STENOSIS WITH PORCINE VALVE . 5. URINARY TRACT INFECTION . 6. CHOLANGITIS . 7. ANEMIA . HISTORY OF PRESENT ILLNESS : This is a 70 year old gentleman with metastatic rectal cancer who presented with biliary obstruction . In the past , he had biliary stents placed which clotted off . The patient was admitted to the Short Stay Unit for further evaluation . The day prior , the patient had endoscopic retrograde cholangiopancreatography done with dilated ducts times two and eventually had interventional radiology attempt to place percutaneous drains to decompress his biliary tree . The patient had two drains placed after a prolonged course and difficult procedure . After being transferred from the interventional radiology table to the stretcher , one of his lateral percutaneous drains had been pulled out inadvertently . He was admitted to the Short Stay Unit , given Ancef and Gentamicin per the team for antibiotic prophylaxis and observed overnight . PAST MEDICAL HISTORY : As above . ALLERGIES : None . MEDICATIONS ON ADMISSION : Cipro 500 mg p.o. b.i.d. , Vasotec 10 mg q.d. SOCIAL HISTORY : The patient denies any alcohol or tobacco . FAMILY HISTORY : Significant for colon carcinoma . REVIEW OF SYSTEMS : Unremarkable . PHYSICAL EXAMINATION : Temperature was 99.1 , blood pressure 132/74 , heart rate 80 , respirations 18 , 02 sat 99% on room air . The patient was an alert , jaundiced gentleman in no acute distress . LUNGS : were clear to auscultation . HEART : had a regular rate and rhythm with a II / VI systolic murmur at the right sternal border . ABDOMEN : was soft , nontender , with good bowel sounds . He had midline catheter that was still in place and was draining bile . EXTREMITIES : were without edema . NEUROLOGICAL : exam within normal limits . LABORATORY : White count was 8.2 , hematocrit 35 . AST was 175 , ALT 76 , LDH 454 . Total bilirubin was 12 and direct bilirubin 8 . Alkaline phosphatase was 372 . HOSPITAL COURSE : The patient was admitted to the Short Stay Unit and continued to receive antibiotics overnight . The next morning , he was doing well with the intact drain draining bilious material without any difficulty . The patient was doing well with minimal to no belly pain and no nausea or vomiting . The patient was taken back to surgery by the interventional radiology team and had a second drain placed without any difficulty and was transferred back to the Short Stay Unit . The patient was observed overnight without any problems . He was tolerating p.o. and feeling back to his baseline . He was discharged in stable condition . DISCHARGE MEDICATIONS : Same as admission . He will continue Cipro p.o. for prophylaxis . FOLLOW-UP : Follow-up with Dr. Loydsadd in one to two weeks . He is also to have AH for his home stent care . Dictated By : Attending : LILLBI FYFEBREUN , M.D. KE15 TB326/0625 Batch : 56777 Index No. M2ZRS51Y3Q D : 06/18/97 T : 06/21/97