Report from IBC Hospital
Tijuana, Mexico
Attending Physician: Jose A. Henriquez M.D.
Admission Date: 2003 December 21
Discharge Date: 2004 January 17
File Number : 10508

ADMITTING DIAGNOSIS:
Adenocarcinoma of the colon with liver metastases

DISCHARGE DIAGNOSIS:
Colon Adenocarcinoma/Liver Mets/St.post/Chemotherapy

CHIEF COMPLAINT:
Abdominal cramps, nausea, weakness

PRESENT ILLNESS:
This is a 45 y/o, male patient with a diagnosis of Adenocarcinoma of the colon with liver metastases. This gentleman has had gastrointestinal problems most of his life so, according to him, in '98 when he developed colic-like pains and distension he did not pay too much attention. He started his most severe problems 12/2000 when severe abdominal cramps started associated with nausea and vomiting. By Dec 12, 2000 he underwent emergency exploratory laparotomy due to complete intestinal obstruction finding a tumor in the splenic flexure. He had a partial resection of the colon. The CEA was 1.9 ng/mL. He was offered an experimental immune therapy but he refused and started to do alternative programs. On Mar 17, 2003 the CEA=10.2 ng/ml but he had a negative CT scan. By Sep 4, 2003 the CEA was 29.2 ng/ml, so he underwent a colonoscopy on Oct 8, 2003 showing a tumor at about 15 cm from the anal verge. CT scan showed 4 liver metastases and there was mild hydronephrosis due to extrinsic compression of the right ureter. Insertion of a ureteral stent was mentioned but not worked upon. Liver biopsy was refused. The CEA continued to rise until Nov 25, 2003 that it was 76.9 ng/ml. On Nov 28 a CT scan showed progression of his metastatic disease both in number and size of his hepatic lesions; there was also the hydronephrosis. As of Dec 18, 2003, the CEA=137 ng/ml, and CA 19-9=8.2 U/ml. Currently he is anxious, he has abdominal cramps, occasional hematochezia and constant mucus. He is eating mostly liquids and his stools are very thin.

REVIEW OF SYSTEM
Respiratory : Negative.
Cardiovascular : Negative. He is very fit and used to run marathons.
Digestive : Abdominal cramps, nausea, occasional weakness. Stools are very thin.
Genitourinary : Negative.
Endocrine : Negative.
Musculoeskeletal : Negative.
Nervous : Anxiety, nervousness.

PAST MEDICAL HISTORY
Childhood Disease : Negative.
Surgeries : Exploratory laparotomies with resection of tumor from the colon.
Accidents : He suffered a motorcycle accident in '83 where he sustained injuries ending with a fractured arm and leg as well as deep muscular lascerations in his leg.
Allergies : Negative.

FAMILY HISTORY
His mother died of natural causes.

SOCIAL HISTORY
Alcohol : Moderate, but nothing now.
Tobacco : Negative.
Drugs : Negative.

PHYSICAL EXAMINATION

This is a well-developed, well-nourished, well-oriented, 45 y/o, male patient in no acute distress. He cooperated well with the procedure.

HEENT normocephalic with thinning mostly gray hair. Eyes PERRLA, EOMI, no icterus or injection. Ears and nose within normal range. Mouth s/p extensive dental work and gold fillings.

NECK supple, no adenomegalies or thyromegaly. Trachea is located in the midline. Carotid pulses are normal.

CHEST, lungs clear to both auscultation and percussion. Heart is regular with sinus rhythm, no murmurs or gallops.

ABDOMEN s/p exploratory laparotomy with a midline incision extending from the epigatrium down to the suprapubic area, there is a non-absorbable suture palpated in the proximal area. On palpation the abdomen is soft and non tender with tympanism over both left quadrants. No masses are visceromegalies that could be palpated. Peristaltic sounds are normal.

RECTAL with normal sphyncter although with the presents of hemorrhoidal disease. the prostate feels somewhat irregular and mildly enlarged but benign. There was no blood in the examining finger.

EXTREMITIES with normal peripheral pulses, color, temperature and DTR except in both knees where patellar reflex was not elicited.

NEUROLOGIC grossly normal.

DISCHARGE SUMMARY

45 y/o gentleman admitted with diagnosis of Adenocarcinoma of the colon with liver metastases. He was treated as impatient for a period from December 21 of 2003 to January 17 of 2004. He underwent whole body hyperthermia on two occasions and received five day cycle of chemotherapy with fluorouracil. Intravenous nutritional support was utilized daily, the patient tollerated his treatment very well. He his discharged with follow up program in good general condition.