425680098 SC
55925443
867222
8/7/1992 12:00:00 AM
Discharge Summary
Unsigned
DIS
Admission Date :
08/07/1992
Report Status :
Unsigned
Discharge Date :
08/10/1992
HISTORY OF PRESENT ILLNESS :
This is an 81 year old female with a right breast mass with a discharge .
A mammogram of the right breast with shadow biopsy was negative .
In the fall of 1991 , nipple changes and discomfort was again noted .
A mmamogram showed no change on right , but new biopsy was positive .
On the left , there was a new shawdown but the biopsy was negative .
The patient presents now for right modified radical mastectomy with impant .
PAST MEDICAL HISTORY :
Unremarkable .
MEDICATIONS ON ADMISSION :
None .
ALLERGIES :
No known drug allergies .
HABITS :
Smoked twenty years ago .
PHYSICAL EXAMINATION :
Clear lungs , normal heart , Pagett 's type changes on the right breast and left breast without apparent masses with scarring supra-areolar and infra-areolar .
A biopsy scar on the right breast from 1990 .
HOSPITAL COURSE :
The patient was taken to the Operting Room on 8/7/92 , where a right modified radical mastectomy was performed .
Subsequently a saline-filled right breast implant was performed .
The patient tolerated the procedure extremely well .
Two drains were used .
One drain was removed on postoperative day number two , and the second drain she will be discharged to home with .
DISPOSITION :
The patient is discharged to home in good condiiton .
Discharge medications include Percocet and Colace .
Folloowup is in one week with Dr. Ralekote .
DP337/1857 DETIASAIRE KAYSJARDUHE , M.D. PQ01
D :
08/08/92
Batch :
9736
Report :
J3725F1
T :
08/10/92
Dictated By :
LA JESCCOT , M.D. KC44