Author Kelsy WasmuthAnderson HealthcareJuly 3rd, 2024 4:37pm

Note Date/Time July 3rd, 2024 4:26pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Discharge Summary SignedPatient: Towell,Alexnder R MR#: M000499848 DOB: 08/04/1975 Acct:V00003676858Age: 48 ADM Date: 07/01/24 Loc: ANH3MEDSUR 303-01 Attending Dr: Pei Chang Chung M.D.cc: Chung, Pei Chang MD; Suthan***, Nanthini MD~DS: Admitting DiagnosisDischarge Date07/03/2024Admitting DiagnosisIleal mass, adenocarcinomaStatus post partial colectomyAnemiaHistory of colon cancerDS: Discharge DiagnosisDischarge Diagnosis(1) Colon cancer: Code(s):C18.9 - Malignant neoplasm of colon, unspecified Status: Acute(2) Status post partial resection of colon: Code(s):Z90.49 - Acquired absence of other specified parts of digestive tract Status: Acute(3) History of colon cancer: Code(s):Z85.038 - Personal history of other malignant neoplasm of large intestine Status: Acute(4) Anemia: Qualifiers: Anemia type: unspecified type Qualified Code(s): D64.9 - Anemia, unspecified Code(s):D64.9 - Anemia, unspecified Status: AcuteDS: SummaryHospital CourseReason for hospitalization: This is a 48-year-old man who has a history of colon cancer status post hand assisted laparoscopic sigmoid colectomy in 2021. He underwent chemotherapy following surgery. Recently, in May of 2024, he was found to have a small-bowel obstruction on a CT scan. He then had a colonoscopy on 05/29/2024 with pathology coming back as moderately differentiated adenocarcinoma from a possible ileal mass. He was seen as an outpatient by Dr. Chung and decision wasmade to proceed with a hand assisted laparoscopic right colectomy. He presentedfor surgery on 07/01/2024.Hospital Course: He underwent hand assisted laparoscopic right colectomy with mobilization of hepatic flexure by Dr. Chung the on 07/01/2024. During surgery he was found to have a palpable mass in the terminal ileum with noted masses in the mesentery consistent with lymph node spread. He was admitted for monitoring and management postoperatively. His diet has slowly been advanced. He is tolerating a solid diet today. No nausea or vomiting. He is tolerating activity. Postoperative pain has been well controlled. Labs monitored postop day 1 and appeared stable. He was voiding independently without any issues. After discussing with Dr. Chung, the patient is stable for discharge postop day 2.Status at DischargeFunctional status at discharge: independent ambulationOverall status at discharge: patient is progressing back to baselineTime Spent with PatientTime attestation: Total time spent providing and/or coordinating discharge services:Time spent: Less than 30 minutesExamConst: General: comfortable and no acute distress Resp: Effort & Inspection: normal respiratory effort Auscultation: clear toauscultation bilaterally Cardio: Rate: regular rate Rhythm: regular rhythm GI: Inspection: non-distended and incision (incisions dry and intact) GI Palp: Yes Soft to palpation, Yes Tenderness to palpation present (GI) (incisional) and No Guarding due to palpation present (GI) Auscultation: normal bowel sounds Neuro: General: moves all extremities and no focal motor deficits Extrem: General: no calf tenderness and no edema Psych: Mental Status: mental status grossly normal Insight: Good insight present (Psych) DS: DataData Completed and PendingCompleted studies during hospitalization: Pending at discharge07/01/24 14:38Surgical [PTH] Routine Procedures/Treatments: Procedures Operation Date: 07/01/24 12:00Actual Procedure Side Surgeonp Hand Assisted Laparoscopic Right Colectomy Right Pei Chang Chung, MDImagingRadiologist’s impression: ITS ImpressionsAbdomen X-Ray 07/01/24 15:32

IMPRESSION: No foreign body detected.Discharge PlanDischargeAttending physician on discharge: Chung,Pei Chang Discharging Clinician: Wasmuth,Kelsy B. Anticipated Discharge Date/Time: 07/03/24 16:33Patient Disposition: Home, Self-CareActivity: may shower and other - see discharge instructionsDiet: as tolerated and regularWound Care Instructions: incision open to airDischarge Instructions: DISCHARGE INSTRUCTION SHEET FOR DR. CHUNG1. May shower in 24 hours, no soaking in bath x 2weeks.2. Call office for:* Wound increasingly painful or bleeding* Vomiting* Fever of greater than 101 degrees3. No heavy lifting > 10-15 pounds x 6 weeks4. No driving for 1 week5. Up walking 10-30 minutes three times per day.6. Follow-up 10-14 days in office for wound check or as previously scheduled. (288-3616)7. Oral pain medications prescription has been sent electronically to the pharmacy.Take Tylenol 500mg every 6 hours and Ibuprofen 600mg every 6 hours for the first 2 days, then as needed. Patient Instructions: Antibiotic FormStand Alone Forms: General Discharge InformationFollow-up/Referrals:Chung,Pei Chang, MD [Physician] - Keep Reg. Scheduled Appt.Discharge Medications:New hydrocodone-acetaminophen 5-325 mg Tablet 1 tablet PO Q4-6H PRN (Reason: Pain Rated 4-6) Qty: 20 0RFContinued Fish Oil Capsule 1,000 mg PO DAILY ferrous sulfate 325 mg (65 mg iron) Tablet 650 mg PO DAILY levothyroxine 100 mcg tablet 100 mcg PO DAILY multivit with min-folic acid [Adult Multivitamin Gummies] 200 mcg Tablet,Chewable 1 tablet PO DAILY cholecalciferol (vitamin D3) [Vitamin D3] 25 mcg (1,000 unit) Tablet 25 mcg PO DAILY Discontinued ciprofloxacin HCl 500 mg tablet 500 mg PO .COMPLEX Qty: 1 0RF Rx Instructions: 500 mg orally at 2:00pm the day before your surgery.; metronidazole 500 mg tablet 500 mg PO .COMPLEX Qty: 3 0RF Rx Instructions: 500 mg orally at 1:00pm, 2:00pm, and 11:00pm the day before your surgery.; Date of admission: 07/01/24 15:35Primary Care Provider: Suthan***,NanthiniAdmitting Provider: Chung,Pei ChangAttending physician on admission: Chung,Pei ChangCondition: StableQualityVTE ProphylaxisVTE prophylaxis: mechanical ordered and pharmacologic orderedThis report may have been done utilizing a voice recognition system. Attempts have been made to correct errors. However, there may be uncorrected grammatical,spelling, and recognition errors present.Report Initialized date/time: Wasmuth, Kelsy B. APN 07/03/24 / 1626Electronically signed by: Wasmuth, Kelsy B. APN 07/03/24 1637