This document outlines a medical record abstracting assignment related to a 67-year-old male patient with digestive issues, detailing his diagnosis of invasive adenocarcinoma of the rectosigmoid, along with type II diabetes and other conditions. It includes surgical procedures performed and the patient's evaluation of various gastrointestinal issues like diverticulosis, hiatal hernia, and gallstones, alongside a comprehensive examination and treatment plan. The report emphasizes the patient's medical history, diagnostic findings, surgical interventions, and postoperative recovery process.

1. Name: Add name here
HIM 2214 Module 6: Medical Record Abstracting
Instructions: In this medical record abstracting assignment you
will first need to download and the records (history & physical,
surgery consultation, operative report, pathology report and
discharge summary) for a patient with digestive system
problems. (Recommend reading them in the order listed).
Save your answers to the following related questions in this
document and submit them for this module's assignment.
1. Define the terms diverticulosis and diverticulitis.
2. What is the pathophysiology of diverticulitis?
3. What is a hiatal hernia?
4. Describe some of the signs or symptoms a person with a
hiatal hernia might have.
5. What is a pulmonary embolus?
6. What was the etiology (cause) of the pulmonary embolus for
this patient?
7. What is gastritis?
8. Which problem is likely a contributor to the patient’s Type II
diabetes mellitus?
9. What was the purpose of the barium enema?
10. What does the abbreviation HEENT stand for?
11. What is thrombophlebitis?

2. 12. What is a surgical resection?
13. Define anastomosis.
14. What is ferrous gluconate and what is it used to treat?
15. What condition is the drug Darvocet used to treat?
16. What are electrolytes?
17. What is exogenous obesity?
18. Where is the femoral pulse found/taken?
19. Where is the popliteal pulse found/taken?
20. What is hepatosplenomegaly?
21. Which condition(s) is/are the drug Humulin used to treat?
22. What is an adenocarcinoma?
23. Which condition(s) is/are the drug Lanoxin used to treat?
24. What is the purpose of ordering the blood test PTT?
25. What is a colon stricture?
26. What is/are the etiologies associated with colorectal cancer?
27. What is the medical term for gallstones?
28. Which condition(s) is the drug Zantac used to treat?
29. What does the pathology report indicate about the spread of
the carcinoma in this patient?
30. What is the etiology of Type II diabetes mellitus?

3. · Academic arguments are designed to get someone to agree
with the author, who may use pathos (emotion), logos (logic and
facts) and ethos (authority and expertise) to persuade.
Academic arguments are not about ranting, screaming or
otherwise increasing conflict, but in fact are the opposite: They
attempt to help the other person understand what the author
believes to be right (opinion) based on the evidence presented
(authority, logic, facts).
For your topic for your final paper, what kinds of arguments can
you develop for your claim (thesis, main idea)?
Health Record Face Sheet
Record Number:
005
Age:
67
Gender:
Male
Length of Stay:
3 days
Service:

4. Inpatient Hospital Admission
Disposition:
Home
Discharge Summary
Patient is a 67-year-old male. He saw the doctor recently with
abdominal pain and constipation. A barium enema showed
diverticulosis and perhaps a stricture near the sigmoid and
rectal junction. He was scoped by the doctor, who saw a
stricture at that point and said he couldn’t rule out a carcinoma.
Upper GI showed a hiatal hernia and duodenal diverticulum.
Ultrasound showed gallstones. The patient had some bladder
incontinence. He has had atrial fibrillation, diabetes, and takes
Lanoxin. Otherwise, he is doing quite well. He has had a
previous right total hip. At the time of admission, it was
thought that he had a stricture, rule out carcinoma, diabetes
mellitus, exogenous obesity, past history of atrial fibrillation,
previous right total hip. His chest film showed some chronic
blunting of the right costophrenic angle, but otherwise was
negative. His admission EKG showed what was thought to be a
normal sinus rhythm. His blood type was AB-positive.
Urinalysis was negative.
Hemoglobin was 13.3, white blood cell count 7,600. PT 12, PTT
was 23. The CEA, which came back several days later, was
quite high at 856. Glucose is 127, albumin is 3.4. Other labs
were normal. After mechanical and chemical bowel prep, he was
taken to surgery. First, we laparoscoped to see if we could do
this resection with the scope. When we found that it was
adherent to loops of adjacent small bowel, he had an open
resection. A large carcinoma of the rectosigmoid junction was
found and resected with an end-to-end anastomosis. A segment
of small bowel that was stuck to the tumor was also resected,

