wiliam sepulvado · web viewbowel prep and preoperative antibiotics and heparin prophylaxis tonight...
TRANSCRIPT
Patient Name DOB: 09/17/YYYY
Talcum Case Review
Case Report
Parameter Findings PDF Ref
First name XXXX 13
Initial R
Last name XXXX
DOB 09/17/YYYY
Gender Female
Documentation of Talc
Usage in medical records
(Yes/No)
No
Brand of talcum powder
used
Not available
Diagnosed with Ovarian
Cancer?
Yes –Right ovary dysgerminoma 17,16,15
Date of Diagnosis 02/18/YYYY (Per available medical records)
*Reviewer’s comment: Upon review of available records, we note
patient was admitted on 02/18/YYYY for the surgical treatment of
ovary dysgerminoma. Prior medical records are not available to
know the exact date of diagnosis
8-9
Stage of Cancer Not known
Metastases (If any) As per the pathology report (Dated 02/19/YYYY), no evidence of
metastasis
15
Other risk factors for
ovarian cancer (hormonal
therapy, obesity, fertility
medications)
Not available
Treatment for Ovarian 02/19/YYYY: Exploratory laparotomy, right oophorectomy, 10-11
1 of 16
Patient Name DOB: 09/17/YYYY
Parameter Findings PDF Ref
cancer appendectomy, pelvic aortic node sampling and partial
omentectomy
Physical side effects of
cancer treatment
None
Other Complications
(Talcosis/Respiratory
problems)
None
Death from Ovarian
cancer?
No
Smoking history Has she ever been a tobacco user? Yes 8
Period of time smoking: Not available
Heaviness of smoking: One or two in a month
Brand of cigarettes smoked: Not available
Has she quit smoking? Not available
When did she quit? Not available
Condition of the patient
per last available record
As on 02/27/YYYY, patient was discharged to home without any
complaints following hospitalization for the surgical treatment of
ovary dysgerminoma. Prescriptions given for Darvocet, Ferrous
Gluconate and Colace with instruction to follow up with Dr.
XXXXXX, M.D. after one month
Reviewer’s comment: Medical records after 02/27/YYYY are not
available to know the condition of the patient post surgical
management of ovarian cancer.
7, 3
Patient History (As on
02/18/YYYY)
Past Medical History: No significant illnesses.
Prior Surgeries: Non-contributory.
Family history: Not available
Allergies: No known drug allergies.
8
2 of 16
Patient Name DOB: 09/17/YYYY
Missing Medical Record:
What Records
are Needed
Hospital/
Medical Provider
Date/Time
Period
Why we need the
records?
Is Record
Missing
Confirmatory or
Probable?
Hint/Clue that records are
missing
Office visits and
diagnostic studies
for abdominal
complaints
Unknown
Prior to
02/18/YYY
Y
To know the exact
date of diagnosis
and also
treatments
underwent for
abdominal
complaints
Confirmatory
Per operative report dated on
02/19/YYYY, We have noted
that patient went to Gynecologist
for her complaints and had
diagnostic studies for the same
Medical records Unknown
After
02/27/YYY
Y
To know the post
operative
condition of the
patient
Confirmatory
Discharged on 02/27/YYYY
with instruction to follow up
with Dr. XXXXXX, M.D. after
one month
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Patient Name DOB: 09/17/YYYY
Detailed Chronology
DATE PROVIDER OCCURRENCE/TREATMENT PDF REF*Reviewer’s Comments:
As per available medical records, we do not have any evidence to suggest that patient used talcum powder.
Medical records prior to 02/18/YYYY are not available to know the abdominal complaints of the patient and its corresponding office visits.
02/18/YYYY
XXXXXX Health
XXXXXX, M.D.
Admission for surgical treatment of a probable dysgerminoma:
Chief complaint: Patient presents for surgical treatment of a probable dysgerminoma.
History of presenting illness: She initially presented to a chiropractor for chronic back pain approximately two months ago and after several weeks of treatment she noted increased abdominal girth and one particular area which was firm and slightly tender in her lower abdomen. Over the last month this mass has become much larger extending to the umbilicus. It is sometimes tender to palpation and does cause her some abdominal pains related to activity and she has noted increased bladder pressure with urgency over the last week or so.
