Malignant neoplasm of kidney except pelvis Personal history of tobacco use Personal history of tuberculosis
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: UROLOGY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
renal mass
 
Major Surgical or Invasive Procedure:
right laparascopic radical nephrectomy- Dr. ___, Dr. 
___ ___

 
History of Present Illness:
___ y/o healthy female with incidental finding of right renal 
mass suspicious for RCC following MRI on ___. 
 
Past Medical History:
PMH: nonspecific right axis deviation  

PSH- cesarean section

ALL-NKDA
 
Social History:
___
Family History:
no history of RCC
 
Pertinent Results:
___ 07:15AM BLOOD WBC-7.6 RBC-3.82* Hgb-11.9* Hct-33.8* 
MCV-89 MCH-31.2 MCHC-35.2* RDW-12.8 Plt ___
___ 07:15AM BLOOD Glucose-150* UreaN-10 Creat-0.9 Na-138 
K-3.8 Cl-104 HCO3-27 AnGap-11
 
Brief Hospital Course:
Patient was admitted to Urology after undergoing laparoscopic 
right radical nephrectomy. No concerning intraoperative events 
occurred; please see dictated operative note for details. The 
patient received perioperative antibiotic prophylaxis. The 
patient was transferred to the floor from the PACU in stable 
condition.  On POD0, pain was well controlled on PCA, hydrated 
for urine output >30cc/hour, provided with pneumoboots and 
incentive spirometry for prophylaxis, and ambulated once. On 
POD1,foley was removed without difficulty, basic metabolic panel 
and complete blood count were checked, pain control was 
transitioned from PCA to oral analgesics, diet was advanced to a 
clears/toast and crackers diet. On POD2, diet was advanced as 
tolerated. The remainder of the hospital course was relatively 
unremarkable. The patient was discharged in stable condition, 
eating well, ambulating independently, voiding without 
difficulty, and with pain control on oral analgesics. On exam, 
incision was clean, dry, and intact, with no evidence of 
hematoma collection or infection. The patient was given explicit 
instructions to follow-up in clinic with ___ in 3 weeks.

 
Medications on Admission:
none
 
Discharge Medications:
1. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q6H (every 6 hours) as needed for break through pain only (score 
>4) .
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*2*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
renal cell carcinoma

 
Discharge Condition:
stable

 
Discharge Instructions:
-You may shower but do not bathe, swim or immerse your incision.

-Do not eat constipating foods for ___ weeks, drink plenty of 
fluids

-Do not lift anything heavier than a phone book (10 pounds) or 
drive until you are seen by your Urologist in follow-up

-Tylenol should be used as your first line pain medication. If 
your pain is not well controlled on Tylenol you have been 
prescribed a narcotic pain medication. Use in place of Tylenol. 
Do not exceed 4 gms of Tylenol in total daily

-Do not drive or drink alcohol while taking narcotics

-Resume all of your home medications, except hold NSAID 
(aspirin, advil, motrin, ibuprofen) until you see your urologist 
in follow-up

-If you have fevers > 101.5 F, vomiting, or increased redness, 
swelling, or discharge from your incision, call your doctor or 
go to the nearest ER

-Call Dr. ___ to set up follow-up appointment and if 
you have any urological questions. ___

 
Followup Instructions:
___

{'renal mass': ['Malignant neoplasm of kidney', 'except pelvis'], 'right axis deviation': [], 'cesarean section': [], 'nonspecific': []}