Discharge Summary Case 1

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  • Topic: Uterus, Gynecology, Sebaceous cyst
  • Pages : 2 (262 words )
  • Download(s) : 228
  • Published : November 16, 2012
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DISCHARGE SUMMARY

PATIENT NAME: Julie Reynolds

HOSPITAL NO.: 11678

ADMITTED: 03/05/2012

DISCHARGED: 03/08/2012

CONSULTATIONS: None.

PROCEDURES: Vaginal hysterectomy and excision of sebaceous cyst of vulva.

COMPLICATIONS: None.

ADMITTING DIAGNOSIS: Pelvic pain.

Patient is a 32-year-old white female, gravada 2, para 1, ab 1. Her only child was born in 1994. Patient presented with pelvic pain and underwent GYN work up. Exam was unremarkable except for a modern degree of uterine prolapsed and tenderness. Patient also had a 1 cm sebaceous cyst of the right labium. Her preoperative hemoglobin was 13.9 g% and a urinalysis was unremarkable. A vaginal hysterectomy and excision of sebaceous cyst of the right labium was carried out on the day after admission. Patient did well postoperatively and was discharged on the third postoperative day after an afebrile course.

Pathologic examination of the removed tissue showed a proliferative endometrium and normal myometrium. There was squamous metaplasia of the cervix. There was also an epidermal inclusion cyst. The patient’s postoperative hemoglobin was 9.7 g%. Chemistry profile was within normal limits. Patient was passing urine and stool normally. She was given instructions on diet and restrictions on heavy lifting, driving, and intercourse for 6 weeks. Follow up appointment in my office in 4 weeks

Discharge medications included Macrobid b.i.d. and Tylenol p.r.n. pain.

(Continued)

DISCHARGE DIAGNOSIES: 1. Proliferative endometrium
2. Squamous metaplasia cervix
3. Epidermal inclusion cyst

_________________________
John Sullivan, M.D.

JS: ad
D: 03/09/2012
T: 03/09/2012

C: Carol Denosky, M.D.
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