Malignant neoplasm complicating pregnancy second trimester Malignant neoplasm of upper-outer quadrant of left female breast Diseases of the respiratory system complicating pregnancy second trimester Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient or of later complication without mention of misadventure at the time of the procedure Postprocedural hypothyroidism Endocrine nutritional and metabolic diseases complicating pregnancy second trimester Spotting complicating pregnancy second trimester 14 weeks gestation of pregnancy Estrogen receptor positive status [ER+] Unspecified asthma uncomplicated Personal history of malignant neoplasm of thyroid Personal history of nicotine dependence
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
Percocet / cucumber
 
Attending: ___
 
Chief Complaint:
Left breast invasive ductal carcinoma
 
Major Surgical or Invasive Procedure:
LEFT BREAST TOTAL MASTECTOMY W/ SENTINEL LYMPH NODE BIOPSY 
___

 
History of Present Illness:
Ms ___ is a ___ year old pregnant female with breast
cancer. She had a palpable left breast lump, underwent
ultrasound, MRI, and core biopsy that showed a grade 2 invasive
ductal carcinoma, ER positive, PR positive, HER2 negative. She
later was found to be pregnant. She
is currently feeling fine apart from tiredness. She reports that
her levothyroxine dose was increased earlier this week. She also
notes some left nipple crusting, that there initially (after the
biopsy) was some bloody output that has since declined and 
become
mild and crusty. Otherwise no changes. 
 
Past Medical History:
PAST MEDICAL HISTORY: thyroid CA, postsurgical hypothyroidism,
IBS, ovarian cysts, PID, spine arthritis, asthma,
mononucleosisreported history of Lyme disease status post 3 
weeks
of antibiotic therapy.  Hashimotos negative prior to surgery per
her report

 
Social History:
___
Family History:
Family history: Aunt and mother with ALS. Mother, aunt,
grandmother: ___.  Father--prostate cancer (age ___.

 
Physical Exam:
VS: Refer to flowsheet
GEN: WD, WN in NAD
CV: RRR
PULM: no respiratory distress
BREAST: L breast - No evidence of hematoma, seroma. Small amount
of ecchymoses. Mildly tender to palpation. Incision healing 
well.
ABD: soft, NT, ND
EXT: WWP
NEURO: A&Ox3
 
Brief Hospital Course:
The patient was admitted on ___ with left breast invasive 
ductal carcinoma for left total mastectomy and left axillary 
sentinel lymph node biopsy with Dr. ___. Please see 
operative note. The patient tolerated the procedure well.  There 
were no immediate complications.  She was awoken from general
anesthesia in the operating room and transferred to the
recovery room in stable condition. On post-operative check, she 
reported pain at the site of the incision and nausea, and had an 
episode of emesis. The OB/GYN team recommended pain control with 
Dilaudid. She was placed on subQ heparin and compression devices 
for prophylaxis. She tolerated a regular diet. On ___, the 
pain continued to have pain, which was discussed with OB/GYN, 
and her dosage of Dilaudid was increased. She was given stool 
softener given the usage of narcotics. She reported some mild 
pink spotting, which was discussed with OB, and they performed 
an ultrasound which showed a strong fetal heart rate of 158. Per 
their report, she has been spotting since earlier in the 
pregnancy as well. The dressing on the incision site continued 
to be clean dry and intact.  There was no ecchymoses or hematoma 
on the chest wall.  Drain output was serosanguineous. At the 
time of discharge on ___, vitals were stable, pain 
well-controlled, and patient felt ready for discharge to home 
with ___, with follow up appointments in place.
 
Medications on Admission:
Meds/Allergies: reviewed in OMR and medications listed here
ALBUTEROL SULFATE [PROAIR HFA] - Dosage uncertain -  (Prescribed
by Other Provider)
LEVOTHYROXINE - levothyroxine 175 mcg tablet. 1 tablet(s) by
mouth daily in the morning on empty stomach, 90 minutes prior to
any food or other meds
PNV ___ FUMARATE-FA [PRENATAL] - Dosage uncertain - 
(Prescribed by Other Provider)
 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q6H  
2.  Docusate Sodium 100 mg PO BID  
3.  HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe  
4.  Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, dyspnea  
5.  Levothyroxine Sodium 175 mcg PO DAILY  
6.  Prenatal Vitamins 1 TAB PO DAILY  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
left breast invasive ductal carcinoma

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for LEFT BREAST TOTAL MASTECTOMY W/ 
SENTINEL LYMPH NODE BIOPSY. You are now stable for discharge.

