Discharge Summary
R-5
Elijah Hanna PA-S
Lock Haven University PA Program
11-28-12
Name: ***** ********
MRN: ********
Race & Gender: Caucasian Female
Insurance: Geisinger Gold
Date Of Birth: 10/4/1950
Date: 11/28/12
Admission Date: 11/27/12
Discharge Date: 11/28/12
Admitting Diagnosis: Right Total Mastectomy, Right Axillary Dissection and
Immediate Right Breast Reconstruction for Right Breast Invasive Ductal Carcinoma
Discharge Diagnosis:
 Principal Discharge Diagnosis: Right Total Mastectomy and Right Axillary
Dissection for Right Breast Invasive Ductal Carcinoma with Immediate Right
Breast Reconstruction secondary to Right Total Mastectomy
 Other Discharge Diagnoses Addressed: None
Consultants:
 GMC Plastic Surgery, Dr. Desantis MD
 GMC Oncology, Dr. Khalil MD
 GMC Care Management, John DeLuca CMC
Procedures: Right total mastectomy and right axillary dissection performed by Dr.
Evans with assistance from Sue Krum PA-C and Elijah Hanna PA-S on 11/28/12. The
patient then underwent immediate right breast reconstruction with a breast
expander implant by the plastic surgery team headed by Dr. Desantis MD. The
patient was put under general anesthesia and intubated by Dr. Zi Lang MD, and
supervised by Amanda Feree CRNA with no complications. The patient had a Foley
catheter placed in a sterile fashion by circulating nurse Evelynn Bowers RN with no
complications. The patient was given 2g IV Ancef 1 hour prior to incision for
infection prophylaxis. The initial right total mastectomy and right axillary dissection
took a total time of 95 minutes, and the right breast reconstruction took a total time
of 70 minutes. Two Blake drainage tubes were placed in the right breast with
external grenade collection bulbs. The patient was stable throughout the entire
procedure, ventilating without assistance 5 minutes after the procedure, extubated
without complications, and had adequate pain control in the immediate postoperative monitoring. Blood loss was minimal and the patient was
hemodynamically stable.
Complications: None
History & Hospital Course: Mrs. ******** is a 62-year-old Caucasian female that
was diagnosed with right invasive ductal carcinoma and right axillary nodal
involvement. The patient presented to her PCP, Dr. Thomas J. Hood MD, for a routine
office visit on 10/18/12. Upon breast exam Dr. Hood felt a mass in the upper outer
quadrant of the right breast. Her last mammogram was on 8/22/11 and read as
benign with no new or suspicious masses, and recommended repeat mammogram
in 12 months. She was then referred to our General Surgery Department to see
breast specialist Dr. Evans on 10/25/12. The patient underwent open excision
biopsy and intra-operative sentinel lymph node mapping on 11/4/12 revealing
right breast Invasive Ductal Carcinoma with right axillary nodal involvement by
pathology. The patient was informed of her diagnosis, treatment options, possible
risks and benefits of the treatment options, and referred to plastic surgery to talk
about breast reconstruction. The patient elected to undergo right total mastectomy,
right axillary dissection, and immediate right breast reconstruction with an interval
breast expander implant on 11/28/12. The patient was referred to our Oncology
Department to see Dr. Khalil to discuss possible chemotherapy and radiation
intervention. The patient was admitted on 11/27/12 and underwent the procedure
described above under the General Surgery and Plastic Surgery departments headed
by Dr. Evans and Dr. Desantis respectively on 11/28/12. The patient tolerated the
procedure well with no complications. In & Out Surgery monitored the patient postoperatively with no complications. Pain was adequately controlled, vital signs were
stable, clear liquids and soft foods were tolerated, urine output was normal, 1
normal bowel movement was confirmed, and the patient was discharged to home on
11/28/12.
Discharge Plan:
 Condition Upon Discharge: A&O x’s 3 in stable condition with adequate
pain control.
 Discharged To: Home
 Treatment/Services: Patient is instructed to start, continue, and
discontinue medications as seen below. Patient will follow up with Dr. Evans
(General Surgery), Dr. Desantis (Plastic Surgery), and Dr. Khalil (Oncology) in
one week here at GMC. PCP, Dr. Hood, will see the patient on Friday,
11/30/12, and was contacted by Dr. Evans about the patient’s admission
course already.
 Activity: Patient instructed to rest for the next 24 hours. Then encouraged to
ambulate regularly as tolerated with minimal (<5 lbs.) right arm exertion
until follow up and instruction in 1 week. No motor vehicle operation for at
least one week, and beyond if still requiring narcotic analgesia.
 Diet: Normal well-balanced diet as tolerated. Protein intake is encouraged at
45-55 grams/day, or 35% of total caloric intake to promote incision wound
healing. If any complications are encountered, encouraged to contact PCP
immediately.


