Discharge Summary

Only available on StudyMode
  • Download(s) : 798
  • Published : June 6, 2012
Open Document
Text Preview
DISCHARGE SUMMARY____________________________________ Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 03/27/---Date of Discharge: 03/30/---Admitting Diagnosis: Ectopic pregnancy. Surgical Procedures 1. Exploratory laparotomy. 2. Partial salpingectomy. 3. Evacuation of hemoperitoneum. 4. Lysis of adhesions. Complications: Blood loss requiring transfusion x2. HISTORY: This 35-year-old white female, gravida 3, para 1-0-2-1, had her last menstrual period in early January. Prior menstrual cycles had been regular. She reported using no contraception but not attempting pregnancy. Patient presented to the emergency room complaining of vaginal bleeding with pain in the lower pelvic area. Ultrasound performed in the emergency room showed a 13.8 cm left adnexal mass with positive cardiac activity compatible with ectopic pregnancy. HOSPITAL COURSE: On March 27 the patient underwent exploratory laparotomy, left partial salpingectomy, evacuation of hemoperitoneum, and lysis of adhesions. Blood loss was approximately 1000 mL and was replaced with transfusion of 2 units of red blood cells. Her blood type was noted to be O, Rh-negative, and RhoGAM was provided. (Continued)

©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a passwordprotected website for classroom use.

DISCHARGE SUMMARY Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 03/27/---Page 2

The patient was discharged on postoperative day number 3 after having had a normal bowel movement. She was discharged without complaints on no medications. She understood her instructions regarding followup, incision care, and limitation of activities.

______________________ Rosemary Bumbak, MD Obstetrics & Gynecology RB:xx D:03/30/---T:04/10/----

©2011 Cengage Learning. All Rights Reserved. May not be copied,...
tracking img