*Reviewer’s comment: Corresponding chiropractic records are not available for review to know the diagnosis and treatment rendered for chronic back pain.
Preoperative workup showed an elevated Lactate Dehydrogenase (LDH) at 4574 with an Alpha-Fetoprotein (AFP) of less than 30 and a Human Chorionic Gonadotropin (HCG) of less than 10. Chest X-ray and CAT Scan results are not available.
*Reviewer’s comment: Corresponding labs reports of LDH, AFP and HCG are not available for review.
Physical examination:Abdomen: Soft and nontender except for a mass which extends from the symphysis to the umbilicus. It appears to be somewhat mobile and is mildly tender.Neurological: Cranial nerves II—XII are grossly intact. She is pleasant and cooperative although somewhat anxious about her hospitalization. Deep tendon reflexes and patellar reflexes 4+ with one beat of clonus
8-9, 25-26
4 of 16
Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REFappreciated.
Impression: Patient with probable dysgerminoma, here for surgical treatment.
Plan: Bowel prep and preoperative antibiotics and Heparin prophylaxis tonight and she will present to the Operating Room in the morning for unilateral salpingo oophorectomy and possible total abdominal hysterectomy and bilateral salpingo oophorectomy.
02/18/YYYY
XXXXXX Health
Labs:Urinalysis:
Parameter ResultsBlood 3+RBC 8-12
CBC:Test Result Reference RangeWBC 4.46 (Low) 4.5-13.5 x103
RBC 3.78 (Low) 4.2-5.4 x106
HGB 10.5(Low) 12.0-16.0 gm/dLHCT 33 (Low) 37-47%
Segmented neutrophil
63.7 (High) 30-60%
37, 35
02/19/YYYY
XXXXXX Health
XXXXXX, M.D.
Operative Report of laparotomy, right oophorectomy, appendectomy, pelvic aortic node sampling and partial omentectomy:
Pre and postoperative diagnosis: Germ cell tumor, Ovary
Anesthesia: General
Procedure performed: Exploratory laparotomy, right oophorectomy, appendectomy, pelvic aortic node sampling and partial omentectomy.
Preoperative Problems & Preparations: The patient is a 20-year-old female who gives a history of increased size of the lower abdomen over the past month or so. The patient obviously has a large pelvic tumor extending up to the umbilicus. Just for the record’s sake, the tumor has been virtually asymptomatic except increased size of the lower abdomen with clothes being tight.
The patient’s Gynecologist verified this clinically by examination, ultrasound and CT scan.
10-11
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REF
*Reviewer’s comment: The corresponding Gynecological visits and the Ultrasound and CT scan reports are not available to note the abdominal symptoms and its findings.
After examining the patient, I had a very lengthy discussion with the patient and her family indicating that this is in all probability a germ cell tumor of the ovary and this will be best treated by conservative surgery if at all possible. I explained to the patient that it might be necessary to do a Total Hysterectomy and Bilateral Salpingo-Oophorectomy (THBSO) if we got into bleeding problems and it was unavoidable or if this turned out to another tumor that required this form of therapy. However, in all probability, we would do conservative surgery removing one ovary, sampling lymph nodes and the patient my require chemotherapy. The risk factors concerning this problem have been discussed with the patient and the family and they fully understand them, especially injury to any of the surrounding structures intraoperatively. By that, I mean any structures that surround the uterus or are in close proximity to the uterus or the ovary. Postoperatively, the patient may have fatal embolism, postoperative infection, hemorrhage, bowel obstruction, etc. The patient fully understands this.
