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Patient Name
DOB: 09/17/YYYY
Talcum Case Review
Case Report
Parameter
Findings
First name
XXXX
Initial
R
Last name
XXXX
DOB
09/17/YYYY
Gender
Female
Documentation of Talc
No
PDF Ref
13
Usage in medical records
(Yes/No)
Brand of talcum powder
Not available
used
Diagnosed with Ovarian
Yes –Right ovary dysgerminoma
17,16,15
02/18/YYYY (Per available medical records)
8-9
Cancer?
Date of Diagnosis
*Reviewer’s comment: Upon review of available records, we note
patient was admitted on 02/18/YYYY for the surgical treatment of
ovary dysgerminoma. Prior medical records are not available to
know the exact date of diagnosis
Stage of Cancer
Not known
Metastases (If any)
As per the pathology report (Dated 02/19/YYYY), no evidence of
15
metastasis
Other risk factors for
Not available
ovarian cancer (hormonal
therapy, obesity, fertility
medications)
Treatment for Ovarian
02/19/YYYY: Exploratory laparotomy, right oophorectomy,
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10-11
Patient Name
DOB: 09/17/YYYY
Parameter
cancer
Findings
PDF Ref
appendectomy, pelvic aortic node sampling and partial
omentectomy
Physical side effects of
None
cancer treatment
Other Complications
None
(Talcosis/Respiratory
problems)
Death from Ovarian
No
cancer?
Smoking history
Has she ever been a tobacco user? Yes
8
Period of time smoking: Not available
Heaviness of smoking: One or two in a month
Brand of cigarettes smoked: Not available
Has she quit smoking? Not available
When did she quit? Not available
Condition of the patient
As on 02/27/YYYY, patient was discharged to home without any
per last available record
complaints following hospitalization for the surgical treatment of
7, 3
ovary dysgerminoma. Prescriptions given for Darvocet, Ferrous
Gluconate and Colace with instruction to follow up with Dr.
XXXXXX, M.D. after one month
Reviewer’s comment: Medical records after 02/27/YYYY are not
available to know the condition of the patient post surgical
management of ovarian cancer.
Patient History (As on
Past Medical History: No significant illnesses.
02/18/YYYY)
Prior Surgeries: Non-contributory.
Family history: Not available
Allergies: No known drug allergies.
2 of 16
8
Patient Name
DOB: 09/17/YYYY
Missing Medical Record:
Is Record
What Records
Hospital/
Date/Time
Why we need the
Missing
Hint/Clue that records are
are Needed
Medical Provider
Period
records?
Confirmatory or
missing
Probable?
To know the exact
Office visits and
diagnostic studies
for abdominal
Unknown
complaints
date of diagnosis
Per operative report dated on
Prior to
and also
02/19/YYYY, We have noted
02/18/YYY
treatments
Y
underwent for
for her complaints and had
abdominal
diagnostic studies for the same
Confirmatory
that patient went to Gynecologist
complaints
After
Medical records
Unknown
02/27/YYY
Y
To know the post
operative
condition of the
patient
3 of 16
Discharged on 02/27/YYYY
Confirmatory
with instruction to follow up
with Dr. XXXXXX, M.D. after
one month
Patient Name
DOB: 09/17/YYYY
Detailed Chronology
DATE
PROVIDER
02/18/YYY XXXXXX
Y
Health
XXXXXX,
M.D.
OCCURRENCE/TREATMENT
*Reviewer’s Comments:
 As per available medical records, we do not have any evidence to
suggest that patient used talcum powder.
 Medical records prior to 02/18/YYYY are not available to know
the abdominal complaints of the patient and its corresponding
office visits.
Admission for surgical treatment of a probable dysgerminoma:
Chief complaint: Patient presents for surgical treatment of a probable
dysgerminoma.
History of presenting illness: She initially presented to a chiropractor
for chronic back pain approximately two months ago and after several
weeks of treatment she noted increased abdominal girth and one
particular area which was firm and slightly tender in her lower abdomen.
Over the last month this mass has become much larger extending to the
umbilicus. It is sometimes tender to palpation and does cause her some
abdominal pains related to activity and she has noted increased bladder
pressure with urgency over the last week or so.
*Reviewer’s comment: Corresponding chiropractic records are not
available for review to know the diagnosis and treatment rendered for
chronic back pain.
Preoperative workup showed an elevated Lactate Dehydrogenase (LDH)
at 4574 with an Alpha-Fetoprotein (AFP) of less than 30 and a Human
Chorionic Gonadotropin (HCG) of less than 10. Chest X-ray and CAT
Scan results are not available.