Education: Patient is aware of medication regimen, activity instructions, diet
recommendations, and follow-up appointments as noted above. Instructed to
measure, document and empty drainage bulbs two times a day or less
depending on the amount of drainage. Informed that it is normal for a small
amount of drainage to occur around drainage tube, and drain sponges should
be changed daily as needed. It is normal for their to be >100 mL of drainage
in the week following surgery, but the drainage should continue to decrease
every two to three days. Once the drainage is <30 mL they may be removed
by the general or plastic surgery departments. Instructed to change dressings
daily with “burn pads” folded in triangles and ABD pads along side of the
breast. The incisions were sealed with Dermabond which usually takes about
2 weeks to fall off spontaneously, and should not be peeled off. There should
be no ointments applied to the incision without instruction from a health
care provider. Surgical bra should be in place at all times for 4-6 weeks and
will be discussed at each follow-up visit. Activity restrictions will also be
discussed each week, and generally will have limitations for up to 6 weeks
post-operatively. Patient can expect a swollen and bruised breast for the first
two weeks, but should continue to decrease daily/weekly. Appetite is
sometimes effected do to general anesthesia initially, but should return to
normal within the first week of discharge. Constipation is a common
complication to anesthesia and narcotic analgesia. An over the counter stool
softener can be tried if this is experienced, and if no improvement is seen the
PCP or general surgery can be contacted. Pain is expected post-operatively,
should continue to decrease daily, and narcotic analgesia is generally
required for up to two weeks PRN. If there is any excessive bleeding, fever
greater than 101 F, persistent nausea and vomiting, redness, swelling, puslike drainage, or pain not relieved by pain medication general surgery should
be contacted immediately.
Date Of Next Appointment: 11/30/12 with PCP Dr. Hood. 12/5/12 with Dr.
Evans (General Surgery), Dr. Desantis (Plastic Surgery), and Dr. Khalil
(Oncolgy).
Medications At Discharge:
 Start Taking These Medications:
1. Keflex 500 mg PO Caps, 1 capsule by mouth QID (4 x’s/day) until
drain is removed.
Patient had no allergies and has taken Keflex before with no
complications. If any hives, difficulty breathing, or complications are
experienced after taking a dose it should be discontinued and
immediate health care intervention should ensue.
2. Endocet 5-325 mg PO Tabs, 1 tablet by mouth every 4-6 hours as
needed for pain.
Patient has taken narcotic analgesics and Endocet before with no
complications. Constipation is a common side effect, and intervention
should be carried out as noted above. Should not operate any motor
vehicle or heavy machinery while taking medication. Should not
exceed the dose prescribed above.

Continue These Medications:
1. Esgic 50-325-40 mg PO, 2 tablets by mouth at onset of headache, then
1 tablet every 4 hours as needed, no more than 5 tablets in 24 hours.
2. ICAPS Plus PO Tablets, Daily
3. Claritin 10 mg PO Tablets, Daily as needed
4. Effexor XR 75 mg PO, 1 capsule by mouth once daily
5. Mobic 15 mg PO Tablets, 1 tablet by mouth daily as needed for pain
6. Vitamin D 1000 U PO Capsules, 1 capsule by mouth daily
7. Fish Oil 1000 mg PO Capsules, 1 capsule by mouth daily
8. Ribovlavin 100 mg PO Capsules, 4 capsules by mouth daily

Stop Taking These Medications: None
Issues To Be Addressed At Follow-Up:
 Drain Output; if <30 mL daily for a week the drains may be removed.
 Pain Control; assess need for dose adjustment, complications or
discontinuation.
 Incision; assess for any possible infection, separation, or complications.
 Oncologist Recommendations; likely chemotherapy and radiation
intervention
 Plastic Surgery; interval breast implant expansion and wound assessment.
CC:
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

PCP- Dr. Thomas Hood MD
Plastic Surgery- Dr. Desantis MD
Oncolgy- Dr. Khalil MD
Elijah Hanna PA-S
(11/28/12)