Description of Procedure: Under general anesthesia, the patient is prepped and draped in the usual sterile manner. Through a low midline incision, the peritoneal cavity was entered. There was only about 10-15 cc of acitic (Must be ascitic) fluid present, but it was aspirated for cytologic purposes. The pathology encountered was a large tumor filling the pelvis and upper and lower abdomen. It extended from the right to the left side. The tumor did originate from the right ovary. There was no recognizable ovarian tissue left. The tumor was approximately 20 cm in greatest diameter. The right tube was normal. There were no adhesions. The tumor had a smooth lobulated surface, dull gray and dull pink in color. The opposite tube and ovary were normal. The uterus was normal in size. Pelvic abdominal exploration was essentially negative, especially the pelvic and aortic node bearing areas. On the right side, the infundibulopelvic ligament was clamped, cut and the pedicle ligated with Chromic 1 catgut and relegated. The remaining connections with the uterus were very easily removed by clamping with a Heaney clamp and excising the tumor. The tumor was sent down to pathology and the path report came back dysgerminoma. With this present, the retroperitoneal space was opened on both sides and pelvic node sampling was carried out involving the iliac vessels, obturator fossa. Small, medium and large hemoclips were used for lymphatic and hemostasis. At the completion of
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REFthe procedure, the retroperitoneal space was irrigated. The anatomy was found to be intact including the genitofemoral nerve, obturator nerve, large iliac vessels, the ureter. The retroperitoneal space was rinsed and on the right side was drained with a large Hemovac suction and brought out through the right lower quadrant of the abdomen. On the left side, it was extremely dry and it was closed with two or three interrupted Chromic catgut sutures leaving the spaces open so that any drainage could drain into the main peritoneal cavity. This was followed by-an incidental appendectomy. The bowel was packed out of the way and the peritoneum was opened over the bifurcation of the aorta up to the retroperitoneal duodenum. Lymph node sampling was carried out in the aortocaval area removing the fat pad 4x6 cm from the bifurcation to the retroperitoneal duodenum. Small and medium hemoclips were used for lymphatic and hemostasis. The retroperitoneal space was closed over Surgicel using Chromic 00 catgut.
As I said before, an incidental appendectomy had been carried out. This was followed by a partial omentectomy on a routine basis. Once again, the entire peritoneal cavity was examined and found to be intact. There were no enlarged nodes that could be palpated anywhere in the pelvis or in the aortic area.
With hemostasis secured and sponge count reported correct, the peritoneal cavity was rinsed and then closed using Chromic 0 to the peritoneum, Vicryl 1 in the anterior rectus sheath, metal clips in the skin. Postoperative condition is good. Blood loss negligible. The patient goes to the Recovery Room in stable condition.
02/19/YYYY
XXXXXX Health
Labs – CBC:Test Result Reference RangeRBC 3.32(Low) 4.2-5.4 x106
HGB 9.6 (Low) 12.0-16.0 gm/dLHCT 29.0 (Low) 37-47%
35
02/20/YYYY
XXXXXX Health
Progress note POD#1: (Illegible)
Vital signs stable. Temperature 100.6 last evening, now 100.Poor _______effortComplains of itching, does not want Patient Controlled Analgesics (PCA) discontinued
Examination: Lungs: Diffused rhonchiAbdomen: Soft, diffuse tenderness and negative bowel soundsIncision clean and dryExtremities: No tenderness
27
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REF
Labs: WBC: 8.45, hemoglobin/ hematocrit 9.6/29.0Pathology pending
Assessment/plan: Stable POD#1 Complains of itching with PCA – Benadryl Increased respiratory effort Increased activity
02/20/YYYY
XXXXXX Health
Labs – CBC:
Test Result Reference RangeRBC 3.16 (Low) 4.2-5.4 x106
HGB 9.3 (Low) 12.0-16.0 gm/dLHCT 28.1 (Low) 37-47%
Segmented neutrophil
63.7 (High) 30-60%
Lymphocyte 21.7 (Low) 25-50%
35
02/20/YYYY
XXXXXX Health
Post operative progress notes: (Illegible)@2045 hrs
Regarding: Temperature 101. 4 °F
Patient has been febrile all day. As per above poor ___ effort. Patient still on PCA and seems drowsy. May not be breathing deeply secondary to sedation. Has been up in chair thrice today. Not doing well with respirer.
Physical examination: Lungs clear to auscultation bilaterally with minimal bibasilar crackles. Cardiovascular regular rhythm with tachycardia. IV sites without erythema.