*Reviewer’s comment: Corresponding labs reports of LDH, AFP and
HCG are not available for review.
Physical examination:
Abdomen: Soft and nontender except for a mass which extends from the
symphysis to the umbilicus. It appears to be somewhat mobile and is
mildly tender.
Neurological: Cranial nerves II—XII are grossly intact. She is pleasant
and cooperative although somewhat anxious about her hospitalization.
Deep tendon reflexes and patellar reflexes 4+ with one beat of clonus
4 of 16
PDF REF
8-9, 25-26
Patient Name
DATE
DOB: 09/17/YYYY
PROVIDER
OCCURRENCE/TREATMENT
PDF REF
appreciated.
Impression: Patient with probable dysgerminoma, here for surgical
treatment.
02/18/YYY XXXXXX
Y
Health
Plan: Bowel prep and preoperative antibiotics and Heparin prophylaxis
tonight and she will present to the Operating Room in the morning for
unilateral salpingo oophorectomy and possible total abdominal
hysterectomy and bilateral salpingo oophorectomy.
Labs:
Urinalysis:
Parameter
Results
Blood
3+
RBC
8-12
37, 35
CBC:
02/19/YYY XXXXXX
Y
Health
XXXXXX,
M.D.
Test
Result
Reference Range
WBC
4.46 (Low)
4.5-13.5 x103
RBC
3.78 (Low)
4.2-5.4 x106
HGB
10.5(Low)
12.0-16.0 gm/dL
HCT
33 (Low)
37-47%
Segmented
63.7 (High)
30-60%
neutrophil
Operative Report of laparotomy, right oophorectomy,
appendectomy, pelvic aortic node sampling and partial
omentectomy:
Pre and postoperative diagnosis: Germ cell tumor, Ovary
Anesthesia: General
Procedure performed: Exploratory laparotomy, right oophorectomy,
appendectomy, pelvic aortic node sampling and partial omentectomy.
Preoperative Problems & Preparations: The patient is a 20-year-old
female who gives a history of increased size of the lower abdomen over
the past month or so. The patient obviously has a large pelvic tumor
extending up to the umbilicus. Just for the record’s sake, the tumor has
been virtually asymptomatic except increased size of the lower abdomen
with clothes being tight.
The patient’s Gynecologist verified this clinically by examination,
5 of 16
10-11
Patient Name
DATE
PROVIDER
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
ultrasound and CT scan.
*Reviewer’s comment: The corresponding Gynecological visits and the
Ultrasound and CT scan reports are not available to note the abdominal
symptoms and its findings.
After examining the patient, I had a very lengthy discussion with the
patient and her family indicating that this is in all probability a germ cell
tumor of the ovary and this will be best treated by conservative surgery if
at all possible. I explained to the patient that it might be necessary to do a
Total Hysterectomy and Bilateral Salpingo-Oophorectomy (THBSO) if
we got into bleeding problems and it was unavoidable or if this turned out
to another tumor that required this form of therapy. However, in all
probability, we would do conservative surgery removing one ovary,
sampling lymph nodes and the patient my require chemotherapy. The risk
factors concerning this problem have been discussed with the patient and
the family and they fully understand them, especially injury to any of the
surrounding structures intraoperatively. By that, I mean any structures
that surround the uterus or are in close proximity to the uterus or the
ovary. Postoperatively, the patient may have fatal embolism,
postoperative infection, hemorrhage, bowel obstruction, etc. The patient
fully understands this.
Description of Procedure: Under general anesthesia, the patient is
prepped and draped in the usual sterile manner. Through a low midline
incision, the peritoneal cavity was entered. There was only about 10-15 cc
of acitic (Must be ascitic) fluid present, but it was aspirated for cytologic
purposes. The pathology encountered was a large tumor filling the pelvis
and upper and lower abdomen. It extended from the right to the left side.
The tumor did originate from the right ovary. There was no recognizable
ovarian tissue left. The tumor was approximately 20 cm in greatest
diameter. The right tube was normal. There were no adhesions. The
tumor had a smooth lobulated surface, dull gray and dull pink in color.
The opposite tube and ovary were normal. The uterus was normal in size.
