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10001725-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / gabapentin / morphine / Amoxicillin / metronidazole / propoxyphene / rofecoxib / Macrobid / furosemide / Amitiza / Sulfa (Sulfonamide Antibiotics) / Tylenol / Hydromorphone / Toradol <ATTENDING> ___ <CHIEF COMPLAINT> For admission: elective gynecologic surgery for urinary retention For MICU transfer: Anaphylaxis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Stage 2 interstim w/ posterior colporrhaphy for rectocele + enterocele ___ <HISTORY OF PRESENT ILLNESS> <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ w/ Hx of cervical CA s/p radical hysterectomy c/b chronic ___ lymphedema and urinary retention, for which she frequently self-caths, Asthma, GERD, IBS, anxiety/depression, fibromyalgia and other issues who was admitted for an elective gynecologic surgery (stage 2 interstim and posterior colporrhaphy w/ graft) for urinary retention and rectocele + enterocele. <PAST MEDICAL HISTORY> Cervical CA s/p radical hysterectomy c/b chronic ___ lymphedema ADHD Anxiety/Depression Asthma Insomnia GERD Raynaud's IBS Fibromyalgia <SOCIAL HISTORY> ___ <FAMILY HISTORY> +Hx of atopy in son, daughter; both w/ frequent allergy rxns requiring epi pens <PHYSICAL EXAM> MICU ADMISSION EXAM: -------------------- Vitals: T: 98.7 BP: 113/83 P: 79 R: 18 O2: 97% ___ ___: Well appearing female in no acute distress, slightly muffled voice, somewhat flushed skin HEENT: Moist mucous membranes, mild lip swelling, tongue not grossly edematous, no angioedema Neck: JVP non elevated CV: Regular rate and rhythm, normal S1 S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes/rales/rhonchi Abdomen: Soft, normoactive bowel sounds, nontender, nondistended, no rebound or guarding GU: Foley in place Ext: Warm, trace ___ edema, peripheral pulses 2+ ___ Neuro: alert and oriented to person, hospital, and date MICU DISCHARGE EXAM: -------------------- Vitals: T: 97.5 BP: 107/62 P: 84 R: 16 O2: 99% ___ ___: Well appearing female in no acute distress, normal voice, somewhat flushed skin, most prominent in malar distribution on face HEENT: Moist mucous membranes, appearance of face unchanged from yesterday, tongue not edematous, no angioedema Neck: JVP non elevated CV: Regular rate and rhythm, normal S1 S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes/rales/rhonchi Abdomen: Soft, normoactive bowel sounds, nontender, nondistended, no rebound or guarding GU: Foley in place Ext: Warm, trace ___ edema, peripheral pulses 2+ ___ Neuro: alert and oriented to person, hospital, and date GYN Floor discharge exam: VSS, AF Gen: NAD A&O x 3 Resp: no visible respiratory distress, speaking in full sentences Abd: soft, NT ND Ext: moving all 4 extremities <PERTINENT RESULTS> MICU ADMISSION LABS: ___ 06: 02PM BLOOD WBC-17.0* RBC-4.33 Hgb-13.9 Hct-39.1 MCV-90 MCH-32.2* MCHC-35.6* RDW-11.8 Plt ___ ___ 06: 02PM BLOOD Neuts-94.5* Lymphs-4.3* Monos-0.7* Eos-0.1 Baso-0.3 ___ 06: 02PM BLOOD ___ PTT-31.8 ___ ___ 06: 02PM BLOOD Glucose-146* UreaN-16 Creat-0.8 Na-140 K-3.9 Cl-106 HCO3-24 AnGap-14 ___ 06: 02PM BLOOD Calcium-9.1 Phos-3.1 Mg-1.5* ___ 06: 02PM BLOOD TRYPTASE-PND MICU DISCHARGE LABS: ___ 02: 59AM BLOOD WBC-20.1* RBC-3.98* Hgb-12.6 Hct-36.3 MCV-91 MCH-31.6 MCHC-34.7 RDW-11.9 Plt ___ ___ 02: 59AM BLOOD Plt ___ ___ 02: 59AM BLOOD Glucose-152* UreaN-18 Creat-0.8 Na-138 K-3.5 Cl-102 HCO3-24 AnGap-16 ___ 02: 59AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.8* PERTINENT LABS: ___ 06: 02PM BLOOD WBC-17.0* RBC-4.33 Hgb-13.9 Hct-39.1 MCV-90 MCH-32.2* MCHC-35.6* RDW-11.8 Plt ___ ___ 06: 02PM BLOOD Neuts-94.5* Lymphs-4.3* Monos-0.7* Eos-0.1 Baso-0.3 ___ 06: 02PM BLOOD ___ PTT-31.8 ___ ___ 06: 02PM BLOOD Glucose-146* UreaN-16 Creat-0.8 Na-140 K-3.9 Cl-106 HCO3-24 AnGap-14 ___ 06: 02PM BLOOD Calcium-9.1 Phos-3.1 Mg-1.5* ___ 06: 02PM BLOOD TRYPTASE-PND PERTINENT IMAGING: None PERTINENT MICRO: None <MEDICATIONS ON ADMISSION> Albuterol sulfate 2.5 mg/3 mL (0.083 %) Neb TID PRN Albuterol ProAir HFA 90 mcg INH 1 puff BID PRN Cephalexin 250 mg Q6H Adderall XR 15 mg BID Ergocalciferol (vitamin D2) 50,000 U Q week Nexium 40 mg ___ QAM Vivelle 0.075 mg/24 hr Transderm Patch 2x / week Diflucan 200 mg Q ___ Hydroxyzine HCl 25 mg QD PRN Ibuprofen 600 mg Q8H PRN Linzess (linactolide) 145 mcg QD Ativan 1 mg QD PRN Metolazone 2.5 mg QD Zofran 8 mg PO PRN Oxycodone 5 mg PO Q6H PRN Potassium chloride 10 % Oral Liquid 30ml PO QID Propranolol ER 80 mg ER QHS Spironolactone 100 mg QD Trimethoprim 100 mg tablet QD Ambien 10 mg QHS #14 ___ catheter Docusate sodium 100 mg BID LACTOBACILLUS COMBINATION <DISCHARGE MEDICATIONS> 1. Docusate Sodium (Liquid) 100 mg PO BID RX *docusate sodium 100 mg 1 tablet by mouth twice a day Disp #*60 Capsule Refills: *0 2. Bisacodyl 10 mg PO/PR DAILY: PRN Constipation RX *bisacodyl 5 mg ___ tablet,delayed release (___) by mouth constipation Disp #*20 Tablet Refills: *0 3. Metolazone 2.5 mg PO DAILY 4. NexIUM (esomeprazole magnesium) 40 mg Oral once Duration: 1 Dose 5. OxycoDONE (Immediate Release) ___ mg PO Q6H: PRN pain do not drive and drink on this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hrs Disp #*20 Tablet Refills: *0 6. Propranolol LA 80 mg PO DAILY 7. Spironolactone 100 mg PO DAILY 8. Zolpidem Tartrate 5 mg PO HS 9. Trimethoprim 100 mg PO DAILY 10. Vivelle (estradiol) 0.075 mg/24 hr Transdermal twice/week 11. Lorazepam 1 mg PO DAILY: PRN anxiety 12. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours Hold for K > <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> urinary retention, rectocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the Gynecology service after your scheduled Stage 2 Insterstim placement and posterior colporrhaphy with graft for urinary retention and rectocele and enterocele. You tolerated the procedure well. However, after your operation, you had a severe allergic reaction, and had to go to the ICU for monitoring. Since then, you have recovered well, and we have determined that you are in stable condition for discharge. Please take your medication and follow-up at your appointments as scheduled. ___ instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet * or anything that concerns you Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * or anything that concerns you To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ y/o F w/ Hx of cervical CA s/p radical hysterectomy c/b chronic ___ lymphedema and urinary retention, Asthma, GERD, anxiety/depression, fibromyalgia. Please refer to the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. However, in the PACU, the patient started feeling itchy. Once the pt returned to the floor, she noted sensation of tongue / lip swelling, difficulty swallowing secretions, and a change in her voice. No SOB, no flushing, no stridor or wheeze. She was administered an Epi-pen, Solumedrol 100 mg IV, Famotidine 20 mg IV, and Hydroxyzine 25 mg IM. She was transferred to the MICU for closer monitoring. The patient has numerous drug allergies and was administered the following medications intra-operatively: Midazolam, Rocuronium, Fentanyl, Dexamethasone, Hydromorphone, Ondansetron, Lidocaine, Propofol, Cefazolin, Glycopyrrolate, Phenylephrine, and Ketorolac. In the MICU, initial VS were HR 87, BP 100/63, RR 17, S 100% ___. The patient was in NAD, without wheeze or poor air movement on exam, but complained of persistent voice change and difficulty swallowing, for which she required 2 more epi pens. Has remained hemodynamically stable and without respiratory compromise. ACTIVE ISSUES: *) Post operative care Her pain was controlled immediately post-op with IV dilaudid and toradol. This was transitioned to po oxycodone as it was difficult to determine what was causing an allergic reaction in Ms. ___. Her vaginal packing was removed on POD 1, on post-operative day 2, her urine output was adequate and her Foley was removed. The patient was able to void spontaneously, but did require self-catheterization ___ times a day based on a sensation of bladder fullness. *) Anaphylaxis: In the PACU the patient awoke and started feeling pruritis. Once she arrived to the floor, the patient noted difficulty talking, subjectively swollen lips/tongue, and vocal changes. No SOB, no flushing, no stridor or wheeze. A trigger was called for anaphyllaxis and she recieved an Epi-pen, Solumedrol 100 mg IV, Famotidine 20 mg IV, and Hydroxyzine 25 mg IM. She was transferred to the MICU for closer monitoring. In the MICU, initial VS were HR 87, BP 100/63, RR 17, S 100% ___. The patient was in NAD, without wheeze or poor air movement on exam, but complained of persistent voice change and difficulty swallowing, for which she required 2 more epi pens. Has remained hemodynamically stable and without respiratory compromise. Of note, patient was lying comfortable in bed around 2200 and continuing to inquire about more Epi-pens vs epinephrine gtt despite comfortable respiration, vocalization, non-edematous oral structures. She also perseverated about her Ativan and Ambien, as well as her propranolol for essential tremor despite explanation that beta blockers can worsen bronchoconstriction and respiratory compromise in anaphylaxis. On the day she was called out to the floor, the pt complained of persistent facial flushing. She was afebrile, hemodynamically stable, and without respiratory compromise or systemic symptoms. Symptomatic care with hydroxyzine and eucerin lotion was provided. Upon step down to the floor, the patient again reported to nursing that she felt throat constriction. Epinephrine and solumedrol were given and the patient felt relief. Allergy was consulted, and they asked us to stop all new medications given to her while at the hospital, and to report all of them as allergies. In addition, we sent out a tryptase level, as well as coordinated outpatient follow-up with them. #Chronic ___ edema: Continue home Metolazone, spironolactone, potassium repletion as not hypotensive. We monitored her K during her stay, which was WNL. #Asthma: Home Albuterol use ___ per week, did not require in the MICU. #GERD: Nexium (was initially held on admission, but per pt request was given on ___ prior to advancing diet) #ADHD: On Adderall, held on admission # Anxiety/depression/fibromyalgia: lorazepam # Insomnia: zolpidem By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was the discharged home in stable condition with outpatient follow-up scheduled. She was also scheduled to have an appointment with Allergy and Immunology.