5. and a functional end-to-end anastomosis was done. At least four
separate liver metastases were noted. Needle biopsy of that was
done as well. The pathology report showed moderate to poorly
differentiated carcinoma, bases through the wall of the colon
and into the perirectal fat. The small intestine was not involved.
The liver metastases were also positive. The patient had a rather
smooth postoperative course. He was thought to be ready for
discharge on the sixth postoperative day. He was seen in
consultation prior to surgery by the doctor, who managed his
medical problems and diabetes and will arrange for appropriate
medication at the time of discharge. He was sent home on
Darvocet for pain. Ferrous Gluconate 324 mg three times a day
for a month to restore his blood count. He is to resume his other
previous medications. He is to restrict his activities for 2
months and to see me in the office in 8 days.
Final Diagnosis:
1. Invasive adenocarcinoma of the rectosigmoid, metastatic to
the liver
2. Type II diabetes mellitus
3. Exogenous obesity
4. Atrial fibrillation
5. Previous right total hip replacement
Surgical Procedure: Resection of rectosigmoid with low pelvic
anastomosis with an EEA, small bowel resection, liver biopsy.
History & Physical
Patient is a 67-year-old male. He has been in to see the doctor
recently with abdominal pain and complains that he was unable
to move his bowels. He was admitted and subsequently had

6. endoscopy following a number of x-rays. The x-rays showed
diverticulosis of the sigmoid and perhaps a stricture near the
sigmoid rectal junction. This was difficult to delineate because
of overlapping loops of bowel. The patient had an upper GI
showing hiatal hernia and a duodenal diverticulum, and an
ultrasound showing gallstones. The patient was subsequently
seen by the doctor. A week ago today, the doctor performed
upper GI endoscopy, which showed a little antral gastritis. A
sigmoidoscopic examination showed, at about 25 cm, a
narrowed area of the bowel with edema and stricture, and some
blood oozing from above. Doctor said that he could not be sure
whether this was strictly a diverticular stricture or whether
there was a tumor above this point. The patient has otherwise
been pretty healthy.
He had a previous fracture in the right hip. He had pulmonary
embolus secondary to thrombophlebitis in his legs on two
different occasions. He is not a smoker and seldom drinks. He
has no known allergies. Both parents are deceased. He has had
type II diabetes for about 5 years and takes Tolinase 150 mg
two times a day. He has had atrial fibrillation in the past and
takes Lanoxin 0.125 mg a day for that condition. He has never
had hypertension, heart disease (other than the atrial
fibrillation), or stroke. He has no chest pain or shortness of
breath. He has had quite a bit of heartburn and indigestion, but
this definitely has been improved by Zantac. He has some
bladder incontinence
Physical Examination
He weighs 174. He is 5’ 61/2” tall. BP 152/84 on the right,
148/78 on the left. Pulse was 80. Examination of the HEENT
was negative. The patient seemed extremely alert. Him has good
carotid pulses without bruits. No goiter or nodes in the neck.
The heart rate was regular. The heart was not enlarged. There
was no murmur. The lungs were clear to auscultation and
percussion. There was a low midline scar. No
hepatosplenomegaly. There was a little left lower quadrant

7. tenderness. Rectal exam was not repeated. He had good femoral,
popliteal, and dorsalis pedis pulses. The ankles were quite
thick. There was a scar on his right hip from previous surgery.
Neurologic function is normal. His skin tended to be sweaty and
clammy, which he says is the normal case for his.
Impression
1. Stricture of the sigmoid seen on barium enema and
colonoscopy, probably secondary to diverticular disease,
causing obstructive symptoms, 2. Type II diabetes mellitus, 3.
Exogenous obesity, 4. Past history of atrial fibrillation. Plan:
Resection.
Surgical Consultation
It was a pleasure to see your patient, who is well known to me
from my office. He is a pleasant 67-year-old white, obese male
who, over the past 3 to 4 months, has had increasing amounts of
difficulty with bowel movements. He has a complaint of small,
pencil-thin bowel movements with some blood noted. The
patient also had some difficulty
with upper GI indigestion, as well as gastritis. He has been
evaluated per gastroenterology at the hospital and diagnosed
with antral gastritis as well as diverticulosis, diverticulitis with
narrowing of the sigmoid colon, approximately 25 cm via
colonoscopy. The patient has had a workup that included an
upper GI series and endoscopies that have shown the above
problem, etiology yet to be determined. The patient has a rather
strong family history of having similar type of etiologies.
Apparently, his three sisters have had similar surgeries,
surgery-like etiology secondary to narrowing of sigmoid colon,
and difficulties with irritable bowel–type symptoms. The patient
has had difficulty with his bowel movements for many years.
However, during the past 3 months they have become somewhat
bloodier, as well as worsened in types. The patient came to my
office approximately 3 months ago with the above etiology.
Workup was done then and is on previous chart for review.