Impression/Plan: POD#0 fever Probable source is respiratory overmedication Will reduce PCA rate to 0.2 every 15 minutes Will increase Albuterol to every 4 hours around the clock Will obtain urinalysis and culture and sensitivity to rule out
Urinary Tract Infection (UTI). Discussed with Urogyn doctor
28
02/21/YYYY
XXXXXX Health
Labs – CBC:
Test Result Reference RangeRBC 3.22 (Low) 4.2-5.4 x106
HGB 9.4 (Low) 12.0-16.0 gm/dL
35
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REFHCT 28.4 (Low) 37-47%
Segmented neutrophil
83.6 (High) 30.60%
Lymphocyte 10.4 (Low) 25-50%02/21/YYYY
XXXXXX Health
XXXXXX, M.D.
POD#2 Progress note: (Illegible)
Patient complains of post operative pain and hot. (Ambient temperature in room probably >75°F)
Physical examination:Tmax 102.3 Overnight treated with aerosols. Morning labs pending.Temperature now 100.3°F BP 110/54Input 4200 output 2700 (JVAC 120 cc)Lungs: Few rales in __ no wheezesHeart: Regular Rate and Rhythm (RRR) without murmurAbdomen: Soft, ___ tender, negative bowel soundsSkin: Dry and intact without erythema. Drain site Okay
Assessment/plan: Post operative fever- if continues today would consider addition of antibiotics for broader spectrum
28
02/22/YYYY
XXXXXX Health
Labs –CBC:
Test Result Reference RangeRBC 3.42 (Low) 4.2-5.4 x106
HGB 10.0 (Low) 12.0-16.0 gm/dLHCT 30.2 (Low) 37-47%
Segmented neutrophil
83.3 (High) 30.60%
Lymphocyte 11.1 (Low) 25-50%
35
02/22/YYYY
XXXXXX Health
XXXXXX, M.D.
POD#3 Progress note: (Illegible)
Patient complains of nausea, emesis x2 yesterday. Positive bowel movements with diet cola.Afebrile. Vital signs stableAbdomen soft and few bowel soundsJVAC patent, 65 cc out in 24 hours
Labs: RBC 8.5, Hb 10.0 HCT 30.2 platelets 261
Assessment/plan:Nausea may secondary to DemerolWill prescribe per oral analgesia with Phenergan as needed
29
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REFWill give Dulcolax again todayDoubt ileusEncourage ambulation
02/23/YYYY
XXXXXX Health
Labs:CBC:
Test Result Reference RangeRBC 2.99 (Low) 4.2-5.4 x106
HGB 8.6(Low) 12.0-16.0 gm/dLHCT 26.3 (Low) 37-47%
Segmented neutrophil
75.7 (High) 30.60%
Lymphocyte 16.5 (Low) 25-50%
Chemistry: Test Result Reference Range
Potassium 3.1 (Low) 3.5-5.5 Meq/LBUN 3 (Low) 9-18 mg/dL
@0835 hrs BUN/Creatinine ratio
5 7-25
@2120 hrs BUN/Creatinine ratio
4 7-25
35, 36
02/23/YYYY
XXXXXX Health
XXXXXX, M.D.
Progress notes POD#4: (Illegible)
No complaints except labial edemaNausea resolved, Positive flatusAfebrile , vital signs stableUrine culture negative , CBC pendingAbdomen soft non tender and normal bowel soundsSkin dry and intactLeft labial edema markedNo erythema, lesions and drainageMinimally tenderJVAC approximately 100 cc over 24 hours
Assessment/plan:Doing wellLabial edema treated with sitz bath, ice and ambulationNo signs and symptoms of hematoma or infectionDiscontinued IV, Changed to Per oral Keflex with JVAC in bowel
___Advance diet
30
02/23/ XXXXXX X-Ray report of abdomen and PA chest: 40
10 of 16
Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REFYYYY Health
XXXXXX, M.D.
Impression: There is gaseous distention of the small bowel out of proportion to the large bowel and therefore suggestive of a small bowel obstruction.
02/23/YYYY
XXXXXX Health
Progress note:@1840 hrsAcute Abdominal Series (AAS) – Suspecting Small Bowel Obstruction (SBO), Marked air fluid levels of small bowel. No air in colonPatient reports nausea with bilious vomiting, Bowel movements X1 today. Small amount of flatus.Abdomen: Not tender non distended minimal (Hypoactive) Bowel sounds
Assessment/plan:SBO versus adynamic ileus – No reason for mechanical obstruction. Most likely with operative ileus. Will place Nasogastric. Keep NPO except ice chips. Repeat potassium tonight. Ask surgical Resident to review pulmonary.