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| 1,058
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10002800-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet / cucumber / Tegaderm <ATTENDING> ___. <CHIEF COMPLAINT> cracked tooth, s/p fall <MAJOR SURGICAL OR INVASIVE PROCEDURE> tooth extraction <HISTORY OF PRESENT ILLNESS> Patient is a ___ year old G1P0 at ___ by U/S w/ h/o breast CA on DDAC chemotherapy in pregnancy and thyroid CA who presents after transfer from ED for tooth pain and for evaluation after a fall two days ago when she tripped on the ice and hit her shoulder. She reports progressive dental pain in the right lower molar. She has been unable to get dental treatment of her fractured molar in the outpatient setting due to concerns about pregnancy and medical complexity. She was therefore referred to the ED. OMFS was consulted while she was in the ED w/ plan for removal in the OR tomorrow. Findings included cracked tooth #29 w/ carriers extending to pulp. The patient was sent to OB triage given the mechanical fall. The patient denies any abdominal trauma or bruising. She has been having very irregular cramping, no contractions. She also reports intermittent sharp shooting pain from the groin to her belly button. Not exacerbated by anything. Pain cannot be reproduced. She denies and VB or LOF. <PAST MEDICAL HISTORY> PNC: - ___ ___ by US - Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown - Genetics: LR ERA - FFS: wnl - GLT: wnl - US: ___, 67%, breech, ___, nl fluid, anterior placenta - Issues: *) breast cancer in pregnancy: unilateral mastectomy w/ sentinel LN biopsy, s/p chemotherapy completed ___, plan for PP tamoxifen *) mild asthma *) History of papillary thyroid cancer x 2, on levothyroxine 175mcg daily; labs ___ - TSH 4.3 (elevated) but normal FT4 (1.1) ROS: per hpi GYNHx: h/o breast cancer OBHx: G1, current PMH: h/o breast cancer, mild asthma, h/o papillary PSH: s/p unilateral mastectomy w/ sentinel LN biopsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family history: Aunt and mother with ALS. Mother, aunt, grandmother: ___. Father--prostate cancer (age ___ <PHYSICAL EXAM> On admission: ___ 19: 03Temp.: 98.0°F ___ 19: 03BP: 121/65 (76) ___ ___: 69 ___ ___: 67 GEN: NAD Respiratory: no increased WOB Abdomen: no bruising, non-tender, gravid SVE: LCP TAUS: vtx, anterior placenta, no sonographic evidence of abruption, MVP 5.4 FHT: 130/moderate/+accels/ no decels On discharge: VS: 98.0, 114/71, 73, 16, O2 96% Gen: [x] NAD Resp: [x] No evidence of respiratory distress Abd: [x] soft [x] non-tender Ext: [x] no edema [x] non-tender Date: ___ Time: ___ FHT: 120s, mod var, +accels, no decels reactive Toco: occ ctx <PERTINENT RESULTS> n/a <MEDICATIONS ON ADMISSION> albuterol, levothyroxine <DISCHARGE MEDICATIONS> Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 Levothyroxine Sodium 200 mcg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cracked tooth <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the ___ service for monitoring after a fall and prior to your procedure with the oral surgeons for a tooth extraction. You procedure went well and your baby was monitored before and after the procedure. You are now stable to be discharged home. Please see instructions below. You should continue biting down on a piece of gauze for 30 minute interval. You may stop after ___ gauze changes. You should NOT have any hot/solid foods for the time being. You may continue drinking cool liquids. You may transition to soft foods (eggs, pasta, pancake) tonight. For pain control, you may take Tylenol as needed (do not take more than 4000mg in 24 hours). Please call your primary dentist with any questions or concerns. Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Patient is a ___ year old G1 with hx of breast CA on DDAC chemotherapy in pregnancy and thyroid CA admitted at 34w2d after a fall. On admission, she had no evidence of abruption or preterm labor. She reported mild cramping and her cervix was LCP. Fetal testing was reassuring. She also had a painful, cracked tooth and had been evaluated by OMFS in the emergency room. A plan was made for extraction in the OR. On HD#2, she underwent an uncomplicated tooth extraction under local anesthesia. Her pain resolved. She continued to have some intermittent cramping and pink discharge, however, she had no evidence of preterm labor. She was discharged to home in stable condition on HD#3 and will have close outpatient follow up.
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| 161
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10002870-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic mass and uterine fibroid. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salpingo-oophorectomy. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___, postmenopausal female, who was found to have a left-sided pelvic mass on routine exam. . Pelvic ultrasound revealed large left adnexal mass. Pelvic MRI was done which revealed a 7.9cm left ovarian mass with some imaging features suggestive a fibroma/fibrothecoma but other features atypical for this diagnosis. There was also a multi-fibroid uterus with material within the endometrial cavity at the level of the fundus. A preoperative CA-125 was 17. An endometrial biopsy showed inactive endometrium. She presents today for definitive surgical management. . She reports baseline urinary frequency, urgency, irritable bowel and abdominal bloating. She denies any vaginal bleeding or abdominal/pelvic pain. <PAST MEDICAL HISTORY> PMH: R Breast Dysplasia, Hypercholesterolemia, Anxiety, Osteoarthritis, Hypothyroidism, Herpes. PSH: L leg muscle graft, knee arthroscopy, R hand ganglion cyst removal, R thyroid lobe removal. OB/GYN: G3P1, post-menopausal, last Pap ___ no hx abnl paps, STIs, gyn dx. <SOCIAL HISTORY> ___ <FAMILY HISTORY> no h/o ovarian, breast, uterine or colon cancer. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable General: No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 06: 05AM BLOOD WBC-12.1* RBC-4.01* Hgb-12.7 Hct-37.8 MCV-94 MCH-31.8 MCHC-33.7 RDW-14.7 Plt ___ ___ 06: 05AM BLOOD Neuts-71.7* ___ Monos-5.6 Eos-1.9 Baso-0.5 ___ 06: 05AM BLOOD Plt ___ ___ 06: 05AM BLOOD Glucose-100 UreaN-11 Creat-0.6 Na-139 K-4.4 Cl-104 HCO3-28 AnGap-11 ___ 06: 05AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9 <MEDICATIONS ON ADMISSION> hydrocodone 5 mg-acetaminophen 325 mg PO QID ibuprofen 800 mg PO BD prn pain levothyroxine 100 mcg, 1 tablet QD for 5 days, 1.5 tablets for 2 days/wk sertraline 100 mg, PO, QD simvastatin 40 mg, PO, QD valacyclovir 500 mg, PO, BD for 4 days prn breakout <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID Take to prevent constipation while taking narcotics. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 3. Levothyroxine Sodium 150 mcg PO 2X/WEEK (MO,FR) 4. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 5. Sertraline 100 mg PO DAILY 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not exceed 4000 mg of acetaminophen in 24h. Do not drive. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Benign ovarian fibroma and fibroid uterus. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ ___ was admitted to the gynecologic oncology service after undergoing total abdominal hysterectomy, bilateral salpingo-oophorectomy, and washings. Please see the operative report for full details. . Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV Dilaudid/Toradol. Her diet was advanced without difficulty and she was transitioned to PO Oxycodone and Ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. . By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10004296-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfamethoxazole / Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> arrest of descent, gHTN, incisional cellulitis with wound abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary low transverse cesarean section <HISTORY OF PRESENT ILLNESS> Patient is a ___ year-old G3P0 with EDC = ___ (EGA = 37w1d on ___ with elevated blood pressures in the office as high as 140/70 over the past week. Repeat BP in OB triage = 142/70, 141/72, 139/85. PIH labs on ___ showed: CBC 15.6 > 10.6 / 30.3 < 312 ALT 21 Cr 0.5 Uric Acid 5.0 UP: C 0.1 She currently denies headache, visual changes, epigastric or RUQ pain. Denies ctx, VB, LOF. +FM <PAST MEDICAL HISTORY> MEDICAL HISTORY Allergies (Last Verified ___ by ___: Penicillins Sulfamethoxazole --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs every four (4) hours PRN BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler. 2 puffs inh twice a day PNV WITH CALCIUM ___ [PRENATAL VITAMINS LOW IRON] - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth once per day, as needed, for constipation --------------- --------------- --------------- --------------- Problems (Last Verified ___ by ___, MD): ASTHMA, EXTRINSIC W/ ACUTE EXACERBATION 493.02 ECZEMATOUS DERMATITIS H/O TOBACCO USE 305.1 Surgical History (Last Verified ___ by ___, MD): Surgical History updated, no known surgical history. Family History (Last Verified ___ by ___, MD): Relative Status Age Problem Comments Other ASTHMA V17.5 F/H GI MALIGNANCY V16.0 <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VSS Gen: NAD Lungs: CTA CV: RRR Abd: 2cm opening on right side of incision with packing, erythema improved from prior, no pus Ext: 1+ pitting edema bilaterally with no calf tenderness <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY 2. Docusate Sodium 100 mg PO DAILY: PRN constipation 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation 2 puffs bid 4. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puffs Q4H: PRN wheezing <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler 2 PUFF IH Q4H: PRN asthma 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 5. Clindamycin 450 mg PO Q6H Duration: 10 Days RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hrs Disp #*108 Capsule Refills: *0 6. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 140 mg (45 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hrs Disp #*30 Tablet Refills: *0 8. Labetalol 300 mg PO BID RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills: *0 9. Prenatal Vitamins 1 TAB PO DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 PUFFS Q4H: PRN wheezing <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> primary low transverse cesarean section gestational hypertension asthma arrest of descent endometritis, cellulitis, wound infection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest x 6 weeks until postpartum visit no heavy lifting or driving x 2 weeks keep incision clean and dry
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The patient is a ___ G3, P0 at 37 weeks 4 days admitted for induction of labor due to gestational hypertension. After a prolonged induction, the patient progressed to fully dilated and +2 station. However, after 5 hours fully dilated and ___ hours pushing, there was no descent of the fetal head and significant caput was noted. The patient was recommended to undergo delivery via cesarean section. She experienced a PPH with EBL 1200cc from cervical extension, but remained stable postpartum. In terms of her gestational hypertension, she had normal labs. She was started on labetalol 200mg BID on ___, which was increased to 300mg BID on ___ for elevated pressures. During her postpartum course she developed an incisional cellulitis with wound abscess. She was noted to have erythema and induration on right side of incision and extending to mons. She was started on IV gent/clinda -> PO clindamycin started ___ ___, 10d course. She incision was opened at bedside ___ and she underwent BID wet to dry dressing changes. She had a wound culture with mixed flora, a negative urine culture, and blood cultures with no growth. Patient also experienced bilateral lower extremity edema during her stay that she found very bothersome. She received Lasix 20mg PO x1, with improvement of symptoms. She was also maintained on Lovenox 40mg daily. She was discharged on ___ in stable condition with plan for outpatient ___ for BID dressing changes and blood pressure monitoring.
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10004365-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfasalazine <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic pain, ruptured ectopic pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> L/s as above. <HISTORY OF PRESENT ILLNESS> 37 g2po (tab1) presents as transfer from ___ for early pregnancy, ___ constant LLQ. Pt s/p RSO. U/s demonstrated enlarged hyperstimulated left ovary w/ nl flow. S/p IVF, VOR ___, UT ___ embryos transferred. <PAST MEDICAL HISTORY> GYN: IF, ovarian cysts PMH: None PSH: L/S, RSO, for ovarian cyst, ___ MEDS: none ALL: sulfa -hives <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> VSS at ED. BP 100/60, P70. Appeared in no distress.COR RRR, PULM CTAB, abd mildly distended, moderately tender, no rbnd, no guarding. Ext w/o edema. <PERTINENT RESULTS> Hct 29% (down from 37%). Labs otherwise unremarkable. TV u/s, preliminary read: Left adnexal mass likely hematoma adjacent to the massive left ovary (hyperstimulated). Single viable intrauterine gestation (7wks), a second intrauterine ___ is nonviable. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Polysaccharide Iron Complex ___ mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. Disp: *0 Tablet(s)* Refills: *0* 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ruptured heterotopic pregnancy with concomittant intrauterine pregnancy. <DISCHARGE CONDITION> Excellent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Activity as tolerated; Niferex 2x day; Tylenol as needed.
