G.S.

HOSPITAL
Maternity, Infertility & Multi - Speciality Hospital

DISCHAllGE SUMMARY
'aticnt Na nw : MRS. n:YANTHI . AGE/ SEX : 40 / FEMALE

1otc of Admission :10-10-2018

•ate of SurgcT)' : 10-10-2018

I
•ate of Discharge : 14-10-20\8 WARD No :2~6

•ia&nosis : CARCINOMA LEFT BREAST T4b NI MO . I

roccdurc : LEFT MODIFlED RADICAL MASTECTOMY (LEFT MRM) DONE O~ 10-10-2018.

linical History :This lady is case of locally advanced carcinoma left breast treated by four ycles neo
Jjuvant chemotherapy. She had good response and admitted for surgery.

aticnt Conscious - Oriented CVS - Sl, S2

cmpraturc - Normal RS - Clear

ulse - 110 / mts Abdomen - Soft RS {+

p - 130 /90 mm Hg CNS - No FND I

I
ocal Exam : Left breast & axilla : 4 x 4 ems residual lump in central sector. Mobile l.5 cmi left axillary
ode+. '.

'ourse in the Hospitals : Patient admitted for LEF1' MODIFIED RADICAL MASTECTOIV Y (LEFT
IRM). Pre operative blood investigation within normal limits. lntrn op nnd post op, IV tlui s, IV
ntibiotics, and analgesics given. Under GA, Left Modified Radical Mnstcctomy (LEFT MR it) done.
'. ourse in hospital uneventful.

lperation Notes : Under GA, by a transverse elliptical incision rm · , ding the kft ni11pk - iu '-'O la :and ttu.·
1volved skin, thin skin flaps raised. The entire left breast with pcctcral fascia dissl'ctcd off ( l'Ctornlis
1ajor. Complete left axillary clearance of all three levels done, safc~!llltrding nll m·uro,·nscul ll' sh·m·turts.
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(aemostasis asccrtai.ned. Suction drain placed. Staples to skin. Counts vcrifkd.

,dvise on discharge :

• T. Clavmn 625 I bd x 5 dnys.

~ 1 (,,. .
0~ r.' ',
• T. Dolo 650 mg I bd x 5 dnys.

• C. Nutrolin R plus : 5 tiny,. " ' ,~

Consulting Doctor Dr.1.llnhu., M.ll., , ll•,_I .K.S~ 1~ •111, MS .. II .. (ON< 0)
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