Personal Care:  
1. You may keep your incisions open to air or covered with a 
clean, sterile gauze that you change daily.
2. Clean around the drain site(s), where the tubing exits the 
skin, with soap and water.  
3. Strip drain tubing, empty bulb(s), and record output(s) ___ 
times per day.  
4. A written record of the daily output from each drain should 
be brought to every follow-up appointment. Your drains will be 
removed as soon as possible when the daily output tapers off to 
an acceptable amount.  
5. You may wear a surgical bra or soft, loose camisole for 
comfort.  
6. You may shower daily with assistance as needed. Be sure to 
secure your drains so they don't hang down loosely and pull out.
7. The Dermabond skin glue will begin to flake off in about ___ 
days.
  
Activity:  
1. You may resume your regular diet.  
2. Walk several times a day.  
3. DO NOT lift anything heavier than 5 pounds or engage in 
strenuous activity for 6 weeks following surgery. 

Medications:  
1. Resume your regular medications unless instructed otherwise 
and take any new meds as ordered .  
2. You may take your prescribed pain medication for moderate to 
severe pain. You may switch to Tylenol or Extra Strength Tylenol 
for mild pain as directed on the packaging. Please note that 
Percocet and Vicodin have Tylenol as an active ingredient so do 
not take these meds with additional Tylenol.  
3. Take prescription pain medications for pain not relieved by 
Tylenol.  
4. Take Colace, 100 mg by mouth 2 times per day, while taking 
the prescription pain medication. You may use a different 
over-the-counter stool softener if you wish.  
5. Do not drive or operate heavy machinery while taking any 
narcotic pain medication. You may have constipation when taking 
narcotic pain medications (oxycodone, percocet, vicodin, 
hydrocodone, dilaudid, etc.); you should continue drinking 
fluids, you may take stool softeners, and should eat foods that 
are high in fiber.  

Call the office IMMEDIATELY if you have any of the following:  
1. Signs of infection: fever with chills, increased redness, 
swelling, warmth or tenderness at the surgical site, or unusual 
drainage from the incision(s).  
2. A large amount of bleeding from the incision(s) or drain(s).  

3. Fever greater than 101.5 oF  
4. Severe pain NOT relieved by your medication.  
  
Return to the ER if:  
* If you are vomiting and cannot keep in fluids or your 
medications.  
* If you have shaking chills, fever greater than 101.5 (F) 
degrees or 38 (C) degrees, increased redness, swelling or 
discharge from incision, chest pain, shortness of breath, or 
anything else that is troubling you.  
* Any serious change in your symptoms, or any new symptoms that 
concern you.  

DRAIN DISCHARGE INSTRUCTIONS  
You are being discharged with drains in place. Drain care is a 
clean procedure. Wash your hands thoroughly with soap and warm 
water before performing drain care. Perform drainage care twice 
a day. Try to empty the drain at the same time each day. Pull 
the stopper out of the drainage bottle and empty the drainage 
fluid into the measuring cup. Record the amount of drainage 
fluid on the record sheet. Reestablish drain suction.  
Please assist patient with drain care. A daily log of individual 
drain outputs should be maintained and brought with patient to 
follow up appointment with your surgeon.

 
Followup Instructions:
___

{'tiredness': ['Malignant neoplasm complicating pregnancy, second trimester'], 'left nipple crusting': ['Malignant neoplasm of upper-outer quadrant of left female breast'], 'bloody output': ['Malignant neoplasm of upper-outer quadrant of left female breast'], 'pain at the site of the incision': ['Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure'], 'nausea': ['Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure'], 'emesis': ['Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure'], 'mild pink spotting': ['Spotting complicating pregnancy, second trimester'], 'strong fetal heart rate of 158': ['14 weeks gestation of pregnancy'], 'pain': ['Postprocedural hypothyroidism', 'Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester'], 'ER positive, PR positive, HER2 negative': ['Estrogen receptor positive status [ER+]', 'Malignant neoplasm of upper-outer quadrant of left female breast'], 'wheezing, dyspnea': ['Unspecified asthma, uncomplicated'], 'history of thyroid CA': ['Personal history of malignant neoplasm of thyroid'], 'history of drug use': ['Personal history of nicotine dependence']}