8. His past medical history is consistent with type II diabetes
mellitus. He is currently on Tolinase bid with fairly good
control at home when the patient follows his diet. The patient
does not have a history of smoking, nor does he drink. He
currently lives alone. The patient had a hip replacement
approximately a year or year and half ago with no sequelae. The
patient has previous history of pulmonary embolus. However, he
has had no difficulty with the previous surgery noted.
The medication protocol at home includes one-a-day aspirin and
Tolinase bid basis. He is also taking Lanoxin 0.125 mg for
previous history of atrial fibrillation, which has currently been
controlled with normal sinus rhythm for the last 1-year period
of time noted. The patient has been evaluated for urinary
incontinence secondary to a low-lying bladder. The patient has
been in fairly good health except for mild diabetes mellitus,
which is controlled with diet as well as oral medications.
Otherwise, he has done well and has been in fairly stable
condition up to the recent history with his colon problems.
On physical examination, the patient’s general HEENT, eyes,
ears, nose, and throat are basically clear. Neck does not show
any cervical nodes. Neck is clear for adenopathy. Lungs are
clear to auscultation; no rales, rhonchi, or friction rubs. No
wheezing. The heart rate is regular rate and rhythm. Abdomen is
soft, not overtly tender at this time. Extremities do not show
any edema. Cranial nerves are grossly intact as tested. The
patient’s EKG shows that of normal sinus rhythm, as evaluated
by the consultant. The lab work shows a glucose of 127. BUN
and creatinine are within normal limits, as are the electrolytes.
Albumin is slightly low at 3.4, with a total protein of 6.0. The
liver function profile, SGOT, alk. phos., and bilirubin are
within normal limits, as well as triglycerides.
Diagnostic Impressions
1.
Diverticulosis/diverticulitis with sigmoid constriction, etiology

9. to be determined,
rule out primary disease, that of diverticulosis or diverticulitis
versus overt tumor
2.
Diabetes mellitus
3.
Atrial fibrillation by history, current normal sinus rhythm
4.
Generalized obesity
Recommendations
1.
Will put the patient on medication protocol, Lanoxin for control
of atrial fibrillation,
normal sinus rhythm.
2.
Will start a sliding scale Insulin, with regular Humulin Iinsulin
while he is
undergoing surgery. Back on Tolinase postsurgery if control is
indicated at that
time.
Operative Report
Preoperative Diagnosis: Probable diverticular stricture of the
sigmoid, rule out carcinoma
Postoperative Diagnosis: Carcinoma of the sigmoid invading
into adjacent small bowel with metastases to the liver
Procedure: Attempted laparoscopic bowel removal, open
exploration with resection of the sigmoid colon and end-to-end
anastomosis with 28 mm EEA. Resection of segment of small
bowel with direct extension of the tumor into that area with the
functional end-to-end anastomosis, doing a side-to-side
anastomosis, biopsy of liver metastases.

