Module1
DISCHARGE SUMMARY
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission: 03/27/----
Date of Discharge: 03/30/----
Admitting Diagnosis: Ectopic pregnancy
Surgical Procedure:
1. Exploratory Laporotonomy
2. Partial Salpingectomy
3. Evacuation of Hemoperitoneum
4. Lysis of Adhesion
Complications: Blood test requiring transfusion x2
HISTORY: This 35-year old white female gravida 3, para 1-0-2-1 had her last menstrual period in early January prior menstrual cycle had been regular to report using no contraception but not attempting pregnancy. Patient presented to the emergency room complaining a vaginal bleeding with pain in a lower pelvic area. Ultrasound preform in an emergency room pseudode 13.8 cm left at adnexal mass with positive cardiac activity compatible with ectopic pregnancy.
HOSPITAL COURSE: On March 27 the patient underwent explotory laparotomy. Left partial Salpingectomy, evacuation of hemoperitoneum and lysis of adhesion. Blood lost was approximately 1,000 ml and was replaced with transfusion of 2 units of red blood cells. Her blood type was noted to be O Rh-negative and RhoGam was provided. The patient was discharged on post-operative day number 3 after having had a normal bowel movement. She was discharge without complaints on no medication. She understood her instruction regarding follow up incision care and limitation of activities.
_____________
Rose Mary Bumbak M.D
OB/GYN
RB: xx
D: 03/30/----
T: 03/30/----
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission: 03/27/----
Date of Discharge: 03/30/----
Admitting Diagnosis: Ectopic pregnancy
Surgical Procedure:
1. Exploratory Laporotonomy
2. Partial Salpingectomy
3. Evacuation of Hemoperitoneum
4. Lysis of Adhesion
Complications: Blood test requiring transfusion x2
HISTORY: This 35-year old white female gravida 3, para 1-0-2-1 had her last menstrual period in early January prior menstrual cycle had been regular to report using no contraception but not attempting pregnancy. Patient presented to the emergency room complaining a vaginal bleeding with pain in a lower pelvic area. Ultrasound preform in an emergency room pseudode 13.8 cm left at adnexal mass with positive cardiac activity compatible with ectopic pregnancy.
HOSPITAL COURSE: On March 27 the patient underwent explotory laparotomy. Left partial Salpingectomy, evacuation of hemoperitoneum and lysis of adhesion. Blood lost was approximately 1,000 ml and was replaced with transfusion of 2 units of red blood cells. Her blood type was noted to be O Rh-negative and RhoGam was provided. The patient was discharged on post-operative day number 3 after having had a normal bowel movement. She was discharge without complaints on no medication. She understood her instruction regarding follow up incision care and limitation of activities.
_____________
Rose Mary Bumbak M.D
OB/GYN
RB: xx
D: 03/30/----
T: 03/30/----