OB-GYN Studies

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS

Infiltrating ductal carcinoma, right breast.

PROCEDURE

Needle biopsy of mass, right breast, with frozen section positive for infiltrating ductal carcinoma, and right modified radical mastectomy.

COMPLICATIONS

None.

HISTORY

This is an 87-year-old woman who had been in the hospital recently because of cardiopulmonary problems.  Shortly after discharge, she noted a mass in her right breast and called this to the attention of her physician.  A fine-needle biopsy was done after mammograms, which showed a suspicious lesion.  Fine-needle was reported out as probably infiltrating ductal carcinoma.

Patient with her family was seen and the options of treatment reviewed.  Patient opted to go for a modified radical mastectomy rather that lumpectomy and followup radiation.  A Tru-Cut needle biopsy was made of the mass prior to doing the mastectomy to assure the diagnosis.  The Tru-Cut needle biopsy was positive for carcinoma.

Following surgery, the patient has done well.  The wound is clean and dry.  There is little duskiness in the upper central portion of the wound, and there is 1 small blister near the wound edge.  The Jackson-Pratt catheters have been removed this date.  Patient has been advised that she may get some accumulation of fluid there that may need to be withdrawn as an outpatient.

She is anxious to go home.  She states she has pain medication at home.  She will be seen in the office in about 3 days for followup and removal of half the skin clips.

At this juncture the final reports on lymph node status are not as yet available, nor do we have the results for estrogen and progesterone receptors.  At this patient’s age and frailty, the ultimate prognosis insofar as the tumor is concerned probably is not all that bad.

FOOTNOTE

Line 45 (Page 1).  The dictated period was changed to a comma for proper punctuation.

OB-GYN Study

LETTER

Date

Name

Address

City, State, Zip

Gentlemen,

At the request of my patient, I am forwarding this brief medical report.

History

This 42-year-old woman was seen in consultation regarding problems referable to her right and left breasts.  This patient has a long history of bilateral fibrocystic disease with episodes of mastitis in both breasts.  The patient underwent a bilateral subcutaneous mastectomy with implant reconstruction.  Subsequently, because of complications with contractures, these implants were removed.  The patient developed a lump in her right breast, which was diagnosed as a probable recurrent cyst near the axilla.  This was followed for almost 1 year without change.  However, the lump became somewhat tender.  Examination revealed some ill-defined induration in the upper outer quadrant of the right breast flap.  Old incisional scars were noted in both breasts.

Diagnoses

1. Probable residual fibrocystic disease in the upper outer quadrant of the right breast.

2. Status postoperative bilateral subcutaneous mastectomy.

Comments

1. The patient is seeking consultation both in regard to the induration in the upper outer quadrant of the right breast as well as for possible reconstructive surgery to both breasts.  She has never fully accepted the resection of the breast tissue and the loss of the implant reconstruction.

2. I have suggested to the patient that we could consider at this point in time removal of the area of induration from the upper outer quadrant of the right breast which is so tender, as well as performing an implant reconstruction of the right and left breasts using polyurethane-type implants.

3. The patient would appreciate a letter stating that this would be covered under her group health insurance program.

4. I have included a copy of the pathology report from the tissue resected.

Sincerely,

Name.

FOOTNOTE

Lines 18, 33, 38 (Page 1).  It is not necessary to type headings in all capitals in a letter, but it is acceptable to do so.

OB-GYN Case Study

DISCHARGE SUMMARY

PROVISIONAL DIAGNOSIS

Intrauterine pregnancy.

FINAL DIAGNOSES

1. Intrauterine pregnancy, delivered.

2. Periurethral tear.

OPERATIONS

None.

HISTORY AND ESSENTIAL PHYSICAL

This is a 27-year-old secundigravida at term, with blood type A positive, who had a pregnancy uncomplicated except for some first-trimester bleeding.  She was admitted after 5 hours of good labor and was brought to the delivery room, complete and pushing, with membranes still intact.  Spontaneous rupture of membranes occurred only 1 minute prior to delivery and revealed light meconium staining.  The delivery was very rapid, though well controlled, and resulted in a superficial periurethral and labial tear which did not require suturing.  No episiotomy required.  The infant was suctioned well on the perineum.  Blood loss was minimal, and both mother and infant were stable following delivery.

HOSPITAL COURSE

Large uterine clots were expressed the first postpartum day, and the initial postpartum CBC revealed a white count of 18.5 with
55 segs, 17 bands, and 23 lymphs.  This was repeated on the second postpartum day and showed white count 16,000 with 69 segs, 7 bands, 19 lymphs, hemoglobin 11.8, hematocrit 35.2.

The patient remained afebrile but had minimal uterine tenderness, and in light of the elevated white count, she was begun on ampicillin 500 mg q.i.d. for a 10-day course.  She was discharged in stable condition.  Activity and diet as tolerated.  To continue Parlodel, ampicillin, prenatal vitamins, and ferrous sulfate as directed, also Colace 100 mg q.h.s. p.r.n. constipation.  Appointment for 6-week postpartum check, but should call sooner if high fever or excessive uterine cramps persist.

OB-GYN Case Study

CHART NOTE

This 24-year-old female relates a history of having her first pregnancy complicated with severe hyperemesis.  She stated she was hospitalized for 6 weeks because of this.  The patient relates she had been vomiting persistently for almost a week to a week and a half with this pregnancy.  The patient had 1+ bacteria in the catheterized urine specimen.  She had no CVA tenderness on examination.

In view of the persistent vomiting and urinary tract infection, the mild dehydration, it was elected to admit the patient for IV hydration and parenteral antibiotic therapy.

IMPRESSION

My impression is intrauterine pregnancy, 7+ weeks’ gestation by dates confirmed clinically, with hyperemesis gravidarum and urinary tract infection.

FOOTNOTE

Line 12.  The slang term cath’d was expanded to catheterized.  The abbreviation CVA was expanded to (costovertebral angle).

Line 16.  Alternative:  I.V.

OB-GYN

CHART NOTE

I was called to stand by for primary cesarean section on this delivery because of cephalopelvic disproportion.  No fetal distress had been noted prior to delivery on fetal monitor.

Infant delivered was a term-appearing male infant with Apgars 8 and 9.  There was no evidence of any severe respiratory distress.  The infant did very well after some stimulation.