Pelvic abdominal exploration was essentially negative, especially the
pelvic and aortic node bearing areas. On the right side, the
infundibulopelvic ligament was clamped, cut and the pedicle ligated with
Chromic 1 catgut and relegated. The remaining connections with the
uterus were very easily removed by clamping with a Heaney clamp and
excising the tumor. The tumor was sent down to pathology and the path
report came back dysgerminoma. With this present, the retroperitoneal
space was opened on both sides and pelvic node sampling was carried out
involving the iliac vessels, obturator fossa. Small, medium and large
6 of 16
PDF REF
Patient Name
DATE
PROVIDER
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
hemoclips were used for lymphatic and hemostasis. At the completion of
the procedure, the retroperitoneal space was irrigated. The anatomy was
found to be intact including the genitofemoral nerve, obturator nerve,
large iliac vessels, the ureter. The retroperitoneal space was rinsed and on
the right side was drained with a large Hemovac suction and brought out
through the right lower quadrant of the abdomen. On the left side, it was
extremely dry and it was closed with two or three interrupted Chromic
catgut sutures leaving the spaces open so that any drainage could drain
into the main peritoneal cavity. This was followed by-an incidental
appendectomy. The bowel was packed out of the way and the peritoneum
was opened over the bifurcation of the aorta up to the retroperitoneal
duodenum. Lymph node sampling was carried out in the aortocaval area
removing the fat pad 4x6 cm from the bifurcation to the retroperitoneal
duodenum. Small and medium hemoclips were used for lymphatic and
hemostasis. The retroperitoneal space was closed over Surgicel using
Chromic 00 catgut.
PDF REF
As I said before, an incidental appendectomy had been carried out. This
was followed by a partial omentectomy on a routine basis. Once again,
the entire peritoneal cavity was examined and found to be intact. There
were no enlarged nodes that could be palpated anywhere in the pelvis or
in the aortic area.
02/19/YYY XXXXXX
Y
Health
02/20/YYY XXXXXX
Y
Health
With hemostasis secured and sponge count reported correct, the
peritoneal cavity was rinsed and then closed using Chromic 0 to the
peritoneum, Vicryl 1 in the anterior rectus sheath, metal clips in the skin.
Postoperative condition is good. Blood loss negligible. The patient goes
to the Recovery Room in stable condition.
Labs – CBC:
Test
Result
Reference Range
RBC
3.32(Low)
4.2-5.4 x106
HGB
9.6 (Low)
12.0-16.0 gm/dL
HCT
29.0 (Low)
37-47%
Progress note POD#1: (Illegible)
Vital signs stable. Temperature 100.6 last evening, now 100.
Poor _______effort
Complains of itching, does not want Patient Controlled Analgesics (PCA)
discontinued
Examination: Lungs: Diffused rhonchi
Abdomen: Soft, diffuse tenderness and negative bowel sounds
Incision clean and dry
7 of 16
35
27
Patient Name
DATE
PROVIDER
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
Extremities: No tenderness
PDF REF
Labs: WBC: 8.45, hemoglobin/ hematocrit 9.6/29.0
Pathology pending
02/20/YYY XXXXXX
Y
Health
02/20/YYY XXXXXX
Y
Health
Assessment/plan:
 Stable POD#1
 Complains of itching with PCA – Benadryl
 Increased respiratory effort
 Increased activity
Labs – CBC:
Test
Result
RBC
3.16 (Low)
HGB
9.3 (Low)
HCT
28.1 (Low)
Segmented
63.7 (High)
neutrophil
Lymphocyte
21.7 (Low)
Post operative progress notes: (Illegible)
@2045 hrs
35
Reference Range
4.2-5.4 x106
12.0-16.0 gm/dL
37-47%
30-60%
25-50%
28
Regarding: Temperature 101. 4 °F
Patient has been febrile all day. As per above poor ___ effort. Patient still
on PCA and seems drowsy. May not be breathing deeply secondary to
sedation. Has been up in chair thrice today. Not doing well with respirer.
Physical examination: Lungs clear to auscultation bilaterally with
minimal bibasilar crackles. Cardiovascular regular rhythm with
tachycardia. IV sites without erythema.
02/21/YYY XXXXXX
Y
Health
Impression/Plan:
 POD#0 fever
 Probable source is respiratory overmedication
 Will reduce PCA rate to 0.2 every 15 minutes
 Will increase Albuterol to every 4 hours around the clock
 Will obtain urinalysis and culture and sensitivity to rule out
Urinary Tract Infection (UTI). Discussed with Urogyn doctor
Labs – CBC:
Test
Result
8 of 16
Reference Range
35
Patient Name
DATE
PROVIDER
02/21/YYY XXXXXX
Y
Health
XXXXXX,
M.D.
