Other malignant neoplasm of skin of lower limb including hip Other left bundle branch block Pure hypercholesterolemia Unspecified essential hypertension Osteoporosis unspecified Esophageal reflux
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: PLASTIC
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Left leg lesion
 
Major Surgical or Invasive Procedure:
1. Excision of left lower extremity lesion
2. Partial local advancement closure left lower extremity.
3. Full-thickness skin graft from left groin 6 x 4 cm from
    left groin to left lower extremity.
4. Local advancement flap closure left groin defect 8 cm.
5. Vacuum-assisted closure dressing placement.
 
History of Present Illness:
___ yo female who presents with about a 6 month history of a left 
shin mass. The mass is described as a small pimple that grew 
over the course of 6 months time. She was evaluated by a 
dermatologist who biopsied the mass and determined that it was 
benign but the pathology report is no present in the ___ 
medical record. She also experiences an episode of cellulitis at 
the area. She was evaluated in the ___ ED and was treated with 
Keflex. The cellulitis resolved.  She now presents for removal 
of the mass.

 
Past Medical History:
Osteoarthritis
Hypertension
Hypercholestrolemia
Colon polyp
Left bundle branch block

 
Social History:
___
Family History:
Non-contributory
 
Physical Exam:
GEN: NAD
HEENT: NCAT, EOMI, no LAD
LUNGS: CTAB
CARDIAC:  RRR, no M/R/G
ABD: +BS, NT/ND
EXT: WWP
SKIN: Lesion 2.5X2.5 cm with brown base, macerated center. No
evidence of cellulitis, no drainage. On mid-tibia region

 
Pertinent Results:
PATH:

SPECIMEN SUBMITTED: left leg lesion.

Procedure date     Tissue received     Report Date    Diagnosed 
by 
___ ___. ___ 

DIAGNOSIS: 

 

Skin, left leg, wide excision (A-Q):

Squamous cell carcinoma, invasive, well differentiated, 
completely excised.

 

Note: The lesion has a crateriform (keratoacanthoma-like) 
architecture.

 
Brief Hospital Course:
The patient was admitted to the plastic surgery service on 
___ and had:
1. Excision of left lower extremity lesion
2. Partial local advancement closure left lower extremity.
3. Full-thickness skin graft from left groin 6 x 4 cm from
    left groin to left lower extremity.
4. Local advancement flap closure left groin defect 8 cm.
5. Vacuum-assisted closure dressing placement.

Skin lesion was found to be squamous cell cancer.

The patient tolerated the procedures well.

Neuro: Post-operatively, the patient had adequate pain control 
and tolerated PO pain meds.

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. Intake and output were 
closely monitored.  Pt urinating without Foley.

ID: Post-operatively, the patient was started on IV Ancef. 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 on POD#7, the patient was doing well, 
afebrile with stable vital signs, tolerating a regular diet, 
ambulating, voiding without assistance, and pain was well 
controlled.  Pt was evaluated by ___ and was able to walk stairs 
without assistance.  ___ recommended a walker to assist when pt 
is not walking stairs.

 
Medications on Admission:
Omeprazole 20 QD
Metoprolol 50 mg AM, 25 mg QHS
Evista 60 mg QD
ASA 81 mg QD
Centrum
 
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QHS 
(once a day (at bedtime)).  
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.  
5. Centrum Silver     Tablet Sig: One (1) Tablet PO once a day: 
with food.  
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain: no more than 4g total of 
acetaminophen (Tylenol) in 24 hours.  
7. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
every ___ hours as needed for pain for 1 weeks: no more than 4g 
total Acetaminophen (Tylenol) in one day, one pill has 500mg 
Acetaminophen (Tylenol).
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day) as needed for constipation for 1 weeks: take this 
while you take Vicodin to keep from getting constipated.
Disp:*14 Capsule(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as 
needed for constipation for 1 weeks: take this if you are using 
Vicodin to prevent constipation.
Disp:*7 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Squamous cell carcinoma

 
Discharge Condition:
Good

 
Discharge Instructions:
Physical therapy recommended that you use the walker that they 
gave you for assistance.  You did well with stairs without any 
assistance.

Please limit your walking to less than 15 minutes at a time.  
Keep your left leg elevated when you are sitting or are in bed.

Home with ___ for wound care.  ___ will come change your 
dressings and will help teach you and your caretakers how to 
change them.  

You do not need antibiotics.

Do not take more than 4g Acetaminophen (Tylenol) in one day, 
both regular Tylenol and Vicodin contain Tyleno.  Vicodin 
contains 500mg Tylenol in each pill.

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.

 
Followup Instructions:
___

{'shin mass': ['Other malignant neoplasm of skin of lower limb, including hip'], 'cellulitis': ['Other malignant neoplasm of skin of lower limb, including hip'], 'pain': ['Other malignant neoplasm of skin of lower limb, including hip', 'Pure hypercholesterolemia', 'Unspecified essential hypertension', 'Osteoporosis, unspecified', 'Esophageal reflux']}