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PREOP DX: Pelvic pain, possible ruptured heterotopic pregnancy vs ruptured adnexal cyst POST OP DX: Ruptured left tubal ectopic pregnancy PROCEDURE: Operative l/s, removal of EP, left salpngectomy ___ ASST: ___: Gen FINDINGS: 1- 150 cc hemoperitoneum 2- 150 cc clot 3- Left FT - ruptured an bleeding at ventral surface ampulla with surrounding clot and presumed gestational tissue. 4 - Enlarged hyperstimulated left ovary w/ normal and vascularized appearance before, during and at the end of case 5 - Surgically absent right FT and ovary 6 - Adhesions of large bowel to LLQ side wall 7 -Enlarged uterus c/w 7 wks GA IVF: ___ cc; 500 cc Hespan U/O:330 cc EBL:350 COMPLICATIONS: none SPECIMEN: Left FT, EP, clot DISPO: Stable to PACU INPATIENT NOTE - ___ SUMMARY Pt seen at ___ontrolled, DTV, no specific complaints. VSS w/ BP 100-110/ 50-60, p70. Exam w/ clear lungs, regular HR, abd mildly distended, mildly tender, incision C/d/i though ecchymosis noted at ___ port site. Labs notalble for : HCT 5 AM 19.7 9 AM 22.4 1PM 21.1 6PM 20 Diet advanced once Hct determined to be stable. TV u/s to be done bedside by residents to assess IU pregnancy viabilit
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10004638-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Phenothiazines / Epinephrine / ppi / Nitrous Oxide <ATTENDING> ___ <CHIEF COMPLAINT> urinary frequency and urgency <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic sacrocolpopexy Tension free vaginal tape Cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ presented for evaluation of urinary complaints and after review of records and cystocopy was diagnosed with a stage III cystocele and stage I vaginal prolapse, both of which were symptomatic. She also had severe vaginal atrophy despite being on Vagifem. Treatment options were reviewed for prolapse including no treatment, pessary, and surgery. She elected for surgical repair. All risks and benefits were reviewed with the patient and consent forms were signed. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Breast cancer survivor, diagnosed in ___, status post mastectomy, chemotherapy, and tamoxifen treatment. 2. Anxiety. 3. Arthritis. 4. Acid reflux. 5. Low back pain. 6. Osteopenia. 7. Vaginal prolapse. PAST SURGICAL HISTORY: 1. Modified radical mastectomy with reconstruction in ___. 2. Vaginal hysterectomy and bilateral salpingo-oophorectomy in ___ for prolapse, Dr. ___ at ___. PAST OB HISTORY: Twelve number of pregnancies, three number of vaginal deliveries, two number of living children, two number of miscarriages, birth weight of largest baby delivered vaginally 7 pounds 2 ounces, positive for forceps-assisted vaginal delivery, negative for vacuum-assisted vaginal delivery. Menopause: Surgical menopause in ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother, heart disease and mitral valve prolapse; father, esophageal cancer; maternal grandfather, asthma; paternal grandmother, stomach cancer. <PHYSICAL EXAM> On postoperative check: VS 97.6 106/70 72 18 100% on 1.5L NC OR/PACU I/O 100PO + 2550 IVF / 420UOP + EBL 100 A+O, NARD RRR, CTAB Abd soft, obese, no TTP, +BS, no R/G Robot port sites with surrounding ecchymosis (all ~2cm in diameter) Dermabond intact, well approximated without erythema/exudate Pad with minimal VB Foley with CYU Ext NT, pboots on <PERTINENT RESULTS> ___ 07: 32AM BLOOD WBC-5.3 RBC-3.73* Hgb-10.9* Hct-33.1* MCV-89 MCH-29.1 MCHC-32.8 RDW-13.0 Plt ___ <MEDICATIONS ON ADMISSION> clonazepam 0.5 TID prn, ibandronate 150 q month, naratriptan 2.5 prn h/a, simvastatin 40', sucralfate 1g TID, ASA (held), vagifem, vitamins allergies: phenothyazides, compazine (anaphy) <DISCHARGE MEDICATIONS> 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pt request. 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 5. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed 12 tabs in any 24 hr period. do not take if dizzy or lightheaded. Disp: *20 Tablet(s)* Refills: *0* 6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain or pt request. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse stress urinary incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. - Please call if you have redness and warmth around the incisions, if your incisions are draining pus-like or foul smelling discharge, or if your incisions reopen. - No driving while taking narcotic pain medication as it can make you drowsy. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal adequately. - Nothing per vagina (no tampons, intercourse, douching for 6 weeks. - Please keep your follow-up appointments as outlined below.
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Ms. ___ underwent an uncomplicated robotic sacrocolpopexy, TVT, and cystoscopy for stage 3 pelvic organ prolapse and stress urinary incontinence; please see the operative report for full details. Her postoperative course was uncomplicated. She was discharged on postoperative day 1 in good condition after passing her trial of void and meeting all postoperative milestones.
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10004638-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Phenothiazines / Epinephrine / ppi / Nitrous Oxide / Benadryl / Protonix <ATTENDING> ___ <CHIEF COMPLAINT> rectocele <MAJOR SURGICAL OR INVASIVE PROCEDURE> posterior repair <HISTORY OF PRESENT ILLNESS> She is a ___ patient who presents with ___ rectocele after having a sacral colpopexy and supracervical hysterectomy in ___ for uterine prolapse and cystocele. At that time, she had no rectocele at all. She has symptoms of bulge and pressure in the vagina that has gotten worse over the past few months. She also complains of feeling of incomplete emptying. She states that after she goes to the bathroom, she could go back and urinate some more. She had some frequency, urgency symptoms, which had resolved postoperatively. She also has resolved diarrhea after being started on Zenpep. She is followed by Dr. ___ and her fecal incontinence has resolved as well as resolved diarrhea. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> She is a breast cancer survivor, anxiety, arthritis, acid reflux, low back pain, and osteopenia. Past Surgical History: Modified radical mastectomy with reconstruction in ___, vaginal hysterectomy, BSO in ___ for prolapse, Dr. ___ lysis of adhesions, ___ sacral colpopexy, cystoscopy, and TVT in ___. Past OB History: She has had three vaginal deliveries. <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> Positive for heart disease. Mitral valve prolapse in the mother. Father with esophageal cancer. <PHYSICAL EXAM> On admission: General: Well developed, well groomed, thin. Psych: Oriented x3, affect is normal. Skin: Warm and dry. Heart: No peripheral edema or varicosities. Lungs: Normal respiratory effort. Abdomen: Soft, nontender, not distended. No masses, guarding, or rebound. No hernias. Genitourinary: Vulva: Normal hair pattern, no lesions. Urethral Meatus: No caruncle, no prolapse. Urethral meatus nontender, no masses or exudate. Bladder: Moderately atrophic. She is on vaginal estrogen with Vagifem in particular. Caliber and resting tone are normal. There is a stage III rectocele. The anterior wall and apex were extremely well supported. The bladder is nonpalpable and nontender. Cervix is absent as of the uterus and adnexa. No masses in the anus or perineum. <PERTINENT RESULTS> No labs during this hospitalization. <MEDICATIONS ON ADMISSION> BETAMETHASONE DIPROPIONATE - 0.05 % Cream - apply to affected area(s) daily as directed CLONAZEPAM - 0.5 mg Tablet - 1 (One) Tablet(s) by mouth three times a day as needed for prn ESTRADIOL [VAGIFEM] - 10 mcg Tablet - 2 twice per week for maintenence IBANDRONATE [BONIVA] - 150 mg Tablet - 1 Tablet(s) by mouth every month LIPASE-PROTEASE-AMYLASE [ZENPEP] - 20,000 unit-68,000 unit-109,000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth with meals one with snacks SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day SUCRALFATE - 1 gram Tablet - 1 Tablet(s) by mouth up to four times per day SUMATRIPTAN SUCCINATE - 100 mg Tablet - 1 Tablet(s) by mouth first sign of headahce can repeat in two hours if needed ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth once a day CALCIUM CARBONATE-VITAMIN D3 [CALTRATE-600 PLUS VITAMIN D3] GLUCOSAMINE ___ 2KCL-CHONDROIT [GLUCOSAMINE SULF-CHONDROITIN] MICONAZOLE NITRATE - (BID TO AFFECTED AREA) MULTI VIT W MN-FA-LYCO-LUT-ALA <DISCHARGE MEDICATIONS> 1. Clonazepam 0.5 mg PO TID: PRN anxiety 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q8 hours Disp #*30 Tablet Refills: *2 3. Sucralfate 1 gm PO TID 4. Zenpep *NF* (lipase-protease-amylase) 20,000-68,000 -109,000 unit Oral with meals Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 2 tab with meals 5. Simvastatin 40 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> rectocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms ___ underwent an uncomplicated posterior repair for stage III rectocele; see operative report for details. She had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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10004648-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> presumed ectopic pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 with LMP ___ with presumed ectopic (never seen on ultrasound) presents to ED with severe abdominal pain after treatment with MTX on ___. She was having some mild abdominal pain responsive to Tylenol but this morning her pain became ___ and unresponsive to Tylenol. She describes the pain as located across her low abdomen, left > right. It was "unbearable" and she had trouble walking although wasn't lightheaded, just overwhelmed with pain. In the ambulance ride, she received 50mcg fentanyl and 4mg zofran IV. Her pain is now ___. She also notes vaginal bleeding, ~3 pads per day. No clots. ___ TVUS (prelim): Focal thickening of the endometrium, portion with vascular flow -> consistent with ongoing SAB. Cystic structure in left ovary most likely corpus luteum. <PAST MEDICAL HISTORY> PGynHx: Notes severe dysmenorrhea, normally takes Aleve. Previously on OCPs. PMHx: denies PSHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VS on arrival: 97.4 58 106/55 100% RA General: NAD Cardiac: RRR Pulm: CTA Abdomen: Soft, no focal tenderness with NO rebound or guarding. +BS Bimanual: Mildly enlarged AV uterus without tenderness or CMT. Some left adnexal fullness without discrete tenderness (pt notes diffuse "tenderness") Ext: NT, NE Labs: HCG 1845 CBC 7.8>41.7<221 Blood type O+ <PERTINENT RESULTS> ___ 11: 57AM BLOOD WBC-7.8# RBC-4.77 Hgb-13.3 Hct-41.7 MCV-88 MCH-27.9 MCHC-31.9 RDW-14.0 Plt ___ ___ 11: 57AM BLOOD ___ PTT-28.0 ___ ___ 11: 57AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-136 K-4.4 Cl-105 HCO3-25 AnGap-10 ___ 11: 57AM BLOOD Mg-2.0 ___ 11: 57AM BLOOD HCG-1845 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Percocet 7.5-325 mg Tablet Sig: ___ Tablets PO every ___ hours. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> PRESUMED ECTOPIC PREGNANCY <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted with abdominal pain in the setting of suspected ectopic pregnancy. This was thought to be due to either ongoing miscarriage or aborting tubal ectopic. There was no evidence of a ruptured ectopic pregnancy. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication
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Ms. ___ is a ___ year old G1 with LMP at end of ___ and a presumed ectopic who presents with severe abdominal pain after methotrexate administration. On arrival in the ED, she was hemodynamically stable with a hematocrit of 41 and benign abdominal exam. Ultrasound showed a small amount of material in the lower uterine segment, no adenxal masses or free fluid. She was admitted for observation in the absence of any signs of ruptured ectopic. She did well overnight, only requiring tylenol for analgesia. She remained hemodynamically stable without change in abdominal exam. She was discharged to home on HD 2 in good condition.