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
RBC
3.22 (Low)
4.2-5.4 x106
HGB
9.4 (Low)
12.0-16.0 gm/dL
HCT
28.4 (Low)
37-47%
Segmented
83.6 (High)
30.60%
neutrophil
Lymphocyte
10.4 (Low)
25-50%
POD#2 Progress note: (Illegible)
PDF REF
28
Patient complains of post operative pain and hot. (Ambient temperature in
room probably >75°F)
Physical examination:
Tmax 102.3 Overnight treated with aerosols. Morning labs pending.
Temperature now 100.3°F BP 110/54
Input 4200 output 2700 (JVAC 120 cc)
Lungs: Few rales in __ no wheezes
Heart: Regular Rate and Rhythm (RRR) without murmur
Abdomen: Soft, ___ tender, negative bowel sounds
Skin: Dry and intact without erythema. Drain site Okay
02/22/YYY XXXXXX
Y
Health
02/22/YYY XXXXXX
Y
Health
XXXXXX,
M.D.
Assessment/plan:
Post operative fever- if continues today would consider addition of
antibiotics for broader spectrum
Labs –CBC:
35
Test
Result
RBC
3.42 (Low)
HGB
10.0 (Low)
HCT
30.2 (Low)
Segmented
83.3 (High)
neutrophil
Lymphocyte
11.1 (Low)
POD#3 Progress note: (Illegible)
29
Reference Range
4.2-5.4 x106
12.0-16.0 gm/dL
37-47%
30.60%
25-50%
Patient complains of nausea, emesis x2 yesterday. Positive bowel
movements with diet cola.
Afebrile. Vital signs stable
Abdomen soft and few bowel sounds
JVAC patent, 65 cc out in 24 hours
Labs: RBC 8.5, Hb 10.0 HCT 30.2 platelets 261
9 of 16
Patient Name
DATE
DOB: 09/17/YYYY
PROVIDER
02/23/YYY XXXXXX
Y
Health
OCCURRENCE/TREATMENT
PDF REF
Assessment/plan:
 Nausea may secondary to Demerol
 Will prescribe per oral analgesia with Phenergan as needed
 Will give Dulcolax again today
 Doubt ileus
 Encourage ambulation
Labs:
CBC:
Test
Result
Reference Range
RBC
2.99 (Low)
4.2-5.4 x106
HGB
8.6(Low)
12.0-16.0 gm/dL
HCT
26.3 (Low)
37-47%
Segmented
75.7 (High)
30.60%
neutrophil
Lymphocyte
16.5 (Low)
25-50%
35, 36
Chemistry:
02/23/YYY XXXXXX
Y
Health
XXXXXX,
M.D.
Test
Result
Potassium
3.1 (Low)
BUN
3 (Low)
@0835 hrs
5
BUN/Creatinine ratio
@2120 hrs
4
BUN/Creatinine ratio
Progress notes POD#4: (Illegible)
Reference Range
3.5-5.5 Meq/L
9-18 mg/dL
7-25
7-25
No complaints except labial edema
Nausea resolved, Positive flatus
Afebrile , vital signs stable
Urine culture negative , CBC pending
Abdomen soft non tender and normal bowel sounds
Skin dry and intact
Left labial edema marked
No erythema, lesions and drainage
Minimally tender
JVAC approximately 100 cc over 24 hours
Assessment/plan:
 Doing well
 Labial edema treated with sitz bath, ice and ambulation
 No signs and symptoms of hematoma or infection
 Discontinued IV, Changed to Per oral Keflex with JVAC in
10 of 16
30
Patient Name
DATE
PROVIDER
02/23/YYY XXXXXX
Y
Health
XXXXXX,
M.D.
02/23/YYY XXXXXX
Y
Health
02/24/YYY XXXXXX
Y
Health
02/24/YYY XXXXXX
Y
Health
(Signed
date)
XXXXXX,
M.D.
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
bowel ___
 Advance diet
X-Ray report of abdomen and PA chest:
PDF REF
40
Impression: There is gaseous distention of the small bowel out of
proportion to the large bowel and therefore suggestive of a small bowel
obstruction.
Progress note:
@1840 hrs
Acute Abdominal Series (AAS) – Suspecting Small Bowel Obstruction
(SBO), Marked air fluid levels of small bowel. No air in colon
Patient reports nausea with bilious vomiting, Bowel movements X1
today. Small amount of flatus.
