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Hysterectomy – Discharge Summary – 1

ADMISSION DIAGNOSES:
1. Menometrorrhagia.
2. Dysmenorrhea.
3. Small uterine fibroids.

DISCHARGE DIAGNOSES:
1. Menorrhagia.
2. Dysmenorrhea.
3. Small uterine fibroids.

OPERATION PERFORMED: Total vaginal hysterectomy.

BRIEF HISTORY AND PHYSICAL: The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries. She is having increasing menometrorrhagia and dysmenorrhea. Ultrasound shows a small uterine fibroid. She has failed oral contraceptives and surgical therapy is planned.

PAST HISTORY: Significant for reflux.

SURGICAL HISTORY: Tubal ligation.

PHYSICAL EXAMINATION: A top normal sized uterus with normal adnexa.

LABORATORY VALUES: Her discharge hemoglobin is 12.4.

HOSPITAL COURSE: She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia. Postoperatively, she has done well. Bowel and bladder function have returned normally. She is ambulating well, tolerating a regular diet. Routine postoperative instructions given and said follow up will be in four weeks in the office.

DISCHARGE MEDICATIONS: Preoperative meds plus Vicodin for pain.

DISCHARGE CONDITION: Good.

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