30
02/24/YYYY
XXXXXX Health
Labs – Chemistry:
Test Result Reference RangePotassium 3.3 (Low) 3.5-5.5 Meq/L
36
02/24/YYYY(Signed date)
XXXXXX Health
XXXXXX, M.D.
Pathology Report:
Collected date: 02/19/YYYY
Tissue submitted: Pelvic and aortic node sampling, omental biopsy
Frozen section diagnosis: Germ cell tumor, consistent with a dysgerminoma.Gross:The specimens are submitted in nine containers.Container A: This specimen is an ovary, which has been completely replaced by a 17 x 8.5 x 11 cm tumor mass. The capsule of the ovary which is smooth, glistening, grayish white is intact and free of adhesions. Sectioned surfaces of the tumor mass are smooth, soft, and tan pink, with focal areas of hemorrhage and cystic degeneration, but no gross massive necrosis. A fallopian tube is not identified on the external aspect of the ovary. (Multiple sections including sections from the cystic and hemorrhagic areas.)Container B: Right obturator lymph nodes. Four lymph nodesContainer C: Right common iliac lymph node. Two lymph nodes.Container D: The specimen is a 7 cm. vermiform appendix, which is
17,16,15
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REFgrossly unremarkable on sectioning. (One section).Container E: Omentum biopsy. The specimen consists of an 8.5 x 4 x 2.5 cm. piece of omentum, the sectioned surfaces of which do not show any significant gross lesions. (Random sections).Container F: Right external iliac lymph node. One lymph node.Container G: Left obturator lymph nodes. Three lymph nodes.Container H: Left external iliac lymph nodes. Three lymph nodes.Container I: Aortic lymph nodes.Diagnosis:
Specimen A, right ovary, dysgerminoma (pure). Specimens B, C, F, G, H, I, lymph node groups, total of 16 lymph
nodes, no evidence of metastatic tumor Specimen D, vermiform appendix, a few peritoneal inclusion
cysts, serosal surface of the appendix. Specimen E, omentum, chronic inflammation and mesothelial
cell proliferations (no evidence of metastatic tumor) 02/24/YYYY
XXXXXX Health
Progress notes POD#5: (Illegible)
Patient with discomfort secondary to N6; labial edema improved but still with discomfort
Physical examination:Tmax 100°F Pulse 100’s otherwise stable vital signsAbdomen: Soft non tender, hyperactive bowel soundsIncision clean and dry intact without erythema. Labial edema decreased
Labs reviewedAssessment/plan:
POD#5, Patient still with decreased bowel sounds. Plan to continue N6___
Patient appears to be otherwise stableTachycardia to secondary to decreased Hb. Will follow. May need
transfusion if symptomatic
31
02/25/YYYY
XXXXXX Health
Labs:CBC:
Test Result Reference RangeRBC 3.13 (Low) 4.2-5.4 x106
HGB 8.8 (Low) 12.0-16.0 gm/dLHCT 27.7 (Low) 37-47%
Segmented neutrophil
78.6 (High) 30.60%
Lymphocyte 13.0 (Low) 25-50%
35, 36
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REFChemistry:
Test Result Reference RangePotassium 3.1 (Low) 3.5-5.5 Meq/L
BUN 3 (Low) 9-18 mg/dLBUN/Creatinine ratio 5 (Low) 7-25
02/25/YYYY
XXXXXX Health
POD#6 Progress note: (Illegible)@0835 hours
Patient with discomfort from N6, Otherwise no complaints.
Physical examination: Tmax 100.7°F, tachycardia, vital signs otherwise stable. 3900/3730 over 24 hours. N6 ____ guaiac negativeAbdomen: Soft, non tender and no bowel sounds noted. No erythema around incision. Incision clean, dry and intact achieved with staples. Labial edema resolved
Assessment/plan: Patient remains without bowel sounds – Plan to repeat AAS
possibly consult surgery if unchanged from 02/23 Continue N6 suction, patient unchanged from yesterday. JVAC drain discontinued per Dr. XXXX Pathology indicated dysgerminoma without no nodal
involvement.
