Summary Natasha Featherstone 10/15/1958

Patient Summary

MRP	Dr. Heart
Admit Date	Today
Primary Diagnosis	Stage 2A Ovarian Cancer Patient History: Approximately 6 months ago Natasha reported experiencing irregular vaginal bleeding, fatigue, changes in digestion and an increased urgency to urinate. Upon an internal pelvic exam, a mass was felt around her right ovary and her uterus was enlarged. An ultrasound located a large solid tumour (approx. 8cm in diameter) which had grown into the fallopian tube and the uterus thus is regarded as a stage 2A. We discussed treatment options and she has confirmed her decision to proceed with a total hysterectomy and bilateral salpingo-oophorectomy. She is aware of the potential risks and complications.
SECONDARY DIAGNOSES

Implanted Device	none
Blood Consent	Yes		Blood Type:	O+
Aggression	History of Violence: n/a		Physically Aggresive:
Behaviour	Verbally Aggresive:		Violence Prevention Toolkit:
Religion	unknown
OXYGEN	As per orders		SUCTION
SURGERY	Total Hysterectomy and Bilateral Salpingo-oopherectomy – operative report in Physician Reports
DRAIN	Foley catheter
WOUND	Abdominal incision
Isolation			Code Status:
Substance Use	unknown		Last Use:
Alcohol Use	unknown		Last Use:
Tabacco Dependence:		no	Last Use:
ALLERGIES	Reaction type:			Severity:
	Reaction type:			Severity:
	Reaction type:			Severity:
DIET	As per Enhanced Recovery After Surgery Post-Op order set

DIET	As per Enhanced Recovery After Surgery (ERAS) Post-Op Order Set
V S	DAY see records	Temp (F)	Pulse	Resp Rate	BP	O2
I & O	See records
FOLEY	Day		Night		DC date:
TUBES	Type:		Type:
IV Lines:	RL @ 75 cc/hr		Pain:	see PCA Protocol	Pain Level:	See PCA protocol
Collection:		Intake:		Output:
Pending Tests & Diagnostics:		Post-op days 1: CBC
Appointments:
Blood Glucose (Time/ Reading)		0500 in PAR- 5.2