Outpatient Summary Sample:
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|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 enlarged. The 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.
FINAL DIAGNOSIS: Menometrorrhagia.