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Report 40

Jacobs, Jennifer C.

Room No. 597

Hospital No. 450321

Discharge Summary

ADMITTING DATE: September 10, 2014

DISCHARGE DATE: September 16, 2014

ADMITTING DIAGNOSIS

Family planning by surgical sterilization, bilateral partial salpingectomies.

FINAL DIAGNOSES

1. Family planning by surgical sterilization, bilateral partial salpingectomy.

2. Retention cysts, multiple, bilateral infundibulum and uterine body.

OPERATION

Bilateral partial salpingectomies, infundibulectomies, removal of the retention cysts from the uterine body and tubes.

Admitting Summary

This patient entered the hospital on September 10, 2013 for elective surgical sterilization, bilateral partial salpingectomies. This patient has obstetrical history of gravida 2 para two and is entirely satisfied with her family situation and wished to have this surgical procedure to terminate her reproductive plan.

X-Ray and Laboratory

Routine chest xray and other laboratory examinations revealed to be satisfactory for operative condition.

Complications During Hospitalization

None.

Discharge Summary

During the course of the hospitalization, the patient has gone through said surgical procedure on September 11, 2104. There was no immediate postoperative hemorrhage or any other complication noted. During the course of the recovery period, the patient made a satisfactory progress except for usual low-grade postoperative fever, and occasional cough.

Re-evaluation prior to dismissal revealed temperature had returned to normal, the patient was feeling well, ambulating well, having a good appetite, and all systems appeared to be satisfactory enough to be dismissed.

Incision was inspected on September 14, 2014, without evidence of infection or drainage. New dressing applied.

Followup Plan

Personal care and activities at home were discussed. First followup appointment was made to my office for September 19, 2104, to remove stitches and reexamination of the incision. No medication prescribed.

David B. Wilcox, MD

student’s initials

D: current date

T: current date