tokens: 989519730 WGH 4708487 265076 4927849 05/09/2004 12:00:00 AM Discharge Summary Signed DIS Report Status : Signed DISCHARGE SUMMARY NAME : GINSLENT , A L UNIT NUMBER : 537-43-35 ADMISSION DATE : 05/09/2004 DISCHARGE DATE : 05/16/2004 PRINCIPAL DIAGNOSIS : Colon cancer . ASSOCIATED DIAGNOSES : History of diverticulitis , status post cholecystectomy , status post appendectomy , and hypertension . PRINCIPAL PROCEDURE : Transverse colectomy for tumor . ASSOCIATED PROCEDURES : None . HISTORY OF PRESENT ILLNESS : The patient is an 84-year-old woman with a history of diverticulitis who was found to have colon cancer on colonoscopy , which was performed in March of 2004 . An invasive moderately differentiated adenocarcinoma was noted in the transverse colon at 80 cm . The patient reports a history of bloating and flatulence as well as increased fatigue . She has also had some discomfort in her left lower abdomen and notes diarrhea every 4-5 days . She says that her appetite is good and has noted no weight loss . PAST MEDICAL HISTORY : Cholecystectomy in 1994 , colonoscopy 2004 , status post tonsillectomy , status post appendectomy , status post ORIF of left wrist , status post left ear surgery , NSVD x5 , and hypertension . MEDICATIONS : Premarin vaginal once a month , enalapril , Tylenol , vitamins , and Halcion at night . ALLERGIES : No known drug allergies . SOCIAL HISTORY : She is married and lives in an assisted living facility with her husband . She has five grown children . PHYSICAL EXAMINATION : On exam she is afebrile . Her vital signs are stable . Baseline blood pressure of 144/61 , heart rate of 73 , and oxygen saturation of 96% on room air . She is a pleasant well appearing elderly woman in no acute distress . Lungs are clear to auscultation bilaterally . Heart is regular without murmurs , rubs , or gallops . Abdomen is soft , nontender , and nondistended . Her extremities are without edema and are warm . HOSPITAL COURSE : The patient was consented for surgery and on the day of admission was taken to the operating room for transverse colectomy for tumor . The patient tolerated the procedure well and there are no complications . Her postoperative course was unremarkable . She was maintained on an epidural and PCA for pain control . She was kept NPO initially and her diet was slowly advanced as tolerated . When she was taking clear liquids , her pain medication was switched to p.o. pain regimen with good affect . For blood pressure control she was maintained on metoprolol at the request of her primary care physician and enalapril was discontinued . With the help of physical therapy the patient was ambulated and on postoperative seven , with the patient tolerating a post surgical soft diet and with pain well controlled on oral pain medications , she was discharged to rehabilitation facility . DISCHARGE MEDICATIONS : 1. Tylenol 650 mg p.o. q.4.h. p.r.n. pain . 2. Metoprolol 25 mg p.o. b.i.d. 3. Motrin 400 mg p.o. b.i.d. p.r.n. pain . 4. Halcion 0.25 mg p.o. at night . 5. Dulcolax 10 to 20 mg PR b.i.d. p.r.n. constipation . 6. Senna 2 tablets p.o. b.i.d. DISCHARGE INSTRUCTIONS : Consume a diet as tolerated avoiding carbonated beverages . Her activity level is as tolerated . She is to contact Dr. Warm &apos;s office to schedule a follow up appointment . She is to also call the office if she has any fever greater than 101 , bleeding from the surgical wounds , or pus from the wounds . She is to be maintained on metoprolol for blood pressure control and the restarting of her ACE inhibitor is to be decided by her primary care physician . ALEN L CREDKOTE , M.D. DICTATING FOR : Electronically Signed OIE LIMOR WARM , M.D. 05/18/2004 11:28 _____________________________ OIE LIMOR WARM , M.D. TR : ep DD : 05/16/2004 TD : 05/16/2004 7:28 A 265076 cc : OIE LIMOR WARM , M.D. CH GILD WARM , M.D.