Abdomen: Not tender non distended minimal (Hypoactive) Bowel
sounds
30
Assessment/plan:
SBO versus adynamic ileus – No reason for mechanical obstruction. Most
likely with operative ileus. Will place Nasogastric. Keep NPO except ice
chips. Repeat potassium tonight. Ask surgical Resident to review
pulmonary.
Labs – Chemistry:
36
Test
Potassium
Pathology Report:
17,16,15
Result
3.3 (Low)
Reference Range
3.5-5.5 Meq/L
Collected date: 02/19/YYYY
Tissue submitted: Pelvic and aortic node sampling, omental biopsy
Frozen section diagnosis: Germ cell tumor, consistent with a
dysgerminoma.
Gross:
The specimens are submitted in nine containers.
Container A: This specimen is an ovary, which has been completely
replaced by a 17 x 8.5 x 11 cm tumor mass. The capsule of the ovary
which is smooth, glistening, grayish white is intact and free of adhesions.
Sectioned surfaces of the tumor mass are smooth, soft, and tan pink, with
focal areas of hemorrhage and cystic degeneration, but no gross massive
necrosis. A fallopian tube is not identified on the external aspect of the
ovary. (Multiple sections including sections from the cystic and
hemorrhagic areas.)
11 of 16
Patient Name
DATE
PROVIDER
02/24/YYY XXXXXX
Y
Health
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
Container B: Right obturator lymph nodes. Four lymph nodes
Container C: Right common iliac lymph node. Two lymph nodes.
Container D: The specimen is a 7 cm. vermiform appendix, which is
grossly unremarkable on sectioning. (One section).
Container E: Omentum biopsy. The specimen consists of an 8.5 x 4 x
2.5 cm. piece of omentum, the sectioned surfaces of which do not show
any significant gross lesions. (Random sections).
Container F: Right external iliac lymph node. One lymph node.
Container G: Left obturator lymph nodes. Three lymph nodes.
Container H: Left external iliac lymph nodes. Three lymph nodes.
Container I: Aortic lymph nodes.
Diagnosis:
 Specimen A, right ovary, dysgerminoma (pure).
 Specimens B, C, F, G, H, I, lymph node groups, total of 16 lymph
nodes, no evidence of metastatic tumor
 Specimen D, vermiform appendix, a few peritoneal inclusion
cysts, serosal surface of the appendix.
 Specimen E, omentum, chronic inflammation and mesothelial
cell proliferations (no evidence of metastatic tumor)
Progress notes POD#5: (Illegible)
PDF REF
31
Patient with discomfort secondary to N6; labial edema improved but still
with discomfort
Physical examination:
Tmax 100°F Pulse 100’s otherwise stable vital signs
Abdomen: Soft non tender, hyperactive bowel sounds
Incision clean and dry intact without erythema. Labial edema decreased
02/25/YYY XXXXXX
Y
Health
Labs reviewed
Assessment/plan:
 POD#5, Patient still with decreased bowel sounds. Plan to
continue N6___
 Patient appears to be otherwise stable
 Tachycardia to secondary to decreased Hb. Will follow. May
need transfusion if symptomatic
Labs:
CBC:
Test
Result
Reference Range
RBC
3.13 (Low)
4.2-5.4 x106
HGB
8.8 (Low)
12.0-16.0 gm/dL
HCT
27.7 (Low)
37-47%
12 of 16
35, 36
Patient Name
DATE
PROVIDER
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
Segmented
78.6 (High)
30.60%
neutrophil
Lymphocyte
13.0 (Low)
25-50%
PDF REF
Chemistry:
02/25/YYY XXXXXX
Y
Health
Test
Result
Potassium
3.1 (Low)
BUN
3 (Low)
BUN/Creatinine ratio
5 (Low)
POD#6 Progress note: (Illegible)
@0835 hours
Reference Range
3.5-5.5 Meq/L
9-18 mg/dL
7-25
32
Patient with discomfort from N6, Otherwise no complaints.
Physical examination: Tmax 100.7°F, tachycardia, vital signs otherwise
stable. 3900/3730 over 24 hours. N6 ____ guaiac negative
Abdomen: Soft, non tender and no bowel sounds noted. No erythema
around incision. Incision clean, dry and intact achieved with staples.
Labial edema resolved
02/25/YYY XXXXXX
Y
Health
Assessment/plan:
 Patient remains without bowel sounds – Plan to repeat AAS
possibly consult surgery if unchanged from 02/23
 Continue N6 suction, patient unchanged from yesterday.
