ADMITTING DIAGNOSIS
Cystocele with urinary incontinence.
FINAL DIAGNOSIS
Cystocele with urinary incontinence.
PROCEDURE
Anterior repair.
COMPLICATIONS
None.
HISTORY
This is a 65-year-old woman who had had a previous hysterectomy, who developed urinary incontinence, and was found to have a large cystocele.
Physical examination was unremarkable except for the cystocele.
Laboratory work including a panel, CBC, ECG, and chest x-ray, was essentially within normal limits.
Following surgery the patient has done well. The vaginal pack was removed this date and the Foley catheter. She will be checked for residual. If the residual is over 150 cc, the Foley will be replaced and the patient taught to use the catheter plug, and she will be discharged. She will be seen in the office in approximately 1 week for followup.
FOOTNOTE
Line 11. The physician dictated same to indicate that the Final Diagnosis is the same as the Admitting Diagnosis. The Final Diagnosis should be written out in full for clarity.
Line 26. Were was changed to was for subject-verb agreement (Lab work ... was). The abbreviations were expanded for clarity.
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