915093496 RWH
0802338
045989
2923113
12/13/2002 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY
NAME :
GIENGBEENEA , NAA
UNIT NUMBER :
799-54-08
ADMISSION DATE :
12/13/2002
DISCHARGE DATE :
12/14/2002
ADMITTING DIAGNOSIS :
1. Undesired fertility .
2. Undesired adiposity .
HISTORY OF PRESENT ILLNESS :
The patient is a 30 -year-old Gravida III , Para II who presented desiring definitive surgical sterilization .
She was extensively counseled regarding other methods of birth control and desired to proceed with definitive surgical therapy .
In addition , the patient desired liposuction of varying areas as well .
The patient was consented for both procedures and brought to the Operating Room .
PAST MEDICAL HISTORY :
None .
PAST SURGICAL HISTORY :
Appendectomy at the age of 14 , open .
PAST OBSTETRIC HISTORY :
Spontaneous vaginal delivery x 2 .
PAST GYN HISTORY :
Regular menses , on Ortho-Tri-Cyclen .
No history of sexually transmitted disease , no history of domestic violence .
MEDICATIONS ON ADMISSION :
1. Ortho Tri-Cyclen .
ALLERGIES :
No known drug allergies .
PHYSICAL EXAMINATION :
Height 5 ' 1 " , weight 138 lb.
Blood pressure :
130/82 and heart rate 80 .
Breasts :
no masses .
Lungs :
clear to auscultation and percussion bilaterally .
Heart :
regular rate and rhythm , S1-S2 .
Abdomen :
soft , nontender , nondistended .
Extremities :
within normal .
Pelvic exam revealed normal vulva , vagina normal , cervix normal , uterus anteverted , small , nontender .
Adnexa :
no masses or tenderness .
Rectal :
deferred .
HOSPITAL COURSE AND TREATMENT :
The patient was admitted to the Operating Room where she underwent an unremarkable laparoscopic tubal ligation .
This was done with Falope rings .
The estimated blood loss was minimal and the patient received 600 cc. of intravenous fluid .
Of note , the patient had a negative urine pregnancy test prior to the surgery .
The patient then underwent liposuction of her abdomen , inner thighs , hips , flanks , chest and arms with Dr. Chain .
She did well and was admitted to the GYN Service postoperatively because the patient had persistent pain .
On postoperative day #one , she was then stable with no complaints .
She remained afebrile .
Her Foley was removed .
Her diet was advanced without difficulty and the patient was stable for discharge .
The patient was to follow up in several days time with Dr. Chain of the Plastics Clinic .
DISCHARGE MEDICATIONS :
Motrin and Percocet as needed .
PADA MARONNESSGRE CHAIN , M.D.
DICTATING FOR :
Electronically Signed PADA MARONNESSGRE CHAIN , M.D. 04/25/2003 09:50
_____________________________ PADA MARONNESSGRE CHAIN , M.D.
TR :
wwi
DD :
04/17/2003
TD :
04/18/2003 8:28 A 045989
cc :
PADA MARONNESSGRE CHAIN , M.D.