How to Answer Case Discharge Summary Questions (Complete Guide)
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Original Question
CASE 11-2E Discharge Summary LOCATION: Inpatient, Hospital PATIENT: Gladys Hardy PRIMARY CARE PHYSICIAN: Ronald Green, MD ATTENDING PHYSICIAN: Ronald Green, MD PRINCIPAL DIAGNOSES: 1. Endometrial uterine adenocarcinoma 2. Porcelain gallbladder POSTOPERATIVE DIAGNOSIS: Wolff-Parkinson-White syndrome OPERATIVE PROCEDURE: Hysteroscopy with fractional dilatation and curettage converted to a total abdominal hysterectomy with bilateral salpingo-oophorectomy, open cholecystectomy, lysis of adhesions, open biopsy frozen section of ovary and fallopian tube, arterial line insertion, and postoperative fluid overload. CONSULTANTS:Drs. Martinez, Sanchez, White, and Orbitz. IDENTIFICATION HISTORY OF PRESENT ILLNESS:The patient had preoperative history and physical by Dr. Green. PREOPERATIVE GYN NOTE:The patient is a 62-year-old white female, gravida 2, para (to bring forth) 2, who is postmenopausal with postmenopausal bleeding. Pap smear 11/03. Mammogram unknown. REASON FOR THE VISIT:The patient had a chief complaint of postmenopausal bleeding. Evaluation by Dr. Monson (radiology), including pelvic ultrasound, demonstrates the uterus to be enlarged for age with multiple calcifications suggesting residuals of prior fibroid and thickened endometrium with what appears to be a 3.2 × 3.3 × 2.3-cm (centimeter) solid mass in the endometrium with some surrounding fluid. Differential diagnoses are endometrial polyp, localized hyperplasia, and even malignancy. Endometrial sample for further evaluation is highly recommended. The right ovary is normal size and texture. The left ovary is not well visualized, probably due to atrophy. MEDICATIONS: Multivitamins and calcium MEDICAL PROBLEMS: None ILLNESSES: None INJURIES: None SURGERY: None ALLERGIES: No known drug allergies TOBACCO: None. ALCOHOL: None. SOCIAL HISTORY: The patient is a retired bookkeeper. FAMILY HISTORY: Positive for colon cancer, breast cancer, and heart disease. REVIEW OF SYSTEMS: The patient is positive for eyeglasses, arthritis of left shoulder, the above genitourinary findings, pelvic relaxation, stress urinary incontinence, and postmenopausal bleeding. EXAMINATION:Blood pressure is 110/68. Height: 631/2 inches. Weight: 138 pounds. Neck is supple. Nonpalpable thyroid. Breasts negative for masses, discharge, or tenderness. Breasts are symmetrical. Pelvic: Adult female genitalia, marital clean vagina. Cervix multiparous. Adnexa negative. Rectal: Deferred. BUS (Bartholin’s, urethra, and Skene’s glands) within NORMAL LIMITS. Some pelvic relaxation is noted. IMPRESSION:Postmenopausal bleeding with abnormal pelvic ultrasound and symptomatic pelvic relaxation. HOSPITAL COURSE: During the hysteroscopy and D&C (dilation and curettage), it was noted that there was perforation of the uterus, at which time the procedure was converted to a total abdominal hysterectomy and bilateral salpingo-oophorectomy. During that time there was noted to be a gelatinous mass posterior to the uterus, which was sent to pathology. At the time of frozen-section pathologic evaluation, it was determined that the endocervical curettings were benign endocervical mucosa. Uterus, left fallopian tube, and ovary resection with endometrial adenocarcinoma endometrioid-type: Predominantly grade 1 with focal areas of FIGO (International Federated Gynecological Oncology) grades 2 and 3 with focal invasion limited to the inner third of the myometrium. Left ovary and fallopian tube resection: No pathologic diagnosis. Multiple intramural and subserosal leiomyomata showing extensive hyalinization with focal calcification. Focal adenomyosis: Myometrium, benign. Right ovary and fallopian tube: Portion of benign ovary and fallopian tube. Gallbladder excision: Extensive calcification of the gallbladder. The cytologic washings returned atypical cells; cannot rule out malignancy. The hospital course continued with the patient developing problems with fluid overload, at which time Dr. Orbitz (nephrology) was consulted, and he determined that the patient had Wolff-Parkinson-White syndrome, which was aggravated by the stress of surgery. The patient also had frequent episodes of atrial fibrillation and was anticoagulated, and he thought she should remain anticoagulated until she was further evaluated in 4 to 6 weeks. She was discharged on Toprol XL 100 daily, and he thought she should stay on the beta-blocker indefinitely. She should also have a Holter monitor done in 4 to 6 weeks. Then if she is in sustained sinus rhythm at that time, it would be reasonable to remove the anticoagulation. The patient was discharged postoperative day 8 with instructions to return to the clinic in 1 week for incision check and in 4 weeks for postoperative evaluation. A consultation was arranged with oncology, who felt that she would not require additional treatment; yet they recommend a cautious approach with obtaining imaging studies, CT (computerized tomography) scan of the pelvis and abdomen every 3 months times 1 year. The patient was not willing to proceed with any aggressive treatment at the time of discharge. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg (milligram) q.12h. 2. Coumadin 1 tablet q.d. (every day) at 1 PM 3. Tylenol p.r.n. (as needed) This narrative discharge summary is being sent to Dr. White to render an opinion regarding recommendations about further treatment for this cancer relative to perforation of the uterus at time of D&C hysteroscopy (tumor cells spilled into abdomen). We will also send copies of the cytology and slides for that evaluation. I spent a total of 45 minutes providing this discharge service for this patient. SERVICE CODE(S): ICD-10-CM DX CODE(S):
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