Malignant neoplasm of upper-outer quadrant of female breast Difficulty in walking Other acute postoperative pain Other specified disorders of skin Constipation unspecified Late effects of acute poliomyelitis Personal history of irradiation presenting hazards to health Personal history of malignant neoplasm of breast Tobacco use disorder
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: PLASTIC
 
Allergies: 
Iodine; Iodine Containing / Latex
 
Attending: ___.
 
Chief Complaint:
Acquired absence of the right breast, status post nipple sparing 
mastectomy for breast cancer
 
Major Surgical or Invasive Procedure:
Immediate reconstruction of nipple-sparing mastectomy with deep 
inferior epigastric perforator flap from the contralateral side, 
harvest of pedicle of the flap, and anastomosis of the 
thoracodorsal artery and vein (___)

 
History of Present Illness:
Patient is a ___ female with a history of having a 
mammogram finding of newly diagnosed ductal carcinoma on the 
right breast with a focus of suspicious
microinvasion.  She has a history of microinvasive carcinoma of 
the right breast diagnosed first in ___ of which she 
was found to have been diagnosed with invasive ductal carcinoma 
with ER negativity and HER-2/neu positivity.  She has also been 
treated with breast conservation surgery as well as 
postoperative radiotherapy. She is now here for planned 
mastectomy for breast cancer to be followed by desired immediate 
breast reconstruction.
 
Past Medical History:
PMH: Polio, breast disease, radiation therapy, left knee Bakers 
cyst
PSH: Lumpectomy ___, cholecystectomy ___, tubal ligation ___

 
Social History:
Smokes 1.5 ppd for 30+ years, trying to quit; denies alcohol 
yes; last used IV drugs ___ years ago
 
Physical Exam:
VS: Afebrile, VSS
Gen: NAD
CV: RRR, no murmurs
Resp: CTAB, no crackles or wheezes
Breasts: R breast flap viable and intact, incision c/d/i without 
hematoma, Dopplerable pulse. JP with serosanguinous fluid.
Abd: Soft, mildly TTP, +BS. Incision c/d/i without hematoma.
Ext: Warm, distal pulses palpable
 
Pertinent Results:
___ 04:14AM BLOOD WBC-12.0*# RBC-3.55* Hgb-11.1* Hct-32.6* 
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.4 Plt ___
 
Brief Hospital Course:
The patient was admitted to the plastic surgery service on 
___ and had an immediate reconstruction of nipple-sparing 
mastectomy with deep inferior epigastric perforator flap from 
the contralateral side, harvest of pedicle of the flap, and 
anastomosis of the thoracodorsal artery and vein. She tolerated 
the procedure well.

Neuro: The patient received morphine PCA with good effect and 
adequate pain control. When tolerating oral intake, the patient 
was transitioned to oral pain medications.  

CV: The patient was stable from a cardiovascular standpoint; 
vital signs were routinely monitored. 

Pulmonary: The patient was stable from a pulmonary standpoint; 
vital signs were routinely monitored. 

GI/GU: Post-operatively, the patient was given IV fluids until 
tolerating oral intake. Her diet was advanced when appropriate, 
which was tolerated well. She was also started on a bowel 
regimen to encourage bowel movement. Foley was removed on POD#2. 
Intake and output were closely monitored. 

ID: Post-operatively, the patient was started on IV cefazolin. 
The patient's temperature was closely watched for signs of 
infection. 

Prophylaxis: The patient received subcutaneous heparin during 
this stay, and was encouraged to get up and ambulate as early as 
possible.  

At the time of discharge, the patient was doing well, afebrile 
with stable vital signs, tolerating a regular diet, ambulating, 
voiding without assistance, and pain was well controlled.

 
Medications on Admission:
Depakote, fluoxetine, quetiapine, trazodone
 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Acquired absence of the right breast, status post nipple sparing 
mastectomy for breast cancer.

 
Discharge Condition:
Good

 
Discharge Instructions:
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.
* Please resume all regular home medications and take any new 
meds as ordered. 
* 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.
* ___ nursing services will help you with JP drain care. Empty 
JP drains daily and record daily output.
 
Followup Instructions:
___

{'Acquired absence of the right breast': ['Malignant neoplasm of upper-outer quadrant of female breast'], 'Difficulty in walking': ['Difficulty in walking'], 'Other acute postoperative pain': ['Other acute postoperative pain'], 'Other specified disorders of skin': ['Other specified disorders of skin'], 'Constipation': ['Constipation'], 'Late effects of acute poliomyelitis': ['Late effects of acute poliomyelitis'], 'Personal history of irradiation': ['Personal history of irradiation'], 'presenting hazards to health': ['presenting hazards to health'], 'Personal history of malignant neoplasm of breast': ['Personal history of malignant neoplasm of breast'], 'Tobacco use disorder': ['Tobacco use disorder']}