Malignant neoplasm of ovary Polyp of corpus uteri Other specified disorders of female genital organs Endometriosis of uterus Postmenopausal bleeding Disorder of bone and cartilage unspecified Diaphragmatic hernia without mention of obstruction or gangrene
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: OBSTETRICS/GYNECOLOGY
 
Allergies: 
Insect Extracts
 
Attending: ___
 
Chief Complaint:
Post menopausal bleeding
 
Major Surgical or Invasive Procedure:
Total ___ hysterectomy, right salpingo-oophorectomy, 
omentectomy, and cystoscopy. 

 
History of Present Illness:
___ year-old gravida 0 who experienced postmenopausal bleeding 
that led to a pelvic ultrasound at ___ Ultrasound 
___.  This study dated revealed an endometrial polyp 
measuring 2.3 cm.  This polyp had internal vascularity.  The 
right ovary was well visualized and within it was a 1.8 cm 
complex cyst with multiple solid areas and areas of peripheral 
mural thickening and nodularity, some of which were 
vascularized.  Notably, she has a history of bilateral 
borderline ovarian cancer and is status post a left 
salpingo-oophorectomy and right ovarian cystectomy in ___.
 
Past Medical History:
OB/GYN History:  She is a gravida 0.  She reports that her last
Pap smear was about a year ago and was normal.  She has never 
had
an abnormal Pap smear.  She denies any history of pelvic
infections or STDs.
- History of bilateral borderline ovarian cancers.  She 
underwent
an exploratory laparotomy, left salpingo-oophorectomy, right
ovarian cystectomy, partial omentectomy in ___. 
Postoperatively, she has had no evidence of disease recurrence
and has been followed with annual visits.
- Menopause a few years ago but has had some concerns with 
osteoporosis and therefore began bioidentical hormones under
the care of Dr. ___.  She has stopped using these 
since
the bleeding that she had.
.
Past Medical History:  She reports a history of osteopenia.  She
denies any history of asthma, hypertension, cardiac disease,
coronary artery disease, mitral valve prolapse, thromboembolic
disorder, or cancer.  She reports being up-to-date with
mammograms, colonoscopies, and bone density evaluation.
.
Past Surgical History:  As above.

 
Social History:
___
Family History:
She reports a maternal first cousin had breast cancer.  Both her 
mother and her father had colon cancer but at old ages.  Her 
mother had the disease at the age of ___, and her father had the 
disease diagnosed just prior to his death in ___.

 
Physical Exam:
Performed by Dr. ___ on ___:
GENERAL:  Appears stated age, no apparent distress.
NECK:  Supple.  No masses.
LYMPHATICS:  Lymph node survey, negative cervical,
supraclavicular, axillary, or inguinal adenopathy.
CHEST:  Lungs clear.
HEART:  Regular rate and rhythm.
BACK:  No spinal or CVA tenderness.
ABDOMEN:  Soft, nontender, nondistended.  There is no mass. 
There is no hepato or splenomegaly.  There is no fluid wave.
EXTREMITIES:  There is no clubbing, cyanosis, or edema.  There 
is
no calf tenderness to palpation.
PELVIC:  Normal external genitalia.  Inner labial folds normal. 
Urethral meatus normal.  Walls of the vagina are smooth.  Apex 
is
normal.  Cervix is normal.  Bimanual exam reveals a mobile 
uterus
without mass or lesion.  There is no cul-de-sac nodularity.

 
Brief Hospital Course:
Ms. ___ underwent a ___ right salpingo-oophorectomy, 
intraoperative pathology revealed borderline ovarian cancer and 
a total ___ hysterectomy, omentectomy, and cystoscopy 
was performed. She had a benign post-operative course and was 
discharged home on post-operative day #1 on oral pain 
medications, she was ambulating, tolerating a regular diet, and 
able to urinate without difficulty. 
 
Medications on Admission:
None
 
Discharge Medications:
1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every ___ 
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
every ___ hours as needed for pain: Do not drive while taking 
this medication.
Disp:*60 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: ___ Capsules PO BID (2 
times a day) as needed for constipation: Take daily while taking 
narcotic to prevent constipation.
Disp:*60 Capsule(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Borderline ovarian cancer

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

 
Discharge Instructions:
Call your doctor for:

* fever > 100.4

* severe abdominal pain

* difficulty urinating

* vaginal bleeding requiring >1 pad/hr

* abnormal vaginal discharge

* redness or drainage from incision

* nausea/vomiting where you are unable to keep down fluids/food

or your medication

General instructions:

* Take your medications as prescribed.

* Do not drive while taking narcotics.

* No strenuous activity, nothing in the vagina (no tampons, no

douching, no sex), no heavy lifting of objects >10lbs for 6

weeks. 

* You may eat a regular diet.

Incision care:

* You may shower and allow soapy water to run over incision; no

scrubbing of incision.  No bath tubs for 6 weeks.

* If you have steri-strips, leave them on. They will fall off on

their own or be removed during your followup visit.

 
Followup Instructions:
___

{'Postmenopausal bleeding': ['Malignant neoplasm of ovary', 'Polyp of corpus uteri', 'Other specified disorders of female genital organs'], 'Endometrial polyp': ['Malignant neoplasm of ovary', 'Polyp of corpus uteri', 'Other specified disorders of female genital organs'], 'Complex cyst with solid areas': ['Malignant neoplasm of ovary', 'Other specified disorders of female genital organs'], 'Osteopenia': ['Disorder of bone and cartilage']}