 JVAC drain discontinued per Dr. XXXX
 Pathology indicated dysgerminoma without no nodal
involvement.
Ultrasound of Kidney, Ureter and Bladder (KUB):
41
Impression: The evidence of small bowel obstruction is no longer seen.
XXXXX, M.D.
02/26/YYY XXXXXX
Y
Health
35, 36
Labs:
Test
RBC
HGB
HCT
MCHC
Segmented
neutrophil
Lymphocyte
Result
3.00 (Low)
8.3 (Low)
26.7 (Low)
31.3 (Low)
74.0 (High)
Reference Range
4.2-5.4 x106
12.0-16.0 gm/dL
37-47%
32-36 g/dL
30.60%
16.4 (Low)
25-50%
Chemistry:
13 of 16
Patient Name
DATE
PROVIDER
02/26/YYY XXXXXX
Y
Health
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
Test
Result
Reference Range
Potassium
3.6
3.5-5.5 Meq/L
BUN
3 (Low)
9-18 mg/dL
BUN/Creatinine ratio
6 (Low)
7-25
Cardiac enzymes:
Test
LDH
Urine Culture report:
Collected date: 02/18/YYYY
(Result
date taken)
02/26/YYY
Y
N.XXXXXX,
M.D.
XXXXXX
Health
Final: No growth
(Result
date taken)
N.XXXXXX,
M.D.
Sample: Peritoneal wash
02/26/YYY XXXXXX
Y
Health
Result
305 (High)
PDF REF
Reference Range
118-242 U/L
Extragenital cytology report:
Collected date: 02/19/YYYY
Final: No malignant cells seen, RBC seen.
POD #7 Progress notes: (Illegible)
38
38
32
Patient much improved. N6 discontinued without complaints, positive
bowel movements
Tmax 100.6°F. vital signs stable. Input/ Output 1800/2000
Incision clean/dry/intact with staples
02/26/YYY XXXXXX
Y
Health
02/27/YYY XXXXXX
Y
Health
Assessment/plan:
 Patient stable repeat AAS showed resolution of small bowel
obstruction
 N6 tube discontinued. Diet advanced
 Remove staples today
Progress note: (Illegible)
33
Skin chips out
Eating well and had bowel movements
Soft and regular diet and have to be followed by Resident in clinic
Note: Explained necessity of close follow-up ___ and no more than 85%
POD#8 Progress note: (Illegible)
33
No complaints
XXXXXX,
M.D.
Labs:
14 of 16
Patient Name
DATE
PROVIDER
02/27/YYY XXXXXX
Y
Health
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
LDH: 308-decreased from 4574 preop, Hgb 8.3
Assessment/plan:
Home with Darvocet, Iron. Instructions given. Follow-up in 4 weeks
Discharge Summary:
PDF REF
3
Admit date : 02/18/YYYY
XXXXXX,
M.D.
Disposition: Home or self care
Final ICD9 diagnoses:
 Principle: 1830-Malignant neoplasm of ovary
 Final diagnosis: 2768-Hypopotassemia
 Final diagnosis: 9974-Gastrointestinal complication, not
elsewhere classified
 Final diagnosis: 5609-Small bowel obstruction
02/27/YYY XXXXXX
Y
Health
Procedure information:
 Unilateral Oophorectomy
 Excision or destruction of peritoneal tissue
 Biopsy of lymphatic structure
 Incidental appendectomy
Final diagnosis: Uterus and adnexa procedures for ovarian or adnexal
malignancy.
Discharge Instructions:




7
Darvocet N-100 for every 4-6 hours as needed for pain
Ferrous Gluconate 300 mg 3x day
Colace 100 mg per oral daily
No sex, no heavy lifting and shower
Follow up: In one month with XXXXXX, M.D.
Discharged condition: Discharged to home with family member via
wheelchair.
02/18/YYY XXXXXX
YHealth
08/29/2016
*Reviewer’s comment: Medical records after 02/27/YYYY are not
available to know the condition of the patient post surgical management
of ovarian cancer.
Hospitalization and other non-related records
15 of 16
59-61, 2, 48, 4,
5-6, 12-14, 1924, 43-46, 47,
Patient Name
DATE
PROVIDER
DOB: 09/17/YYYY
OCCURRENCE/TREATMENT
PDF REF
62-63, 64, 65,
66-68, 88-89,
90-91, 94-95,
97-98, 42, 1, 96,
69-87, 99-156,
49-58, 92-93
16 of 16