SURGICAL ONCOLOGY

DIAGNOSIS: RIGHT BREAST ABSCESS

PROCEDURE: WIDE LOCAL EXCISION WAS DONE ON 11/3/2024.

PAST HISTORY: NO COMORBIDTIES

PRESENTING COMPLAINTS: PATIENT PRESENTED WITH SWELLING OVER RIGHT BREAST, PUS DISCHARGE FROM SWELLING. C/O PAIN. NOW ADMITTED FOR FURTHER EVALUATION AND MANAGEMENT.

PHYSICAL EXAMINATION: PATIENT CONSCIOUS, COHERENT

Vitals:PR:88/MIN        BP:130/90MMHG     Temp: 98.6F         Spo2:99%           RR:20/MIN

           Heart:S1, S2+        Lungs:BAE +               P/A: SOFT        

COURSE IN THE HOSPITAL: PATIENT PRESENTED WITH ABOVE MENTIONED COMPLAINTS. ULTRASOUND BOTH BREASTS WAS DONE WHICH S/O HYPOECHOIC COLLECTION WITH MULTIPLE INTERNAL ECHOES WITH PERIPHERAL INCREASED ECHOGENICITY AND VASCULARITY IN SUBCUTANEOUS PLANE OF OUTER INNER QUADRANT OF RIGHT BREAST AT 7-8 O CLOCK POSITION.UNDER PECS BLOCK 1 WIDE LOCAL EXCISION OF LESION WAS DONE ON 11-03-2024 AND SENT FOR HPE.

INTRAOP FINDINGS:

1. 4x3 cm ULCERATED INDURATED LESION AT 7'O CLOCK POSITION OF RIGHT BREAST

 INTRA OP AND POST OPERATIVE PERIOD WAS UNEVENTFUL. TREATED WITH IV ANTIBIOTICS, ANALGESICS AND OTHER SUPPORTIVE MEDICATIONS. DISCHARGED ON POD 0 IN STABLE CONDITION. 

DIET:  NORMAL  DIET

MEDICATION ADVICE:

1. TAB ACTON OR THRICE DIALY FOR 7 DAYS. 8AM-1PM-8PM

2. TAB  AUGMENTIN 625MG  TWICE A DAY[8AM-8PM]  FOR 7DAYS

3. TAB PAN D TWICE A DAY[7AM-7PM] BEFORE FOOD FOR 7DAYS

4. TAB OROFER XT ONCE A DAY AT 2PM FOR 1 MONTH

ORTHOPAEDICS

DIAGNOSIS: LEFT KNEE ACL TEAR + MEDIAL MENISCUS TEAR

PROCEDURE:  LEFT KNEE ARTHROSCOPIC ACL RECONSTRUCTION + MENISECTOMY   WAS DONE.

PRESENTING COMPLAINTS:  ALLEGED H/O SKID AND FALL. NO H/O FEVER/COUGH. GOT ADMITTED HERE FOR FURTHER MANAGEMENT.

PHYSICAL EXAMINATION: PATIENT CONSCIOUS, COHERENT.

Vitals: PR:87BPM              BP:110/60MMHG             Temp:98.6F            Spo2:98%           RR:20/MIN

            Heart:S1S2 +           Lungs:BLAE +                  P/A:SOFT              CNS:E4V5M6     Others:

COURSE IN THE HOSPITAL: PATIENT ADMITTED WITH ABOVE COMPLAINTS. AFTER ALL NECESSARY INVESTIGATION WERE DONE. PATIENT DIAGNOSED AS  LEFT KNEE ACL TEAR + MEDIAL MENISCUS TEAR .PAC WAS DONE. HENCE POSTED FOR SURGERY, UNDER SPINAL ANAESTHESIA  LEFT KNEE ARTHROSCOPIC ACL RECONSTRUCTION + MENISECTOMY   WAS DONE ON 15-03-2024. PROCEDURE  WAS UNEVENTFUL. POST OP PATIENT WAS  TREATED WITH IV ANTIBIOTICS, ANALGESICS, ANTACIDS, IV FLUIDS AND OTHER SUPPORTIVE MEDICATIONS.

ADVISE AT THE TIME OF DISCHARGE: NOW, PATIENT IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION WITH FOLLOWING MEDICATIONS.

DIET: NORMAL DIET

MEDICATION ADVICE:

1.TAB CETIL 500MG TWICE DAILY FOR 12DAYS (8AM-8PM)

2.TAB UGESIC TWICE DAILY FOR 5DAYS (8AM-8PM)

3.TAB PAN 40MG ONCE DAILY BBF FOR 5 DAYS (7AM) 

4.TAB SUPRADYN ONCE DAILY FOR 1 MONTH (2PM)

5.TAB FOLIFIED HD ONCE DAILY FOR 1 MONTH (2PM)

6.TAB DIFFUZYME THRICE DAILY BEFORE FOOD FOR 3 DAYS (7AM-1PM-7PM)

7.TAB TENDFIT TWICE DAILY FOR 1 MONTH (8AM-8PM)