Hospital: Fairbanks

Hospital, 1001 Noble St, Fairbanks, AK 99701

Name: Mrs Sally Fletcher
Date of Birth: 3/10/1993
Marital status: Married, 5 yearsAppointment date: 25/03/2018
Diagnosis: Endometriosis
Past medical history: Painful periods
years 3
Wants children, trying
++ year 1
.Social background: Accountant, regular western diet
Exercises 3 x week
local gym
Medical background: Frequent
.acute menstrual pain localised to the lower left quadrant
Pain persists despite taking OTC
.naproxen
.Shy discussing sexual history
,Occasional constipation
.associated with pain in lower left quadrant
Trans-vaginal ultrasound showing 6cm cyst, likely of
endometrial origin.Patient recovering post op from laparoscopic surgery
.nocomplications – )25/03/2018(
.Post op care: Keep incisions clean and dry
Showering is permitted 26/03/2018
.Mobility post op: Patient can ambulate if confident
.Driving is prohibited when on analgesics
Driving can be resumed 24-48 hrs after final dose
.analgesics
.Sexual activity can be resumed 2 weeks post op
Nursing
:management
.Encourage oral fluids
.Patient may return to regular diet
.Ambulation encouraged as per patient tolerance
Medical progress: Afebrile. Hct, Hgb, Plts, WBC, BUN, Cr, Na, K, Cl, HCO3, Glu all
within normal limits. Patient
,sitting comfortably
,alert
.oriented × 4 (person, place, time, situation)
Assessment: Good progress overall.Discharge plan: Patient to be discharged when can eat,
ambulate, urinate
.independently
Patient must be discharged to someone who can drive them
.home
Dr Stevens
Mill Street Surgery
Farnham
GU10 1HA

March 2018 25
,Dear Dr Stevens
Re: Mrs Sally Fletcher
D.O.B 3/10/1993

Your patient, Sally Fletcher, was admitted to the surgical ward of Fairbanks
Memorial Hospital on 25 March 2018 for the purpose of laparoscopic
surgery to treat an endometrial cyst. She is now ready for discharge into
.the care of her husband

When admitted, Sally had been suffering from painful periods over the past
years, which she had been attempting to treat with naproxen, but the 3
pain persisted. An ultrasound scan revealed a cyst had formed in her
abdomen. She arrived at the ward this morning and underwent
laparoscopic surgery, which successfully located and removed a 6cm cyst
.from her abdomen without complication

She has been advised to keep the incision sites clean and dry. She has
received narcotic pain medication and has been advised that she is unable
to drive while taking this medication. You should monitor her progress, and
advise when to cease taking this medication. She may resume driving 24-48
.hours after the last dose is taken

Sally may resume her normal diet today, and is encouraged to drink plenty
.of fluids. She is also encouraged to walk as much as she can tolerate
.Sexual activity can resume in two weeks
.If you have any questions please feel free to contact me

,Yours sincerely
Doctor