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10005001-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Abdominal bloating <MAJOR SURGICAL OR INVASIVE PROCEDURE> Right salpingo-oophorectomy Left cystectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ gravida 0 woman who complains of abdominal bloating. She has a long gynecological history significant for uterine fibroids, endometriosis, and endometriomas. While she first started having symptoms of abdominal bloating, menorrhagia, severe menstrual cramping, urinary frequency, nocturia, and constipation in ___, her multiple gynecological diagnoses were not made until she received her first pelvic ultrasound in ___. After multiple myomectomies with Dr. ___ patient was followed biannually, then annually, and finally as needed for symptoms. In ___, ___ noticed abdominal bloating, which she described as a sensation of heaviness in her lower abdomen. A pelvic ultrasound in ___ showed an unchanged fibroid uterus, an unchanged 5.6cm left-sided endometrioma, and a new nodular 7.5cm right-sided endometrioma up to 5mm in wall thickness, concerning for malignant transformation. The patient presents today for surgical evaluation of her imaging findings. ROS was negative for F/C, CP, SOB, abdominal pain, N/V, C/D, changes in bowel or bladder habits, or intermenstrual bleeding. ROS was positive for mild dysmenorrhea, relieved by OTC NSAIDs. <PAST MEDICAL HISTORY> Past OB/GYN: The patient has regular menses. She has never had a pregnancy. Her last Pap smear was in ___, which was normal. She does have a history of genital warts. The patient has a long history of uterine fibroids, endometriosis, endometriomas. She is in a monogamous relationship with a female partner and uses a Mirena IUD. PMH: Allergic rhinitis Depression Uterine fibroids Endometriosis Endometriomas Pseudocholinesterase deficiency PSH: Medial collateral ligament release ___ Abdominal MMY <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her mother had hypertension and died of colon cancer. Her father has hypertension and prostate cancer. <PHYSICAL EXAM> DISCHARGE EXAM: VS: Gen: This is a well-developed, well-nourished woman in no apparent distress. HEENT: Mucus membranes moist. Oropharynx clear. CV: Regular rate and rhythm. Normal S1 and S2 without murmurs, rubs, or gallops. Pulm: Clear to auscultation bilaterally Abd: Normoactive bowel sounds. Soft, nondistended, nontender. No hepatosplenomegaly. Well-healed ___ scar from her previous MMY. Incision intact. Pelvic: Normal female external genitalia. No rashes or lesions. Bartholin, urethral, and Skene's glands were normal. The vaginal vault contained normal-appearing vaginal discharge. The cervix was nulliparous, without cervical motion tenderness. Uterus was mobile and adnexa were difficult to appreciate given the patients habitus. Ext: 2+ peripheral pulses. No clubbing, cyanosis, or edema. Neuro: Awake, alert, and oriented to person, place, and time. Gross motor and sensory functions intact. <MEDICATIONS ON ADMISSION> Duloxetine 60mg PO QD Lorazapam 0.5mg PO QD as needed <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *2* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for dyspepsia. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary diagnosis: Endometriomas Secondary diagnoses: Fibroid uterus, endometriosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ gravida 0 with a history of uterine fibroids, endometriosis, and endometriomas who complains of worsening abdominal bloating and was found to have a 7.5 cm right endometrioma concerning for malignancy. She was taken to the OR for right salpingo-oophorectomy and left cystectomy with possible total abdominal hysterectomy and cancer staging. Intraoperatively, she was found to have an unchanged fibroid uterus, evidence of endometriosis, and bilateral endometriomas. A right salpingo-oophorectomy and left cystectomy were performed. Frozen pathology sections were found to contain only benign columnar epithelium, and therefore the patient was closed. Cystoscopy showed bilateral ureteral jets of indigo ___ dye, suggestive of intact ureters at the end of the procedure. Please refer to the operative note for full details. Postoperatively, the patient did well, tolerating a regular diet and oral pain medications by POD1. On POD1, her Foley catheter was removed. She was discharged to home in good condition on post-operative day 2.
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10005001-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus, left ovarian cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, lysis of adhesions, multiple myomectomy, left ovarian cystectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ gravida 0 with a long history of recurrent ovarian cyst and endometriosis who on ___, underwent a right salpingo-oophorectomy, left ovarian cystectomy for endometriomas. In ___, she had a multiple myomectomies for symptomatic fibroid uterus. The patient presents today for followup of unknown left adnexal cyst. The patient notes that she has no abdominal pain. She is simply experiencing increased bloatedness and pelvic pressure. New symptoms, she has developed stress urinary incontinence with sneezing. We discussed that this certainly can be related to this large adnexal cyst in addition to her overweightedness. On ___, she had an ultrasound, which showed an anteverted uterus that measured 14.3 x 6.7 x 9.2 cm, slightly smaller than previous measurement on ___, where it measured 15.2 x 7.4 x 10.4 cm. Multiple masses were consistent with uterine fibroids. The dominant fibroid was seen at the fundus and measured 3.3 x 3.3 x 3.5 cm. The endometrium was distorted due to fibroids and not well evaluated. An IUD was demonstrated within the endometrial cavity. The patient is status post right oophorectomy, previously seen 10.7 cm left adnexal cyst again visualized and now measuring slightly larger at 10.8 x 10 cm. It predominantly was thin walled; however, there was one area with the appearance of an incomplete septation. This either represented a hydrosalpinx or peritoneal inclusion cyst, less likely a cystadenoma. There was no free pelvic fluid. These findings were discussed with the patient. <PAST MEDICAL HISTORY> Past OB/GYN: The patient has regular menses. She has never had a pregnancy. She does have a history of genital warts. The patient has a long history of uterine fibroids, endometriosis, endometriomas. She is in a monogamous relationship with a female partner. PMH: ___ rhinitis Depression Uterine fibroids Endometriosis Endometriomas Pseudocholinesterase deficiency PSH: Medial collateral ligament release ___ Abdominal MMY <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her mother had hypertension and died of colon cancer. Her father has hypertension and prostate cancer. <PHYSICAL EXAM> Discharge <PHYSICAL EXAM> AVSS Gen NAD CV RRR P CTAB Abd soft, nondistended, appropriately tender to palpation, incision c/d/I Ext WWP <PERTINENT RESULTS> ___ 07: 25AM WBC-5.9 RBC-4.30 HGB-13.4 HCT-40.5 MCV-94 MCH-31.2 MCHC-33.1 RDW-11.9 RDWSD-41.6 ___ 07: 25AM PLT COUNT-268 <MEDICATIONS ON ADMISSION> Duloxetine 60mg QD <DISCHARGE MEDICATIONS> 1. DULoxetine 60 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN severe pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus, ovarian cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing an exploratory laparotomy, lysis of adhesions, left ovarian cystectomy, abdominal myomectomy for symptomatic fibroid uterus and left ovarian cyst. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, Tylenol and ibuprofen (pain meds). By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10005001-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Malignant transformation of endometriosis - final pathology report pending. <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, total abdominal hysterectomy, left salingo-oophrectomy, omentectomy, para-aortic lymph node biopsy, liver resection, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G0 with a history of fibroids and endometriosis who presents today for consultation regarding a large left adnexal mass identified on imaging. In ___ she underwent an abdominal myomectomy with left ovarian cystectomy for 27 fibroids and a 15-cm endometrioma. She reports recovering well until around ___, when she started to experience epigastric discomfort and occasional shortness of breath. She underwent CTA of the chest to evaluate for PE, which was negative and there was no lymphadenopathy or suspicious nodule seen. In ___, she got the heaviest period she has had since her Mirena IUD was placed. She underwent endometrial biopsy on ___, which showed chronic endometritis. She was already taking doxycycline for a positive Lyme titer while awaiting confirmatory testing, but continued to have vaginal bleeding. Her followup Lyme testing was negative. She continued to feel quite fatigued and noted abdominal pain epigastrically as well as in the LLQ, back pain, and decreased appetite and constipation which got progressively more bothersome during ___. She ultimately went to the ED on ___ where she underwent CT scan of the abdomen and pelvis, which showed a large 10-cm left complex adnexal cystic mass with septations and irregular solid components. Additionally, there were multiple subcapsular hepatic lesions and peritoneal implants, as well as retroperitoneal lymphadenopathy. Findings were concerning for a metastatic primary ovarian neoplasm, such as cystadenocarcinoma, versus atypical distribution of endometriotic implants. On ___ patient underwent an MRI of the abdomen and pelvis lower thorax showed clear lung bases no focal consolidations no pleural or pericardial effusion. Liver showed multiple nonenhancing cystic subcapsular implants likely representing hemorrhage. The largest right arises from the right lobe of the liver and measured 4.1 x 2.8 cm. There was no associated enhancement likely represent adherent clot. There were no suspicious enhancing lesions intrinsic to the hepatic parenchyma. Again, in regard to the pelvis, there was a large cystic multiloculated left adnexal structure measuring up to 10.8 x 10.1 cm. The septations were thin without significant enhancement or nodular components. The loculations demonstrated fluid-filled areas correction fluid-filled levels also likely representing hemorrhage. Within one of the loculations, there was a dark spot sign a finding that could be consistent with endometriosis. A smaller right adnexal cystic structure was seen measuring 3.5 x 3.0 cm. Uterus was enlarged with multiple small fibroids and IUD was seen within the endometrial cavity at. There was a trace free fluid within the pelvis multiple cystic anterior peritoneal implants were visualized with fluid-filled levels likely representing hemorrhage. There was peripheral enhancement, which may be reactive in nature. One of these peritoneal implants appeared to have significant surrounding fat stranding. A left periaortic retroperitoneal lesion had a similar appearance. Multiple subcentimeter periaortic lymph nodes were nonspecific. There was no inguinal or pelvic lymphadenopathy. She saw Dr. ___ in the office on ___ and received a 1-month dose of Lupron. She was referred to ___ Oncology for further evaluation given atypical imaging findings. Of note, she had a CA125 checked on ___, which was 108, decreased from 209 in ___. CEA was 0.9 on ___. Today she reports abdominal bloating, constipation, decreased appetite and increased abdominal girth. She noted decreased vaginal spotting since her Lupron shot, but it has been persistent. She also reports continued fatigue and occasional nausea. She denies chest pain, shortness of breath, diarrhea or dysuria. <PAST MEDICAL HISTORY> GYN HX: G0 - LMP ___, only minor spotting while IUD in place except when bleeding began in ___ - Currently sexually active with female partner - ___ history of abnormal Pap smears; last Pap ___ - Denies history of pelvic infections or sexually transmitted infections - Known history of fibroids and ovarian cysts - Known endometriosis PMH: - allergic rhinitis - depression - pseudocholinesterase deficiency - Denies hypertension, diabetes, asthma, thromboembolic disease PSH: - ___ knee surgery - ___ abdominal myomectomy - ___ RSO, L ov cystectomy -> Path: endometriotic cyst with focal metaplastic/reactive changes - ___ abdominal myomectomy, LOA, L ovarian cystectomy -> Path: leiomyomata with degenerative changes, endometriotic cyst <SOCIAL HISTORY> ___ <FAMILY HISTORY> FHx: - Father living, hx of bladder, prostate, skin, and throat cancer (non-smoker) - Mother died age ___ of colon cancer, also had DM and glaucoma - Brother is healthy - Niece with cystic fibrosis - No known family history of breast, uterine, ovarian, or cervical <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <MEDICATIONS ON ADMISSION> duloxetine 60mg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *2 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 3. Enoxaparin Sodium 30 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time Take this medication for a total of 28 days after your surgery, ending ___. RX *enoxaparin 30 mg/0.3 mL 30 mg SC twice a day Disp #*50 Syringe Refills: *0 4. Ferrous GLUCONATE 324 mg PO DAILY RX *ferrous gluconate 324 mg (36 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *2 5. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 6. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe do not drive or drink alcohol, causes sedation RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 7. DULoxetine 60 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> malignant transformation of endometriosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparaotomy, total abdominal hysterectomy, left salpingo-oophorectomy, omentectomy, para-aortic lymph node biopsy, liver resection and cystoscopy for malignant transformation of endometriosis. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural and Dilaudid PCA with toradol. Her diet was gradually advanced without difficulty and she was transitioned to oral oxycodone, Tylenol and ibuprofen. On post-operative day #2, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 5, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10005812-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Premature Preterm Rupture of Membranes <MAJOR SURGICAL OR INVASIVE PROCEDURE> D+E <HISTORY OF PRESENT ILLNESS> ___ G3P1 at ___ presented to the ED with leaking of fluid and N/V x 1d. N/V started last night after eating at ___, had emesis x 1, sudden onset. Woke this morning with persistent nausea, emesis x 1 today. Had "gush of fluid" after emesis last night with persistent leaking of clear fluid throughout the day; she has needed to wear a pad. Mild lower abd cramping also started today. Denies F/C, cough, dysuria, changes in bowel habits, sick contacts, vaginal bleeding. Continues to feel flutters of FM. U/S in ED demonstrated cervical funneling with an open internal os. An MRI also confirmed this, with no evidence of appendicitis. <PAST MEDICAL HISTORY> PNC: - ___: ___ - labs: unknown - screening: per pt, FFS wnl POBHX: G3 ___ - LTCS x 1, term, ___ arrest of dilation 5cm - SAB x 1 PGYNHX: - menstrual cycle: regular - Paps: denies hx abnl; no hx cervical procedures - STIs: denies PMH: - pseudotumor cerebri PSH: - LTCS - ACL reconstruction <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VS: 98.4 110 127/74 16 100RA GENERAL: NAD CARDIO: RRR PULM: CTAB ABDOMEN: soft, very mild TTP b/l LQ R>L, no R/G, mildly gravid EXTREMITIES: NT b/l SSE: +pooling, +nitrazine with membranes seen at os, which appears 2-3cm dilated bedside TAUS: adeq fluid, +FM, FHR 168bpm (M-mode) <PERTINENT RESULTS> ___ 09: 50PM WBC-25.4* RBC-4.02* HGB-12.2 HCT-35.2* MCV-88 MCH-30.4 MCHC-34.6 RDW-14.1 ___ 09: 50PM PLT COUNT-304 ___ 09: 50PM NEUTS-84.0* LYMPHS-12.0* MONOS-3.3 EOS-0.4 BASOS-0.3 ___ 09: 50PM ALT(SGPT)-21 AST(SGOT)-17 ALK PHOS-99 TOT BILI-0.4 ___ 09: 50PM LIPASE-17 ___ 09: 50PM GLUCOSE-110* UREA N-5* CREAT-0.6 SODIUM-137 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-20* ANION GAP-17 ___ 10: 31PM ___ PTT-28.4 ___ ___ 10: 31PM ___ ___ 09: 40PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09: 40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM ___ 09: 40PM URINE ___ BACTERIA-RARE YEAST-NONE EPI-0 ___ 05: 52AM WBC-24.8* RBC-3.77* HGB-11.8* HCT-34.0* MCV-90 MCH-31.3 MCHC-34.8 RDW-13.1 ___ 05: 52AM PLT COUNT-283 ___ 05: 52AM ___ PTT-25.4 ___ ___ 05: 52AM ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 5: 55 am SWAB Fluid should not be sent in swab transport media. Submit fluids in a capped syringe (no needle), red top tube, or sterile cup. SWAB OF VAGINAL -AMNIOTIC FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). FLUID CULTURE (Final ___: Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. HAEMOPHILUS SP. SPARSE GROWTH. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *20 Tablet(s)* Refills: *0* 3. Doxycycline Monohydrate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp: *14 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p D+E for pprom at 20 wks <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Pelvic rest for 6 weeks
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Mrs. ___ was transferred from the ED to L+D, where she was initially expectantly managed for her PPROM. She was started on ampicillin, gentamicin, and clindamycin. However, it became apparent that she had developed chorioamnionitis (foul-smelling green-tinged amniotic fluid as well as fundal tenderness and an elevated white count). She was counseled regarding the prognosis and the significant risks to herself, and she agreed to undergo dilatation and evacuation of the fetus. Dr. ___ this procedure on ___. It was uncomplicated; op-note available in OMR. The patient was transferred to the Gynecology service post-operatively where she was continued on triple antibiotic therapy. She did well on this and remained afebrile on post-op day #1, when she was discharged home on oral doxycycline. She saw social work as well during her stay.