32
02/25/YYYY
XXXXXX Health
XXXXX, M.D.
Ultrasound of Kidney, Ureter and Bladder (KUB):
Impression: The evidence of small bowel obstruction is no longer seen.
41
02/26/YYYY
XXXXXX Health
Labs:Test Result Reference RangeRBC 3.00 (Low) 4.2-5.4 x106
HGB 8.3 (Low) 12.0-16.0 gm/dLHCT 26.7 (Low) 37-47%
MCHC 31.3 (Low) 32-36 g/dLSegmented neutrophil
74.0 (High) 30.60%
Lymphocyte 16.4 (Low) 25-50%
Chemistry:Test Result Reference Range
Potassium 3.6 3.5-5.5 Meq/LBUN 3 (Low) 9-18 mg/dL
BUN/Creatinine ratio 6 (Low) 7-25
35, 36
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REF
Cardiac enzymes:Test Result Reference RangeLDH 305 (High) 118-242 U/L
02/26/YYYY
(Result date taken)
XXXXXX Health
N.XXXXXX, M.D.
Urine Culture report:Collected date: 02/18/YYYY
Final: No growth
38
02/26/YYYY
(Result date taken)
XXXXXX Health
N.XXXXXX, M.D.
Extragenital cytology report:Collected date: 02/19/YYYY
Sample: Peritoneal wash
Final: No malignant cells seen, RBC seen.
38
02/26/YYYY
XXXXXX Health
POD #7 Progress notes: (Illegible)
Patient much improved. N6 discontinued without complaints, positive bowel movementsTmax 100.6°F. vital signs stable. Input/ Output 1800/2000Incision clean/dry/intact with staples
Assessment/plan: Patient stable repeat AAS showed resolution of small bowel
obstruction N6 tube discontinued. Diet advanced Remove staples today
32
02/26/YYYY
XXXXXX Health
Progress note: (Illegible)
Skin chips outEating well and had bowel movementsSoft and regular diet and have to be followed by Resident in clinicNote: Explained necessity of close follow-up ___ and no more than 85%
33
02/27/YYYY
XXXXXX Health
XXXXXX, M.D.
POD#8 Progress note: (Illegible)
No complaints
Labs:LDH: 308-decreased from 4574 preop, Hgb 8.3
Assessment/plan:Home with Darvocet, Iron. Instructions given. Follow-up in 4 weeks
33
02/27/ XXXXXX Discharge Summary: 3
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REFYYYY Health
XXXXXX, M.D.
Admit date : 02/18/YYYY
Disposition: Home or self care
Final ICD9 diagnoses: Principle: 1830-Malignant neoplasm of ovary Final diagnosis: 2768-Hypopotassemia Final diagnosis: 9974-Gastrointestinal complication, not
elsewhere classified Final diagnosis: 5609-Small bowel obstruction
Procedure information: Unilateral Oophorectomy Excision or destruction of peritoneal tissue Biopsy of lymphatic structure Incidental appendectomy
Final diagnosis: Uterus and adnexa procedures for ovarian or adnexal malignancy.
02/27/YYYY
XXXXXX Health
Discharge Instructions:
Darvocet N-100 for every 4-6 hours as needed for pain Ferrous Gluconate 300 mg 3x day Colace 100 mg per oral daily No sex, no heavy lifting and shower
Follow up: In one month with XXXXXX, M.D.
Discharged condition: Discharged to home with family member via wheelchair.
*Reviewer’s comment: Medical records after 02/27/YYYY are not available to know the condition of the patient post surgical management of ovarian cancer.
7
02/18/YYYY-08/29/2016
XXXXXX Health
Hospitalization and other non-related records 59-61, 2, 48, 4, 5-6, 12-14, 19-24, 43-46, 47, 62-63, 64, 65, 66-68, 88-89, 90-91, 94-95, 97-98, 42, 1, 96, 69-87, 99-156,
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Patient Name DOB: 09/17/YYYY
DATE PROVIDER OCCURRENCE/TREATMENT PDF REF49-58, 92-93
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