348301810
CTMC
65055310
421501
2/19/1991 12:00:00 AM
Discharge Summary
Unsigned
DIS
Admission Date :
02/19/1991
Report Status :
Unsigned
Discharge Date :
02/25/1991
ADMISSION DIAGNOSIS :
ENDOMETRIAL CANCER .
OPERATION :
Total abdominal hysterectomy , bilateral salpingo oophorectomy 2-19-91 by Dr. Lako Coma .
HISTORY OF PRESENT ILLNESS :
This is an 81-year-old who presented with postmenopausal spotting and had an endometrial biopsy which was read at the Etearal Etsystems/ Hospital as showing grade I adenocarcinoma .
Accordingly she presents for operative therapy at this time .
PAST MEDICAL HISTORY :
Negative .
PAST SURGICAL HISTORY :
None .
MEDICATIONS :
None .
ALLERGIES :
None .
PHYSICAL EXAMINATION :
She is somewhat obese elderly female .
HEENT unremarkable .
Lungs clear .
Abdomen obese , no scars .
Pelvic exam showed a small mobile uterus .
Extremities show no edema .
LABORATORY DATA :
All within normal limits .
HOSPITAL COURSE :
The patient was brought to the Operating Room on 2-19-91 where she had an exploratory laparotomy , TAH / BSO , and omental biopsy .
She had a normal abdominal exploration of a small uterus with superficial invasion on gross examination , normal ovaries .
Washings were sent .
A subfascial J-P was left .
The patient did well postoperatively and had a regular diet by the third postoperative day .
Subfascia drain was discontinued .
The patient 's postoperative Hct was 34 .
DISPOSITION :
She will have follow-up with Dr. Lako Coma .
YM263/3597 LAKO C. COMA , M.D. TH0
D :
02/25/91
Batch :
4620
Report :
A5427C65
T :
02/27/91
Dicatated By :
TA K. JESC , M.D.