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10006196-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 25w0d with known posterior previa who presents with first episode of spotting in this pregnancy. No ctx, LOF. +FM. <PAST MEDICAL HISTORY> ___ ___ tri us Labs Rh+/Abs-/RI/RPRNR/HBsAg-/HIV-/GBS unknown Genetics LR ERA FFS normal, complete posterior previa GLT not yet done Issues 1. post previa on FFS OBHx: G1 GynHx: hx LGSIL ___, no f/u. PMH: denies PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 98.6, HR 108, BP 113/71 GENERAL: A&O, comfortable ABDOMEN: soft, gravid, nontender GU: no bleeding on pad EXT: no calf tenderness TOCO no ctx FHT 150/mod var/+accels/-decels On discharge: afebrile, VSS Gen: NAD Abd: soft, nontender, gravid ___: without edema <PERTINENT RESULTS> n/a <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Ranitidine 150 mg PO BID: PRN heartburn <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> posterior placenta previa, spotting <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the antepartum service after having some spotting, which has since resolved. You received a complete course of steroids and had reassuring monitoring during your stay. You had an ultrasound done which showed a persistent placenta previa covering the cervix. Your doctors feel ___ are safe to go home with outpatient followup. Please call your doctor right away if you notice any additional vaginal bleeding or start having contractions. Your zantac prescription has been sent to the ___ on ___ ___.
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___ y/o G1P0 with posterior previa diagnosed at 20 weeks admitted to the antepartum service at 25w0d with small spotting. On admission, she was hemodynamically stable with no further bleeding. Speculum exam was deferred given her spotting had resolved. Fetal testing was reassuring. She was admitted to the antepartum service for observation. She had an ultrasound in the CMFM which revealed persistent complete previa. She was given two doses of betamethasone and had no active bleeding so she was discharged home in good condition on hospital day 2 with bleeding precautions and outpatient followup.
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10010362-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> "s/p cesarean section complicated by PPH requiring transfusion" <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean section <HISTORY OF PRESENT ILLNESS> The patient is a ___ gravida 2, para 0, who presented in early labor on ___ after spontaneous rupture of membranes. She progressed to 8 cm at around 10 a.m. on ___ with expectant management, but cervical dilitation did not progress. The patient agreed to augment her labor with Pitocin. However, she did continue to labor without neuraxial anesthesia. The Pitocin was titrated per protocol, but she did not make any cervical change for several hours. At this point an intrauterine pressure catheter was recommended; the patient declined. She did elect for a combined spinal epidural and afterwards the Pitocin was continued to be titrated per protocol. However, after 12 hours, she was still found to be 8 cm, 100%, and -1 station. Therefore, the recommendation was made to proceed with a primary cesarean section due to arrest. The risks and benefits were discussed with the patient and her partner, all questions were answered, all consents were signed. She had a reassuring fetal status prior to surgery. Total EBL was 800cc. She was transferred to the postpartum floor and then experienced several gushed of bright red blood mixed with clots from her vagina. She was brought back to the Labor floor. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On examination during PPH, pt had bled out 400cc of blood clots in the bed. U/S showed some lower uterine segment clots. Endometrial stripe appeared adequate. Evacuated 400cc more of blood from lower uterine segment. She received 1000mcg of cytotec and 40 units of pitocin. Pt was transferred back to labor and delivery for continued bleeding. <PERTINENT RESULTS> ___ 12: 15AM BLOOD WBC-15.5* RBC-4.59 Hgb-14.1 Hct-39.4 MCV-86 MCH-30.7 MCHC-35.7* RDW-13.4 Plt ___ ___ 12: 41AM BLOOD WBC-20.4* RBC-3.91* Hgb-12.3 Hct-33.8* MCV-87 MCH-31.4 MCHC-36.4* RDW-13.6 Plt ___ ___ 03: 27AM BLOOD WBC-22.4* RBC-3.50* Hgb-10.9* Hct-30.3* MCV-87 MCH-31.2 MCHC-36.0* RDW-13.7 Plt ___ ___ 07: 31AM BLOOD WBC-15.9* RBC-2.71* Hgb-8.2* Hct-23.2* MCV-86 MCH-30.1 MCHC-35.2* RDW-13.8 Plt ___ ___ 05: 06PM BLOOD WBC-15.1* RBC-3.05* Hgb-9.7* Hct-26.9* MCV-88 MCH-31.7 MCHC-36.0* RDW-14.1 Plt ___ ___ 08: 35AM BLOOD WBC-16.6* RBC-2.90* Hgb-9.0* Hct-25.6* MCV-88 MCH-30.9 MCHC-35.0 RDW-14.2 Plt ___ <MEDICATIONS ON ADMISSION> - Prenatal vitamins <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *60 Capsule(s)* Refills: *1* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for Pain. Disp: *45 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *1* 4. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO twice a day. Disp: *60 Capsule, Extended Release(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p cesarean section s/p blood transfusion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine postpartum
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Ms. ___ was transferred back to labor and delivery when her bleeding failed to stop with 40 units of pitocin, 1000mcg of cytotec and manual evacuation. Her bleeding however did resolve after she received 0.2mg of IM Methergine. Her HCT was trended and found to nadir at 23.2. She had tachycardia and a low urine output. The decision was the made to transfuse her for symptomatic anemia. She received 2 units of red cells and her hematocrit responded appropriately to 25.6, her urine output and heart rate improved significantly. The rest of her postpartum course was uncomplicated.
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10010374-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ year-old Gravida 2 Para 1 at 28 weeks 6 days gestational age who presented with acute onset left lower quadrant pain while laying still in bed. She got up and urinated and it gradually worsened to ___. She had never experienced this kind of pain before. It was twisting and very sharp in nature and constant. Worse with legs extended vs flexed. A couple of hours after the pain started, she started to feel uterine tightening. Denied fever, chills, nausea, vomiting, diarrhea, dysuria, vaginal bleeding, leaking of fluid, hematuria, abnormal vaginal discharge. + Fetal movement. Last intercourse the morning prior. <PAST MEDICAL HISTORY> PRENATAL COURSE - Estimated Due Date: ___ - labs: A+/Ab- - screening: GLT wnl, FFS wnl . OBSTETRIC HISTORY Gravida 2 Para 1 (___) @ ___: Vacuum-assisted vaginal delivery @ 34 ___ wks, spontaneous preterm labor, had been hospitalized during pregnancy @ 30 weeks with vaginal bleeding and received betamethasone. 5#4, male GYNECOLOGIC HISTORY: remote history of chlamydia . PAST MED/SURG HISTORY: benign <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS: T 98.3, RR 18, BP 97/66, HR 130->115 GENERAL: crying, lying on her side in fetal position, very uncomfortable, able to speak in full sentences CARDIO: reg rhythm, tachy PULM: CTAB BACK: no CVA tenderness ABDOMEN: soft, gravid, most TTP LLQ just superior to inguinal area (no palpable underlying masses) though tender more superiorly as well, no R/G, no uterine TTP EXTREMITIES: NT b/l SSE: def SVE/BME: L/C/P TOCO: no clear ctx FHT: 150, mod var, AGA, no decels BPP: ___, cephalic, DVP 5.3, EFW 1328g 2#15oz <PERTINENT RESULTS> ___ WBC-9.0 RBC-3.95 Hgb-12.8 Hct-36.4 MCV-92 Plt-404 ___ Neuts-72.8 ___ Monos-6.3 Eos-1.4 Baso-0.4 ___ WBC-9.5 RBC-4.04 Hgb-12.3 Hct-36.4 MCV-90 Plt-417 ___ Neuts-70.0 ___ Monos-5.6 Eos-1.1 Baso-0.4 . ___ ___ PTT-31.1 ___ ___ . ___ Glucose-73 BUN-4 Creat-0.5 Na-134 K-4.2 Cl-102 HCO3-22 ___ Calcium-8.7 Phos-3.7 Mg-2.0 . ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM . Pelvic Ultrasound: Limited views demonstrate a live single intrauterine gestation with normal cardiac activity. The cervix remains long and closed. Please note that this limited exam does not substitute a full fetal survey. . Attention was then directed to bilateral superiorly displaced ovaries, necessitating use of linear probe. The left ovary measures 2.7 x 2 x 1.5 cm, with normal arterial and venous flow. The right ovary measures 2.2 x 1.4 x 1 cm, with normal venous flow. Arterial flow on the right is not demonstrated. The ovaries appear normal in size and morphology. There is no focal tenderness over the superiorly displaced ovaries. . Targeted ultrasound was performed to the site of symptomology in the lower abdomen, away from the ovaries, demonstrating no focal pathology. . IMPRESSION: 1. Normal size and morphology of bilateral ovaries. Normal vascularity of the left ovary. Limited arterial assessment of the right ovary. 2. Limited exam of single intrauterine gestation with normal cardiac activity and closed cervix. For full assessment of the fetus, continued routine fetal followup is recommended. 3. Tenderness in the lower abdomen is away from superiorly displaced ovaries. No discrete pathology is demonstrated at the site of symptom. <MEDICATIONS ON ADMISSION> prenatal vitamin folic acid <DISCHARGE MEDICATIONS> prenatal vitamin folic acid <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 29+0 weeks gestation suspected viral gastroenteritis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> stay well hydrated
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Ms. ___ received 0.5mg of IV Dilaudid in triage and her pain greatly improved. As above, her pelvic ultrasound was negative for any pathology and her laboratory studies were unrevealing. She did not require any additional analgesics and was admitted to the antepartum floor for close observation and abdominal exams. While there, she had an episode of emesis after eating and began having chills and feeling generally unwell with no abdominal pain, but abdominal discomfort. She remained afebrile with no elevation of white count and had no other focal signs or symptoms. It was thought that she had a mild viral gastritis. Her left lower quadrant pain never returned. She was given zantac, oral zofran and IV hydration and by the afternoon on hospital day #2 was feeling better. . Fetal testing was reassuring by ultrasound and non-stress testing. She had no signs of labor and her cervix remained closed. . She was discharged home on hospital day #2 symptomatically improved.
