DISCHARGE SUMMARY
DIAGNOSES
1.
Radiation cystitis.
2.
Carcinoma of prostate, stage D.
3.
Left inguinal hernia.
OPERATIONS PERFORMED
Ileal
conduit. Left inguinal hernia repair.
HISTORY
This
60-year-old male with advanced carcinoma of the prostate, who had radiation
therapy for this, was found to have severe contraction of the bladder from the
radiation cystitis. The patient has been
incapacitated by this. Also has had a
painful left inguinal hernia.
After
preop evaluation, patient was brought to surgery where an ileal conduit and
left inguinal hernia repair were performed.
The patient tolerated the procedure well. Estimated blood loss: 750 cc for the total procedure.
The
patient was observed in intensive care for 2 days and then transferred to
surgical floor. The patient received 1
unit of packed cell blood replacement on the second postop day. The patient had slight Jackson-Pratt
drainage, and bowel sounds and flatus were noted. The patient was fed, tolerated this
well. Foley catheter was removed. Bladder was left intact, not removed; it was
very tiny and scarred in.
Patient
continued to improve over the next couple of days and was discharged home on
Home Health followup.
FOOTNOTE
Line
9. The slang term CA was changed to
carcinoma.
Line
23. Was performed was changed to were
performed for subject-verb agreement (conduit and ... repair were).
Line
31. And was deleted to shorten the
run-on sentence.
Line
36. Alternative: Home Health (an organization) as opposed to
home health (a service). Since it is not
clear which is meant, either is acceptable.
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