tokens: Admission Date : 2013-11-21 Discharge Date : 2013-11-26 Date of Birth : 1949-07-18 Sex : F Service : PLASTIC Allergies : Trazodone / Ambien / Sinequan Attending : Bobby Z.S. Ruiz , M.D. Chief Complaint : ACQUIRED DEFECT FROM BASAL CELL CARCINOMA RESECTION Major Surgical or Invasive Procedure : RIGHT NOSE / ALA RECONSTRUCTION USING RIGHT CHEEK ADVANCEMENT AND FOREHEAD LOCAL FLAP History of Present Illness : MS. Marshall IS A 64-YEAR OLD , MENTALLY RETARDED , FEMALE WHO PRESENTED WITH AN AQUIRED DEFECT OF THE RIGHT NASAL ALA AND MEDIAL CHEEK REGION AFTER BASAL CELL CARCINOMA WAS RESECTED BY DERMATOLOGY . Past Medical History : MENTAL RETARDATION DIABETES BIPOLAR DISORDER Social History : LIVES IN A NURSING HOME , HAS A BROTHER WHO IS THE HEALTH CARE PROXY . NO Tifany , ETOH , OR REC DRUG USE . Physical Exam : ON PRESENTATION , PT WAS AFEBRILE WITH NORMAL VITAL SIGNS GEN : NO ACUTE DISTRESS , ABLE TO COMMUNICATE AND FOLLOW ORDERS HEAD AND NECK : 5 CM CIRCULAR FULL THICKNESS DEFECT AT THE JUNCTION OF THE RIGHT ALA AND CHEEK HEART : REGULAR RATE AND RHYTHM LUNGS : CLEAR TO ASCULATION ABDOMEN : SOFT , NON-TENDER , NON-DISTENDED EXTREMITIES : NO EDEMA , CYANOSIS , FULL RANGE OF MOTION Brief Hospital Course : UPON ADMISSION , THE PATIENT WAS PRE-OP 'D AND MADE NPO / IVF . SHE WENT TO SURGERY THE NEXT MORNING AND TOLERATED THE SURGERY WELL . HOWEVER , SHE WAS SLOW TO AWAKE FROM ANESTHESIA , AND WAS ADMITTED TO THE CMED CCU OBSERVATION . SHE WAS TRANSFERED TO THE FLOOR POST-OP DAY 2 WHERE SHE HAD BEEN AFEBRILE WITH NORMAL VITALS , MAKING GOOD URINE , AND TOLERATING A REGULAR DIET . HER WOUND HAS REMAIND DRY AND CLOSED , WITHOUT EVIDENCE OF INFECTION OR BREAKDOWN . SHE HAS BEEN WATCHED BY A SITTER AT ALL TIMES . SHE WILL BE DISCHARGED TODAY BACK TO HER NURSING HOME IN GOOD CONDITION , ON PAIN MEDS , ANTIBIOTICS , AND WITH ANTICIPATED 1:1 WATCH . SHE WILL FOLLOW UP WITH DR. Karen IN 1 WEEK . STAGE TWO OF HER SURGERY WILL BE DONE IN 3 WEEKS . Discharge Medications : 1. Paroxetine HCl 10 mg Tablet Sig : One ( 1 ) Tablet PO AM (). 2. Multivitamin Capsule Sig : One ( 1 ) Cap PO QAM ( once a day ( in the morning )). 3. Divalproex Sodium 500 mg Tablet , Delayed Release ( E.C. ) Sig : One ( 1 ) Tablet , Delayed Release ( E.C. ) PO QAM ( once a day ( in the morning )). 4. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ) as needed : constipation . Disp :* 30 Capsule (s)* Refills :* 0 * 5. Triamcinolone Acetonide 0.1 % Cream Sig : One ( 1 ) Appl Topical BID ( 2 times a day ). 6. Divalproex Sodium Oral 7. Atorvastatin 10 mg Tablet Sig : One ( 1 ) Tablet PO HS ( at bedtime ). 8. Oxybutynin Chloride 5 mg Tablet Sig : One ( 1 ) Tablet PO QPM ( once a day ( in the evening )). 9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig : 1-2 Tablets PO Q4H ( every 4 hours ). Disp :* 40 Tablet (s)* Refills :* 0 * 10. Bacitracin-Polymyxin-Neosp HC Ointment Sig : One ( 1 ) Topical three times a day . Disp :* 1 500 / gram * Refills :* 2 * Discharge Disposition : Extended Care Discharge Diagnosis : AQUIRED DEFORMITY OF THE RIGHT ALA / NOSE AND MEDIAL CHEEK FROM BASAL CELL CARCINOMA RESECTION Discharge Condition : GOOD Discharge Instructions : PLEASE GIVE PATIENT MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS CAREFULLY . IF SIGNS AND SYMPTOMS OF INFECTION , SUCH AS FEVERS / CHILLS , PURULENT DISCHARGE FROM WOUND / INCISION SITE , INCREASED REDNESS , INCREASED PAIN , PLEASE CALL OR GO TO THE EMERGENCY ROOM . REMEMBER TO CALL TO SCHEDULE HER FOLLOW UP APPOINTMENT ( BELOW ). LIGHT ACTIVITIES UNTIL SEEN IN CLINIC . STAGE 2 OF THE SURGERY WILL BE DONE IN 3 WEEKS . MAY SHOWER -- DAB DRY , DO NOT SCRUB . PLEASE CLEAN INCISION SITE WITH NORMAL SALINE OR CLEAN WATER THREE TIMES A DAY AND PLACE ANTIBIOTIC OINTMENT ( GIVEN ) ON TOP OF WOUND . PLEASE KEEP PATIENT AWAY FROM THE SUN . MOST IMPORTANTLY , THE PATIENT MUST BE WATCH ONE-ON-ONE SO THAT SHE DOES NOT PICK AT HER WOUND . Followup Instructions : PLEASE CALL DR.Parson OFFICE FOR A FOLLOW UP ( 989-5361 Mauricio ( 540-4644 Nancy Lois MD 88-449 Completed by : Mary Lisa MD 53-914 2013-11-26 @ 1134 Signed electronically by : DR. David Randazzo on : MON 2013-12-16 7:25 AM ( End of Report )