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10014107-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cramping <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ y/o G5P0040 GDMA, ___ ___ presents to triage with the complaint of cramping and lower back pain. she states the cramping began yesterday and decided that if still cramping would call in the morning. she denies vaginal spotting or leaking. Active fetal movements. <PAST MEDICAL HISTORY> PNC *) Dating ___ ___ by LMP consistant w/7+4 wk u/s *) Labs: AB pos/Ab neg/R-I/RPR-NR/HBsAg neg/HIV negHCV neg *) FFS unremarkable, placenta anterior no previa, cl 44mm *) glucola: ___ ___ ___ issues short CL,on vaginal progesterone, received BMZ and complete on ___. GDMA1 OBHx TAB x 2 SAB x 2 GYNHx LMP ___ LEEP denies STI's PMH benign <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> O: BP 126/73 HR 92 RR 14 temp 98 RRR CTA B ABD gravid, soft, NT FHT 145 ___, AGA Toco ctx q ___ mins fFN obtain but not sent given a change in cx SVE 1.5cm/100/BBOW cephalic by U/S <MEDICATIONS ON ADMISSION> prenatal vitamins insulin <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm labor, insulin requiring gestational diabetes <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest
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Pt was initially found to be 1.5cm dilated. She was observed on the antepartum service and kept on bedrest. On the morning of ___, her cramping increased and became painful, she was found the be 7cm dilated and in active labor. She was transferred to L&D and had an uncomplicated vaginal delivery of a liveborn male, who was brought to NICU. She did well postpartum and was discharged home on PPD#2.
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10014383-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> adhesive / Venomil Yellow Jacket Venom / Codeine / Vicodin / lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> cystocele, stress urinary incontinene <MAJOR SURGICAL OR INVASIVE PROCEDURE> anterior colporrhaphy, suburethral sling, cystoscopy <HISTORY OF PRESENT ILLNESS> The patient is a ___, referred for gynecologic evaluation regarding vaginal prolapse and stress incontinence. The patient was originally managed with a pessary, which she wore for approximately ___ years. She eventually experienced some vaginal spotting and elected for a more definitive management in the form of surgery. She was referred for multichannel urodynamic testing, which confirmed that she has stress urinary incontinence with urethral hypermobility. <PAST MEDICAL HISTORY> PMH: polymyalgia rheumatica, HTN, hypothyroidism, low back pain, SVD x4 PSH: TAH BSO, CCY, appx, carpal tunnel x2, temporal artery ligation <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is siginficant for a sister with ___ cancer and unremarkable for Ovarian or Colon cancer. <PHYSICAL EXAM> Preoperative physical exam: Vaginal exam : External genitalia: no lesions or discharge urethral meatus: no caruncle or prolapse urethra: non tender, no exudate Internal exam: There was moderate/severe vaginal atrophy. Vagina was inspected and there were ulcerations absent # 3 ring w/ support was removed and NOT REINSERTED Discharge exam: Gen: NAD CV: RRR Lungs: CTAB Abd: soft, NT, ND GU: minimal spotting on pad, clear urine in foley Ext: WWP, calves nontender <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after undergoing an anterior repair and sling procedure. You have recovered well and are ready to be discharged. You are being discharged with a foley catheter in place. Please follow the instructions below: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks or until cleared at your post-operative appointment * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ office in ___ on ___ at 9: 20am for catheter removal.
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Ms. ___ was admitted to the gynecology service after undergoing a TVT EXACT sling procedure, anterior colporrhaphy and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 240 mL, voided 0 mL with 400 mL residual. 2. Instilled 300 mL, voided 0 mL with 350 mL residual. Her Foley catheter was replaced and she was instructed in its care. Her diet was advanced without difficulty and she was transitioned to oral pain medications. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. PredniSONE 5 mg PO DAILY 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*3 5. eszopiclone 3 mg oral HS 6. Hydrochlorothiazide 25 mg PO DAILY 7. Ibuprofen 600 mg PO Q8H:PRN Pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*1 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain Do not drive while taking this medication. RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 9. Acetaminophen 1000 mg PO Q6H:PRN pain Do not exceed 4000 mg per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*3 10. Nitrofurantoin (Macrodantin) 100 mg PO DAILY RX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth once a day Disp #*5 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: bladder prolapse stress urinary incontinence urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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| 612
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10016832-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery blood transfusions <HISTORY OF PRESENT ILLNESS> Pt presented with elevated BP, 144/98, and headache at 37w6d in the office. She went to L+D for evaluation. <PAST MEDICAL HISTORY> Her medical history is significant for: 1) hypertension 2) hyperlipidemia 3) seizure disorder secondary to AVM in the brain ___ with her first seizure ___ years ago and her last seizure ___ 4) history of migraine headaches 5) osteoarthritis of bilateral knee joints right greater than left 6) chronic low back pain 7) vitamin D deficiency 8) hepatic steatosis by ultrasound study Her surgical history includes: 1) right parietal-occipital AVM resection ___ 2) placement of a laparoscopic adjustable gastric band ___ 3) removal of adjustable gastric band secondary to prolapse ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> She works as a ___ at ___ and lives with her wife who is a ___. <PHYSICAL EXAM> On admission ___ 12: 41BP: 104/78 (85) ___ 12: 46BP: 131/81 (93) ___ 13: 01BP: 120/94 (97) ___ ___: 96 ___ 13: 16BP: 98/70 (75) ___ ___: 74 ___ 13: 21BP: 138/86 (97) ___ ___: 71 Gen: A&O, comfortable PULM: normal work of breathing Abd: soft, gravid, nontender EFW med-large, cephalic by ___ Ext: no calf tenderness On discharge: Vitals: 24 HR Data (last updated ___ @ 102) Temp: 97.9 (Tm 98.6), BP: 110/56 (109-126/56-76), HR: 65 (65-71), RR: 16 (___), O2 sat: 97% (95-98) Gen: NAD, A&Ox3 Cardiopulm: No respiratory distress Abd: soft, NTND, fundus firm, nontender, below umbilicus Incision: c/d/I, no erythema or purulent drainage Ext: no calf tenderness <PERTINENT RESULTS> ___ 06: 05AM BLOOD WBC-7.3 RBC-2.65* Hgb-8.2* Hct-25.0* MCV-94 MCH-30.9 MCHC-32.8 RDW-15.1 RDWSD-51.8* Plt ___ ___ 02: 01PM BLOOD WBC-7.5 RBC-2.65* Hgb-8.1* Hct-24.9* MCV-94 MCH-30.6 MCHC-32.5 RDW-15.3 RDWSD-52.2* Plt ___ ___ 06: 10AM BLOOD WBC-7.6 RBC-2.63* Hgb-8.1* Hct-24.5* MCV-93 MCH-30.8 MCHC-33.1 RDW-14.9 RDWSD-49.8* Plt ___ ___ 08: 20PM BLOOD WBC-8.7 RBC-2.21* Hgb-7.0* Hct-20.4* MCV-92 MCH-31.7 MCHC-34.3 RDW-14.9 RDWSD-50.2* Plt ___ ___ 06: 17AM BLOOD WBC-10.1* RBC-2.03* Hgb-6.3* Hct-19.1* MCV-94 MCH-31.0 MCHC-33.0 RDW-14.7 RDWSD-50.6* Plt ___ ___ 07: 52PM BLOOD WBC-14.8* RBC-2.51* Hgb-7.9* Hct-24.0* MCV-96 MCH-31.5 MCHC-32.9 RDW-14.3 RDWSD-49.9* Plt ___ ___ 12: 39PM BLOOD WBC-18.7* RBC-2.20* Hgb-7.0* Hct-21.9* MCV-100* MCH-31.8 MCHC-32.0 RDW-14.4 RDWSD-51.8* Plt ___ ___ 10: 30AM BLOOD WBC-15.6* RBC-2.40* Hgb-7.7* Hct-24.2* MCV-101* MCH-32.1* MCHC-31.8* RDW-14.2 RDWSD-51.6* Plt ___ ___ 12: 53PM BLOOD WBC-8.1 RBC-3.67* Hgb-11.7 Hct-34.6 MCV-94 MCH-31.9 MCHC-33.8 RDW-13.5 RDWSD-46.4* Plt ___ ___ 06: 10AM Creat-0.9 ___ 12: 39PM BLOOD Creat-1.2* ___ 12: 53PM BLOOD Creat-0.8 ___ 10: 30AM BLOOD ALT-10 AST-19 ___ 12: 53PM BLOOD ALT-15 AST-34 CXR (___) heart size is enlarged but this might represent physiologic pregnancy increased cardiovascular volume status, although true enlargement of the cardiac silhouette due to pathological causes is a possibility, correlation with echocardiography is recommended. Left retrocardiac opacity might represent atelectasis but infectious process is a possibility. No pulmonary edema. No appreciable pleural effusion. No pneumothorax. CT (___) Large anterior pelvic hematoma measures 15.0 x 9.9 x 9.2 cm. Moderate size hemoperitoneum. No active hemorrhage is identified. CTA (___) IMPRESSION: 1. Large lower anterior uterine segment bladder flap hematoma appears fairly similar in size to slightly contracted compared to prior imaging. No active extravasation of contrast/arterial bleed. 2. Small subcutaneous hematoma is in the lower anterior abdominal/pelvic wall. <MEDICATIONS ON ADMISSION> PNV, Lamictal ___ mg, folic acid, fioricet PRN, celexa 20mg <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H 2. Citalopram 15 mg PO DAILY 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills: *0 5. LamoTRIgine 600 mg PO QPM 6. LamoTRIgine 400 mg PO QAM <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cesarean delivery preeclampsia post-operative bleeding anemia blood transfusions <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Routine postpartum instructions
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Ms ___ is a ___ year old G1P1 who underwent a primary low transverse cesarean section on ___. Delivery by cesarean was chosen due to patient preference because of her history of epilepsy and prior surgery for arteriovenous malformation. Delivery was recommended as patient had developed a headache overnight refractory to medications. She was thus diagnosed with chronic HTN with superimposed severe pre-eclampsia, severe by HA. Her post operative course was complicated by acute blood loss anemia secondary to a large pelvic hematoma. Regarding her chronic hypertension with superimposed pre-eclampsia, her headache improved after delivery. She has normal labs and a urine p:c that was 0.26. She was started on magnesium post partum which was kept for 17 hours. Her magnesium was stopped early given new onset oliguria. A mag level was normal at ___. Regarding her acute blood loss anemia, patient initially started feeling symptomatics with BPs in the ___ on ___. She was noted to be oliguric at 30cc/hr and received a 250cc bolus. Given new shortness of breath, patient underwent a chest xray which returned consistent with atelectasis. Her hematocrit was trended and she was noted to have a significant decrease in her hematocrit from 34.6 pre-operatively to 21.9 on ___. Decision was made to transfuse 2 units of packed RBCs and obtain imaging. A CT abdomen and pelvis was notable for a 15.0 cm hematoma anterior to the lower uterine segment, moderate hemoperitoneum, and no evidence of active bleed. Given stability, ___ embolization deferred. On ___, patient required an additional 2 units of packed RBCs. She had an inappropriate rise in her hct at 20.4 from 19.1 and therefore was transfused another 2 units for a total of 6 units during her hospital stay. Given need for multiple blood transfusions, repeat imaging with CTA was obtained showing interval decrease in the hematoma and no area of active bleeding. Of note, given her acute blood loss anemia, patient suffered an ___, which resolved by ___. By ___, patient was in stable condition with stable vitals and stable labs. She met all her post operative milestones and was discharged to home with close follow up.
