Outpatient Summary Sample:

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OUTPATIENT SUMMARY

DATE OF SURGERY:  07/25/10
DATE OF DISCHARGE: 07/25/10 


REASON FOR ADMISSION:  This is a 36-year-old female who was admitted to the hospital as an outpatient for D&C because the patient had been having irregular vaginal bleeding between her menstruations. 

HISTORY:  By history, she underwent in 2006 a previous D&C for the same reason. 

PHYSICAL EXAMINATION:  Heart and lungs are within normal limits.  Breasts:  No masses, somewhat enlargedThe uterus was somewhat enlarged.  

ALLERGIES:  The patient denies any drug allergies.   

SURGICAL HISTORY:  The patient has a history of tubal sterilization and tubal ligation.

At the time of this examination the patient provided normal pregnancy test that was negative. 

HOSPITAL COURSE:  On admission a D&C carried out with no complications. 

DISCHARGE INSTRUCTIONS:  The patient was discharged the day of the procedure to be seen in the office within a week.   

OPERATION:  D&C.

FINAL DIAGNOSIS:  Menometrorrhagia.