QF/NUR/12

DISCHARGE SUMMARY
IP. Number: 728819 Admission Date: 18/04/2011 Discharge Date: 07/05/2011
Bed No.: 3042 Admission Time: 10:28 a.m. Discharge Time:
Name of Patient: BIPLAB ROY P
Age: 36 years Sex: Male
Guardian’s Name: BENOY KUMAR ROY
Address: JHARGRAM (WEST MIDNAPOOR)
Telephone #: 9830484636
Consultant’s Name: Dr. GAUTAM MUKHOPADHYAY (Consultant Onco Surgeon)

Patient was also seen on referral by: Dr. TAPAN KUMAR DASS (Consultant Physician) and Dr. M. B.
DAS (Consultant Cardiothoracic Surgeon)
Final Diagnosis: SQUAMOUS CELL CARCINOMA OESOPHAGUS (MIDDLE 1/3)
Clinical Summary: This 36-year-old gentleman was admitted with history of gradually increasing
dysphagia (solids >> liquids) since November 2010. Upper GI Endoscopy revealed ulceroproliferative
growth in oesophagus at 32cm from the incision teeth. Endoscopic Biopsy showed Squamous Cell
Carcinoma. CECT Thorax done showed locally advanced disease. The patient was given 3 cycles of
neoadjuvant Chemotherapy with Injection Paclitaxel and Carboplatin. Follow up PET-CT scan showed
metabolically active mass in infracarinal region suggestive of residual disease with no evidence of
metastatic or active disease anywhere else. Relevant investigations were done prior to surgery.
Operative Note: Total radical oesophagectomy (Mckeown's) with oesophagogastrostomy and feeding
jejunostomy done under General Anesthesia and Thoracic Epidural Anesthesia on 21/04/11.
Operative Findings:
 Right Thoracotomy through 5th ICS showed oesophageal growth extending from pulmonary vein
to the carina and infiltrating into the aorta at one region of 2cmx2cm when little bit of tumour
tissue was left behind during resection
 No obvious metastatic lymph nodes were seen.
 No evidence of metastatic disease was seen
The whole procedure took 7-8 hours to complete.
Postoperative recovery was gradual but uneventful. Contrast swallow study done on 12 th Postoperative
day didn’t show any anastomotic leak in the neck. At present, patient is afebrile, haemodynamically
stable, taking liquids orally and is being discharged with the following advice -
Condition of Patient at discharge:
 The patient is discharged with: Feeding Jejunostomy tube in situ.
Advice on discharge:
1. REST: Restful life at home for 7 days.
2. DIET: Diet of liquid consistency orally of about 2 litres / day (2000Kcal/day) and Feeding
Jejunostomy Tube feeds about 1 litre / day (water / clear liquids). Diet should be followed as
per diet chart.
3. TOTAL ADVISED FLUID INTAKE: Liberal.
4. Syrup DIGENE 10ml orally thrice daily to continue till further advice.
5. Syrup IBUGESIC 10ml orally as and when necessary (in case of pain)
6. RESOURCE 4 scoops with 200ml of water 4-5 times orally to continue till further advice.

Name of Patient: BIPLAB ROY

Bed No.: 3042 __/10/2009
Admission Date: 18/04/2011
Consultant’s Name:
Consultant’s Name: Dr. GAUTAM MUKHOPADHYAY (Consultant Onco Surgeon)
7. Review with Dr. Gautam Mukhopadhyay after 7 days with Histopathological Examination
Report at Bengal Oncology Centre (9831369422) or even earlier if necessary with prior
appointment.
8. Regarding any query about reports (biopsy) if applicable and hospital services please contact 9748457100.
9. Continue treatment under regular Supervision of surgeon/physician of choice.
10. Consult your house Physician or Emergency Department of Ruby General Hospital or any other hospital if any
medical problem arises.
11. Remain alert to any Drug Reaction – if any itching / rash / suffocation / any other distress appears after
taking any of the above medicine. Put the MEDICINE on HOLD and consult your physician / local physician
immediately.

Investigations-Reports enclosed / Please contact Front Office for reports pending if any.

________________________
Signature of MO / Consultant

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Name of MO / Consultant

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Registration No. of MO / Consultant

Declaration by guardian of the patient:

Copy of the above mentioned instructions have been received and understood. Reports, old papers and
other documents have been received and verified.

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Signature Name Relationship Date Time