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| 492
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10017530-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Insect Extracts <ATTENDING> ___ <CHIEF COMPLAINT> Post menopausal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total ___ hysterectomy, right salpingo-oophorectomy, omentectomy, and cystoscopy. <HISTORY OF PRESENT ILLNESS> ___ year-old gravida 0 who experienced postmenopausal bleeding that led to a pelvic ultrasound at ___ Ultrasound ___. This study dated revealed an endometrial polyp measuring 2.3 cm. This polyp had internal vascularity. The right ovary was well visualized and within it was a 1.8 cm complex cyst with multiple solid areas and areas of peripheral mural thickening and nodularity, some of which were vascularized. Notably, she has a history of bilateral borderline ovarian cancer and is status post a left salpingo-oophorectomy and right ovarian cystectomy in ___. <PAST MEDICAL HISTORY> OB/GYN History: She is a gravida 0. She reports that her last Pap smear was about a year ago and was normal. She has never had an abnormal Pap smear. She denies any history of pelvic infections or STDs. - History of bilateral borderline ovarian cancers. She underwent an exploratory laparotomy, left salpingo-oophorectomy, right ovarian cystectomy, partial omentectomy in ___. Postoperatively, she has had no evidence of disease recurrence and has been followed with annual visits. - Menopause a few years ago but has had some concerns with osteoporosis and therefore began bioidentical hormones under the care of Dr. ___. She has stopped using these since the bleeding that she had. . <PAST MEDICAL HISTORY> She reports a history of osteopenia. She denies any history of asthma, hypertension, cardiac disease, coronary artery disease, mitral valve prolapse, thromboembolic disorder, or cancer. She reports being up-to-date with mammograms, colonoscopies, and bone density evaluation. . Past Surgical History: As above. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports a maternal first cousin had breast cancer. Both her mother and her father had colon cancer but at old ages. Her mother had the disease at the age of ___, and her father had the disease diagnosed just prior to his death in ___. <PHYSICAL EXAM> Performed by Dr. ___ on ___: GENERAL: Appears stated age, no apparent distress. NECK: Supple. No masses. LYMPHATICS: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. CHEST: Lungs clear. HEART: Regular rate and rhythm. BACK: No spinal or CVA tenderness. ABDOMEN: Soft, nontender, nondistended. There is no mass. There is no hepato or splenomegaly. There is no fluid wave. EXTREMITIES: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. PELVIC: Normal external genitalia. Inner labial folds normal. Urethral meatus normal. Walls of the vagina are smooth. Apex is normal. Cervix is normal. Bimanual exam reveals a mobile uterus without mass or lesion. There is no cul-de-sac nodularity. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: Do not drive while taking this medication. Disp: *60 Tablet(s)* Refills: *0* 3. docusate sodium 100 mg Capsule Sig: ___ Capsules PO BID (2 times a day) as needed for constipation: Take daily while taking narcotic to prevent constipation. Disp: *60 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Borderline ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit.
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Ms. ___ underwent a ___ right salpingo-oophorectomy, intraoperative pathology revealed borderline ovarian cancer and a total ___ hysterectomy, omentectomy, and cystoscopy was performed. She had a benign post-operative course and was discharged home on post-operative day #1 on oral pain medications, she was ambulating, tolerating a regular diet, and able to urinate without difficulty.
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10019003-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G1, P1 who underwent an abdominal ultrasound to evaluate for abdominal aortic aneurysm given her strong history of tobacco use by her primary care physician. That ultrasound revealed a large pelvic mass. She then underwent a CT scan on ___ which revealed a large mass within the pelvis measuring 9.9 x 12.2 x 10.3 cm with internal locules corresponding to the area of nodularity identified in ultrasound. The mass was intensely associated with the left ovary and closely abuts the uterine fundus. While there is no clear fat plane seen between the mass and uterus, it is believed to be of ovarian in origin rather than uterine. There are scattered sigmoid diverticula. No free fluid in the pelvis. Bladder and rectum are unremarkable and there are no enlarged pelvic or inguinal lymph nodes. She states that she has been asymptomatic from this mass. Today, she has no complaints. She denies any vaginal bleeding, abdominal pain, nausea, vomiting, change in bladder or bowel habits. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Significant for breast cancer status post lumpectomy and adjuvant radiation, diabetes, hypertension, hypercholesterolemia, and depression. PAST SURGICAL HISTORY: Laparoscopic cholecystectomy and a right breast lumpectomy. OB AND GYN HISTORY: She is a gravida 1, para 1 with one spontaneous vaginal delivery. Her last menstrual period was when she was in her ___, menarche at age ___ with regular periods lasting four to five days. No history of abnormal Pap smears. Her last Pap was in ___, which was negative. No history of sexually transmitted infections, cysts or fibroids. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denies any family history of GYN malignancies. <PHYSICAL EXAM> Pre-operative exam: GENERAL: Well-appearing, no acute distress. CARDIOVASCULAR: Regular rate and rhythm, no murmurs. LUNGS: Clear to auscultation bilaterally. BACK: No CVA or spinal tenderness. ABDOMEN: Soft, nontender, nondistended. No masses appreciated. No hernias. EXTREMITIES: No edema. LYMPHATICS: No supraclavicular or inguinal lymphadenopathy. PELVIC: Normal external female genitalia. Speculum exam revealed paracervix. No lesions present. Bimanual exam revealed a normal-sized uterus. Mass was difficult to appreciate secondary to body habitus. Rectovaginal exam revealed no nodularity or masses appreciated. Normal rectal tone. Exam on discharge: GENERAL: Well-appearing, no acute distress. CARDIOVASCULAR: Regular rate and rhythm, no murmurs. LUNGS: Clear to auscultation bilaterally. BACK: No CVA or spinal tenderness. ABDOMEN: Soft, nontender, nondistended. Incision clean, dry, intact EXTREMITIES: No edema. Non tender <PERTINENT RESULTS> ___ 09: 22AM BLOOD WBC-10.3# RBC-3.50*# Hgb-11.3*# Hct-33.3*# MCV-95 MCH-32.3* MCHC-33.9 RDW-14.8 Plt ___ ___ 09: 22AM BLOOD Neuts-73.2* Lymphs-17.7* Monos-8.5 Eos-0.3 Baso-0.3 ___ 09: 22AM BLOOD Glucose-232* UreaN-14 Creat-1.1 Na-141 K-4.6 Cl-103 HCO3-30 AnGap-13 ___ 09: 22AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.2 CTA (___): 1. Worsening emphysema. 2. No pulmonary embolus. 3. Bibasilar atelectasis at the lung bases. 4. 3-mm nodule in the right middle lobe. Consider followup in six months to document stability. 5. Hepatic steatosis. CXR (___): No acute intrathoracic process. <MEDICATIONS ON ADMISSION> ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 2 Tablet(s) by mouth daily GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet - 1 Tablet(s) by mouth twice a day LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth day METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth evening PAROXETINE HCL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth morning ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth evening Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by Other Provider; ___) - Dosage uncertain CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth morning OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* 3. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation three times a day as needed for shortness of breath or wheezing. Disp: *1 * Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> large left ovarian cyst, pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) x 6 weeks, no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. We will give you a prescription for an albuterol inhaler. You likely will need more medication or therapy for your lungs, please follow-up with pulmonology whom we have contacted on your behalf.
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Ms. ___ underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and cystoscopy. Please see Dr. ___ ___ for full details. Post-operatively she was admitted to the gyn oncology service. On POD#1 Ms. ___ started to have some oxygen desaturations requiring oxygen via nasal cannula. CTA on ___ revealed worsening emphysema when compared to previously but no pulmonary emboli. CXR ___ did not reveal any acute intrathoracic process. She was started on chest physical therapy and albuterol and atrovent nebulizers. By POD#3 she was able to be weaned off of oxygen. Post-operatively her BPs and finger sticks were within normal limits. By POD#3 she was able to ambulate, tolerate a regular diet, control her pain with oral pain medications and void spontaneously. She was discharged in good condition on POD#3 with follow-up.
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10020728-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy and cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___, G2, P1, with a multi- fibroid uterus and persistent symptoms of left lower quadrant pain and some menorrhagia. <PAST MEDICAL HISTORY> PMHx: SVD x 1, GERD, hiatal hernia PSHx: open ovarian cystectomy <PHYSICAL EXAM> Upon discharge: Vital signs stable General: well appearing in no acute distress Abdominal: soft, nondistented, incisions clean, dry, and intact <PERTINENT RESULTS> SURGICAL FINDINGS: 1. Intact non ___ IUD removed at the beginning of the case. 2. A 10 week size uterus with 6 cm left posterior uterine segment fibroid extending into the broad ligament. 3. Uterus and fibroid total weight 270 g. 4. Normal-appearing ovaries bilaterally with a 2 cm simple cyst in the right ovary and normal tubes. 5. Intact bladder with bilateral ureteral jets on cysto. <MEDICATIONS ON ADMISSION> omeprazole <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q6 hours Disp #*50 Tablet Refills: *1 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4 hours Disp #*30 Tablet Refills: *0 3. MetRONIDAZOLE (FLagyl) 500 mg PO BID Duration: 7 Days RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 5. Senna 8.6 mg PO BID: PRN constipation RX *sennosides [senna] 8.6 mg ___ capsule by mouth at bedtime Disp #*30 Capsule Refills: *0 6. Omeprazole 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hysterectomy for fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms ___, you were admitted after your hysterectomy and you have done well. Please follow instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * If TLH/TVH: Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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The patient was admitted to the gynecology service for her surgical procedure. Her intraoperative course was uncomplicated. The patient was suspected to have bacterial vaginosis and was started on flagyl for cuff dehicense prophylaxis. Upon transition to oral pain medications and meeting other postoperative milestones, the patient was discharged home in stable condition.