10. Patient is a 67-year-old male who presented with abdominal
pain and constipation. Barium enema suggested diverticular
stricture. Patient was seen in consultation by the doctor, who
sigmoidoscoped the patient and found a stricture at about 25
cm. Doctor could not see above the stricture, so we could not
rule out carcinoma. Patient understood the nature of the
problem, the proposed surgical risk, and its possible
complications, and consented to it. He was given a mechanical
and chemical bowel prep.
Patient was brought to surgery and an NG tube was placed in
the stomach and a Foley in the bladder. He was placed in the
lithotomy position; routine prep and drape were done. We made
a small incision in the right upper quadrant, directly into the
peritoneal cavity and inserted the Hasson cannula, insufflated
the peritoneal cavity with C02. Once we had a good tent, we
examined the peritoneal cavity and could not really see the liver
because we were so close to it. We then dissected out the
sigmoid after we put in three other cannulas, a 12-mm in the
right lower quadrant, a 10-mm in the left lower quadrant, and a
5-mm in the left upper quadrant. These were put in under direct
vision. We then grasped the sigmoid and dissected it off the left
pelvic gutter, and dissected down toward the bladder. We could
not get the small bowel to easily come up out of the pelvis. We
then put the colonoscope through the rectum and came up to 25
cm, where we saw not a diverticular stricture, but a carcinoma.
We marked this point. When we were dissecting, we found the
small bowel to be adherent at this time and we elected to open,
so the trocars and instruments were all removed. We then made
a midline incision and, on inspection, found a large mass in the
pelvis. We had already freed up the left side of the sigmoid
colon with laparoscope. We identified the ureter and pushed it
away, opened the right pelvic peritoneum and identified the
right ureter, and then transected the bowel above the junction of
the sigmoid and descending colon with the GIA. We then

11. divided the mesentery between Kelly clamps, including the
inferior mesenteric terminal branch. These were all divided and
ligated with heavy silks. We pulled the small bowel off the side,
but it did look like there was some direct invasion there, and
then further mobilized the tumor and the upper rectum. We
divided all the mesentery between Kelly clamps and ligated
with heavy silk.
We then transected the rectum through its middle and upper one
thirds, with TA55 on the distal side and Kocher on the proximal
side, and then removed the specimen. We brought the proximal
end of the bowel out, cleaned it off of fat and mesentery, put a
pursestring instrument on it, excised the bowel distal to the
pursestring instrument, opened the pursestring instrument, and
then incised it. The size was 28 mm. We then put the anvil of
EEA in the proximal bowel and tightened it down with
pursestring. We put the EEA instrument up through the rectum,
pushed the trocar up through the suture line, then connected the
anvil to the EEA instrument and tightened it down under direct
vision, cut the bowel making the anastomosis and removed the
EEA. We then filled the pelvis with saline, clamped the bowel
proximally, and put in the colonoscope to obtain a good
anastomosis with no bleeding and no leak of air.
We then aspirated the fluid in the pelvis. We resected the
segment of the small bowel with GIA and did a functional end-
to-end anastomosis and transected the bowel loop outside the
anastomosis with a TA55. We actually had done this before we
completed the rectal anastomosis, and when we went back we
found a hematoma in the mesentery.
We dissected through the hematoma to get it controlled, ligated
the bleeders with heavy silk, but then we had to resect another
10 cm of small bowel and then did another functional end-to-
end anastomosis and closed the enterotomy with TA55 and the
mesentery with fine silks. This gave us a nice anastomosis with
good pink bowel, pretty close to the cecum.
We then noted there to be at least three, maybe four, metastases
scattered over different areas of the right lobe of the liver. One

12. was biopsied with a Tru-cut needle and the biopsy site
cauterized. We then had a correct sponge, instrument, and
needle count. We closed the fascia of the right upper quadrant
puncture wound with some interrupted silk Vicryls and closed
the muscles with interrupted Vicryls. The other smaller ports
were closed by skin clips. We then closed the fascia of the
peritoneum of the midline wound with running suture of #l
Vicryl and the fascia with interrupted figure 8 #l Vicryl, closed
the skin with clips, and applied sterile dressings. Sponge,
instruments, and sharp counts were again correct. The patient
tolerated the procedure well and we trust he will do well.
Pathology Report
Specimen—Origin:
I.
Small bowel sigmoid colon
II.
Liver biopsy
Pathologic Diagnosis:
I.
Segments of small bowel: Serosal adhesions
Colon: Invasive adenocarcinoma, moderate to poorly
differentiated, extending into pericolic adipose
Lymph nodes, small bowel mesentery: Negative for metastasis
(0/6 nodes)
Lymph nodes, pericolic: Negative for metastasis (0/6)
Pericolic adipose: Metastatic adenocarcinoma

13. II. Liver (needle biopsy): Metastatic adenocarcinoma
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