641557794 WGH
1460214
715884
957382
5/29/2000 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY
NAME :
FREIERMPRATL , NI L
UNIT NUMBER :
794-23-29
ADMISSION DATE :
05/29/2000
DISCHARGE DATE :
05/30/2000
PRINCIPAL DIAGNOSIS : :
Non-toxic multinodular goiter .
ASSOCIATED DIAGNOSES ;
Left thyroid occult papillary carcinoma .
Chronic lymphocytic thyroiditis , status post right total and left subtotal oophorectomy , asthma , migraine , history of Droperidol allergy .
PRINCIPAL PROCEDURE : :
5-29-00 :
Thyroidectomy .
HISTORY OF PRESENT ILLNESS :
The patient is a 51 year-old female , with a non-toxic multinodular goiter .
She has developed symptoms from a right lower dominant nodule with pressure discomfort in the neck .
She has no dyspnea or dysphagia .
She is euthyroid .
There is no family history of thyroid cancer .
She has not received prior radiation exposure .
PHYSICAL EXAMINATION : :
On physical exam , she is a healthy-appearing female with a normal voice and no exophthalmos .
Vital Signs :
include a blood pressure of 174/84 , respirations 14 , pulse 89 , temperature 98.9 , O2 sat 98% .
Pupils equal , round , reactive to light and accommodation , and extraocular movements intact . , with a benign oropharynx .
Palpation of the neck discloses a multinodular goiter , larger on the right side , with no associated cervical lymphadenopathy .
Carotid pulsations are normal without bruit .
Lungs :
clear to auscultation and percussion .
Bilaterally without stridor .
Her heart rhythm is regular with a normal S1-S2 , and no murmur .
Abdomen is soft , non-tender , with no organomegaly or masses .
Her deep tendon reflexes are symmetric .
HOSPITAL COURSE :
On 5-29-00 , she underwent thyroidectomy with removal of a 3.3 centimeter right lobe microfollicular adenoma and left lobe 6 mm .
papillary carcinoma .
There was no evidence of any middle compartment lymphadenopathy or spread of the tumor outside the thyroid .
She had an uncomplicated postoperative recovery period .
Her sutures were removed on postoperative day # one , at which time she went home in satisfactory condition .
DOCTOR 'S DISCHARGE ORDERS :
1. Synthroid 0.125 mg. daily .
2. She will see Dr. Days in his office in two weeks .
3. She will remove the neck suture lines Steri-Strips in 10 days .
STELLRISH L. LIGHT , M.D.
Cc :
Stellrish L. Days , M.D. ( 3 copies )
Electronically Signed STELLRISH LOISRA LIGHT , M.D. 09/06/2000 04:20
TR :
jrn
DD :
08/16/2000
TD :
08/20/2000 9:25 A
cc :
STELLRISH LOISRA LIGHT , M.D.