This document contains discharge summaries for three patients. Patient 1, a 58-year-old female with diabetes and a breast lump, underwent a biopsy and mastectomy and was discharged after two days with instructions to continue medications and follow up. Patient 2, a 26-year-old female with a breast lump, had a biopsy and was discharged after one day with instructions to remove dressing after 48 hours and follow up with oncology. Patient 3, a 55-year-old male admitted after a fall, underwent surgery for a tibia/fibula fracture, had an uneventful three day recovery, and was discharged with instructions to avoid strain and follow up.

1. NIDA NAEEM
ASSIGNMENT #1
Course Title:
Management Information System in Healthcare
MBA – Spring 2014

2. PATIENT#1:
1.58 years old female patient K/C of DM was admitted with C/O L Breast lump on 27/01/2014.
2. Patient had this condition from 1 month. According to the patient, she was in usual state of
health 1 month back then she noticed Lt Breast lump with no any sign or symptoms.
3. Patient had Lt Breast Tru cut Bx on 14/12/2012. Patient underwent Lt Breast SLNBx and Lt
Mastectomy on 28/01/2014.
4. No active complaints.
5. Physician's notes:
Patient received oriented and conscious, No active complaints.
Nurse notes:
Vitals checked and TPR marked.
Medications given as per day order.
No any active issues.
6. Patient was discharged on 29/01/2014 from female surgical ward after 2 days of admission.
7. Discharge orders were available in the discharge slip.
Discharge instructions:
Continue medications as prescribed.
Follow up on Saturday 01/02/2014 to attend general surgery OPD.
PATIENT#2:
1. 26 year old female was admitted with complain of Lt Breast lump.
2. Patient had this condition from 2 months. According to the patient, she was all right 2 months
back then she noticed a swelling in her Lt Breast.
3. Patient underwent Lt Breast SLNBx on 25/02/2014.
4. Patient did not face any active issues.
5. Physician's notes:
Patient is conscious and cooperative
Active issues: none
Patient is vitally stable.
Nurse notes:
Vital signs checked and TPR marked.
6. Patient was discharged from female surgical ward on 25/02/2014.
7. Discharge orders were available on discharge slip.
Discharge instructions:
Continue medicines as prescribed
Remove dressing after 48 hours.
Follow up after chasing H/ p to attend General Surgery OPD. Follow up with Oncologist.

3. PATIENT#3:
Answer#1:
Patient was admitted in Accident and Emergency Ward on 6 Nov-2013 at 5:30 pm due to fall on
floor (At home) and Swelling in right ankle- Deformity positive. Distal Neurovascular intact-
vitally stable.
Answer#2:
55-year-old male came to the ER with the history of fall in the morning and swelling in right
ankle.
Answer#3:
Patient was diagnosed as Rt Tibia/Fibula Fracture. The patient has its surgery on 7/11/2013 and
ORIF RT Tibia Fibular procedure was attempted and Spinal Anesthesia for RT tibia and Fibula
ORIF.
Answer #4:
Patient did not experience any complication during this admission.
Answer#5
Physician’s progress notes:
On Bed therapeutic done
NWB out of bed mobilized
Dressing and wound normal
Plan to discharge
Nurse notes:
Bedding done, dress changed, I/V care done, vitals checked and marked.
All medications given according to doctor’s order.
No active issues
Answer# 6:
Patient discharged from the orthopedic ward at 9-nov-2013(6:40pm) after 3 days of treatment.
Answer# 7:
Discharge instructions:
Take medications as planned
No physical sports
Avoid lifting heavy things
Do not bend or climb stairs
PACU DISCHARGE FORM:
Vitals: B.P:120/80mmHg, HR: 90/min, R/R20/min
Airway: oral
Conscious level: Awake
Pain Score: none