DS

docx

School

Holmes Colleges Melbourne *

*We aren’t endorsed by this school

Course

801

Subject

Nursing

Date

Nov 24, 2024

Type

docx

Pages

1

Uploaded by CountScience6590

Report
ADMISSION DIAGNOSES: 1. Pelvic pain. 2. Dysmenorrhea. 3. Dyspareunia. DISCHARGE DIAGNOSES: 1. Pelvic pain. 2. Dysmenorrhea. 3. Dyspareunia. PROCEDURE PERFORMED: 1. Total laparoscopic hysterectomy. 2. Bilateral salpingo-oophorectomy. DISCHARGE MEDICATIONS: Estradiol 2 mg and a prescription for Tylenol No. 3 was sent electronically. FOLLOWUP : In six weeks or early if needed. DISCHARGE INSTRUCTIONS: The patient was advised to return including heavy vaginal bleeding, ______ persistence of high fevers or chills, abnormal rash, drainage through the abdominal incisions. HISTORY AND PHYSICAL: Please see pertinent patient’s chart. HOSPITAL COURSE: The patient was admitted on November 14, 2014 with the above complaints, underwent a TLH/BSO without incidents. The mid to late morning on postoperative day #1, she was tolerating diet, she has been urinating well without catheter in with her bladder feeling empty. Denied any nausea or vomiting, fevers or chills otherwise. She was hemodynamically stable. She was desiring discharge by noon on the postoperative day #1. Per the nurse, her incision was clean, dry, and intact. She had had scant vaginal discharge. The patient wished to be discharged even though I could not be present to see her at that time. She was discharged on postoperative day #1 in good satisfactory condition with above written medications, discharge instructions, and follow up as listed above.
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