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10023708-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Darvon / aspirin <ATTENDING> ___ <CHIEF COMPLAINT> Left adnexal mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparascopy converted to open Total Abdominal Hysterectomy Bilateral Salpingo-oophorectomy Omentectomy Peritoneal biopsy <HISTORY OF PRESENT ILLNESS> Ms. ___ is an ___ yo who was taken to the emergency department for symptoms of near syncope, nausea and vomiting, and a CT scan revealed a 3.9 cm solid, vascular mass in the left adnexa on ___. This was followed up with an ultrasound, which confirmed a 3.7x3.9x3.1cm solid, heterogeneous and vascular mass with irregular borders. She denies abdominal pain or bloating, N/V, vaginal bleeding, urinary symptoms or changes in bowel habits. She does note weight loss since ___, but she has attributed this to metformin and stress. Surgical management was recommended. Patient was agreeable to the plan and all consents were signed. <PAST MEDICAL HISTORY> PMH: HTN, ___ diagnosed ___, anxiety/depression (recent). Denies h/o thromboembolic disorder. PSH: D&C ___ secondary to irregular bleeding, cholecystectomy via laparotomy ___, right ankle ORIF ___. OB: G2P2, NVD x2 GYN: Menarche age ___, menopause mid-___. H/O fibroids. Denies h/o previous ovarian cysts, STI or abnormal pap. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Paternal cousin died of breast cancer age ___. Maternal cousin ALS. Multiple family members have HTN, ___ and CAD. Denies family history of ovarian cancer, endometrial cancer and colon cancer. <PHYSICAL EXAM> On discharge No acute distress. Appears stated age Regular rate and rhythm. No murmurs, rubs or gallops Lungs were clear to auscultation bilaterally but with some decreased effort Abdomen was soft and non-distended. Incision with staples was clean, dry and intact. No evidence of infection Extremities were non-tender and non-edematous <PERTINENT RESULTS> ___ 07: 10AM BLOOD WBC-16.8* RBC-4.61 Hgb-12.6 Hct-38.8 MCV-84 MCH-27.4 MCHC-32.6 RDW-14.3 Plt ___ ___ 07: 10AM BLOOD Glucose-185* UreaN-13 Creat-0.7 Na-134 K-4.4 Cl-97 HCO3-28 AnGap-13 ___ 07: 10AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.7 ___ 07: 50AM BLOOD WBC-14.3* RBC-4.38 Hgb-12.0 Hct-37.1 MCV-85 MCH-27.4 MCHC-32.2 RDW-13.9 Plt ___ ___ 07: 40AM BLOOD WBC-11.8* RBC-4.54 Hgb-12.2 Hct-38.4 MCV-85 MCH-26.9* MCHC-31.8 RDW-13.6 Plt ___ ___ 07: 57AM BLOOD WBC-15.3* RBC-5.06 Hgb-13.7 Hct-43.0 MCV-85 MCH-27.2 MCHC-31.9 RDW-13.8 Plt ___ ___ 07: 50AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-137 K-4.1 Cl-98 HCO3-30 AnGap-13 ___ 07: 40AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-141 K-3.3 Cl-101 HCO3-30 AnGap-13 ___ 07: 57AM BLOOD Glucose-145* UreaN-8 Creat-0.7 Na-141 K-3.3 Cl-99 HCO3-30 AnGap-15 ___ 07: 40AM BLOOD Calcium-8.8 Phos-1.9* Mg-1.8 ___ 07: 57AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.1 ___ 07: 50AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8 <MEDICATIONS ON ADMISSION> - Amlodipine 10mg daily - Metformin 250mg twice daily - Simvastatin 20mg daily - Lorazepam 0.5mg twice daily as needed - zolpidem ___ every night as needed <DISCHARGE MEDICATIONS> 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): please do not exceed 4g of acetaminophen in 24 hours. Disp: *120 Tablet(s)* Refills: *2* 4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp: *20 Tablet(s)* Refills: *0* 5. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp: *60 Tablet(s)* Refills: *2* 6. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea: please hold for restlessness or any muscle stiffness. Disp: *30 Tablet(s)* Refills: *0* 7. metformin Oral 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Left adnexal mass Final Pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted into the gynecology oncology service for routine post-operative care following her laparascopy converted to total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal biopsy for left adnexal mass. Her case was uncomplicated. Please refer to operative note for full details of the procedure. #1 Routine Post-op In the PACU, Ms. ___ had an epidural placed and is being followed by acute pain services. Her pain was well controlled. The epidural was discontinued on post-operative day 2. Her nausea responded to reglan and her diet was therefore advanced and she was transitioned to oral pain medications without any problems. On the ___ nighf after surgery, Ms. ___ had a desaturation to 83% on room air, which responed to oxygen via nasal canula to 96%/2L. She was not tachycardic and her lower extremities were not swollen or tender. She also denied any chest pain or shortness of breath. She got a chest x-ray, which demonstrated low lung volumes. Aggressive IS, head elevation and ambulating was recommended and she was slowly weaned off the oxygen without any difficulties. Ms. ___ finally ambulated on post-operative day 3 without difficulty. Her foley was therefore discontinued on post-op day 3 and she voided without difficulty. #2 Hypertension/Type 2 diabetes/Hyperlipidemia Ms. ___ was placed on an insulin sliding scale. Her fingersticks were elevated on the first night in the 250s and her sliding scale was adjusted as necessary and they improved. She was restarted on her antihypertensives on post-operative day 1. She was also asked to restart her metformin upon discharge and simvastatin upon discharge. #3 Persistent Nausea Ms. ___ complained of persistent nausea, which only finally responded to intravenous reglan on post-op day 2. She was transitioned to oral reglan as soon as she was tolerating a regular diet. Her electrolytes were monitored daily and repleted as needed. She was discharged on post-operative day 4 in good condition, tolerating a regular diet, voiding, ambulating and with home ___ and physical therapy for evaluation of safety at home.
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10028683-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Beta-Blockers (Beta-Adrenergic Blocking Agts) <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic evacuation of blood clot, cauterization of surgical sites, hysteroscopy and dilation and curettage. <HISTORY OF PRESENT ILLNESS> ___ yo G2P2 presents post-op day 3 after laparoscopic salpingectomies with severe abdominal pain. <PAST MEDICAL HISTORY> OBHx G2P2-0-0-2. GYN HX: Menarche age ___. - Irregular menses with menometrorrhagia ___ bleeding episodes per month) with heavy flow. LMP ___. - last PAP (___): neg SIL, +LR HPV, -HR HPV. - s/p Essure HSC permanent sterilization in ___, now s/p LSC removal on ___ - Denies history of any STDs. PMHx: endometriosis, asthma, migraines, chronic constipation, B12 defcy, AUB, recurrent vag candidiasis PSHx: ___, laparoscopy ?fulguration of endometriosis at ___ in ___ and ___, Essure ___, laparoscopic excision of endometriosis ___, b/l salpingectomies as noted <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> on presentation: 98.6 63 109/52 16 100RA Appears uncomfortable, speaking in short sentences and bracing herself against gurney RRR CTAB Abd soft, mildly distended, diffusely TTP, mild rebound, no guarding, incisions c/d/i, no erythema Ext WWP, no edema Pelvic copious dark blood in vault, unable to visualize cervix, small anteverted uterus but difficult to examine given severe abdominal tenderness, no adnexal masses Labs 6.7 > 31.8 < 234 PMNs 62.5 no bands INR 1.0 PTT 26.9 ___ 10.8 143 | 105 | 8 ---------------< 101 3.5 | 26 | 0.___bd/pel w contrast Wet read: 1. Moderate blood within the pelvis. No evidence of extravasation of contrast. 2. No evidence of uterine rupture, although ultrasound is more sensitive for the detection of uterine rupture. 3. No evidence of bowel obstruction or ileus. <PERTINENT RESULTS> hematocrit: pre-op Hct 42 -> 31 -> 28 -> 24 -> 29 -> ___ prior to discharge <MEDICATIONS ON ADMISSION> albuterol, fluticasone, ibuprofen, reglan, zofran, percocet, valtrex, colace <DISCHARGE MEDICATIONS> home meds plus: 1. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN pain Do not drive while taking this medication. RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills: *0 2. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4000mg in one day. RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *2 3. Docusate Sodium 100 mg PO BID Take while using dilaudid to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth BOD Disp #*60 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hemoperitoneum <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was readmitted 3 days after laparoscopic bilateral salpingectomies with severe abdominal pain, vaginal bleeding, evidence of hemoperitoneum and falling hematocrit. She was urgently taken back to OR for diagnostic laparoscopy. All surgical sites were noted to be hemostatic but there was 500cc of hemoperitoneum. This was evacuated and surgical sites reinforced. Given no signficiant source identified, she also underwent hysteroscopy (findings: normal cavity) and D&C. Differential diagnosis includes uterine bleeding (menorrhagia) with retrograde flow through cornual surgical sites or resolved surgical bleeding with similar cornual communication and transvaginal passage. She was observed overnight and hematocrit was stable. She was discharged to home in good condition.
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10030852-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> poor diabetes control <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 with T1DM at 32w3d who presents for admission due to poorly controlled diabetes. Pt has been followed by her endocrinologist (Dr ___ but has been poorly controlled for most of the pregnancy. She is a poor historian, unable to give range of her ___ values. States "it depends on the day." She had a CGM which has been falling off her abdomen recently so she hasn't been using it. This morning her ___ was 182 when she woke up. She is not sure of her pump settings, but states she could look at her pump to see them. States her endocrinologist makes the changes for her. She was last seen by Dr ___ 1 week ago. Pt denies any fevers/chills, urinary symptoms, n/v/d. Denies contractions, LOF, or VB. Reports active FM. <PAST MEDICAL HISTORY> PNC: *) ___ ___ by LMP c/w 7wk U/S *) Labs: A+/Ab-,RI,GC/CT-,RPRnr,HbsAg-,HIV-,GBS unk *) nl FFS, anterior placenta, nl sequential screen, per pt nl, fetal echo at 23 weeks at CHB *) s/p flu and Tdap ISSUES: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p lap appendectomy *) T1DM: (dx'd at ___ - s/p multiple admissions for DKA in past (most recent ___ - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, has not done 24hr urine yet - ___ 1911g(68%); AC 84% - HbA1C ~13% at conception per pt (according to PN records) - ___ 8% - ___ 1.78 - UTI in early pregnancy treated ObHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMH: T1DM dx age ___, on inulin pump ___ year SurgHx: lap appendectomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother and father with T2DM <PHYSICAL EXAM> Admission PE VS: BP 126/70, 88, 18, afebrile. ___ 226 (has pump on now) Gen: appears comfortable, NAD Lungs: CTAB Heart: RRR Abd: soft, gravid, NT FHT: 140s, mod var, +accels, no decels Toco: no ctxs Discharge PE VSS Gen: appears comfortable, NAD Lungs: CTAB Heart: RRR Abd: soft, gravid, NT <PERTINENT RESULTS> ___ 04: 30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04: 30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 04: 30PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-3 ___ 04: 30PM URINE AMORPH-RARE ___ 04: 30PM URINE MUCOUS-RARE ___ 03: 30PM GLUCOSE-196* UREA N-9 CREAT-0.4 SODIUM-133 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17 ___ 03: 30PM estGFR-Using this ___ 03: 30PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.7 ___ 03: 30PM WBC-8.9 RBC-4.24 HGB-12.2 HCT-36.2 MCV-85 MCH-28.8 MCHC-33.7 RDW-12.5 RDWSD-38.5 ___ 03: 30PM PLT COUNT-329 <MEDICATIONS ON ADMISSION> Insulin pump, PNV, ASA <DISCHARGE MEDICATIONS> 1. Mastisol Adhesive (gum mastic-storax-msal-alcohol) 1 package to skin prn RX *gum mastic-storax-msal-alcohol apply to skin as needed Disp #*3 Bottle Refills: *5 2. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0200: .85 Units/Hr 0200 - 0600: 1.1 Units/Hr 0600 - 0900: 2.4 Units/Hr 0900 - 1200: 2.4 Units/Hr 1200 - 1500: 1.8 Units/Hr 1500 - 1800: 1.7 Units/Hr 1800 - 2100: 2 Units/Hr ___ - 0000: 1.5 Units/Hr Meal Bolus Rates: Breakfast = 1: 2 Lunch = 1: 4 Dinner = 1: 2 High Bolus: Correction Factor = 1: 12 Correct To ___ mg/dL 3. Aspirin 81 mg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 32 weeks gestation poorly controlled T1DM <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum floor for management of your diabetes. The endocrinologists from ___ met with you and made changes in your insulin regimen. Your fingersticks improved significantly and it was felt it was safe for you to be discharged. Fetal testing was reassuring while you were here. You had an eye exam which revealed no evidence of retinopathy.
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Ms. ___ was admitted on ___ for poorly controlled TIDM and glycemic control. She had no signs or symptoms of DKA on arrival, and had reassuring lab results. She was connected with ___, who followed her during her stay. Her pump settings were adjusted and she received pump teaching. She also had an eye exam done in the ophthalmology clinic on ___ with no signs of diabetic retinopathy. A baseline 24hr urine was done and was 231mg. She also obtained a formal ultrasound that demonstrated mild polyhydramnios with MVP 8.6, EFW 2181g(84%), AC 84%. She was recommended for twice weekly testing based on her polyhydramnios and T1DM. Her glycemic control improved and she was discharged in stable condition on ___ with adjusted pump settings.
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10030852-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> diabetic ketoacidosis with history of Type I diabetes ___ ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 at ___ with T1DM transferred for poorly controlled diabetes. She reports her finger sticks have been more poorly controlled over the past ___ days, reporting fasting FSBG around 200s and pre-prandial lunch/dinner FSBG in 160s-200s. She last changed her insulin pump site ___ days ago because it was falling off; it is currently on her L outer thigh. She denies concerns for pump malfunction. She has been checking her FSBG 3x/day (fasting, pre-lunch, and pre-dinner) but does not check at bedtime or in the middle of the night. Pt presented for a routine OB visit during which she reported recent poor control of her sugars, and was recommended to present to ___. Initial ___ there was 345, and she was bolused 16.2 units through her pump in the late afternoon. No other changes were made to her current pump settings. All ___ there were over 200. Per notes, she was to receive a 1L IVF bolus, however, pt denies receiving any IVF there. She underwent serum and urine labs that were notable for: Na 132, K 3.6, anion gap 13, serum osmolality 285, + serum and urine ketones. She was transferred to ___ for admission for glucose control. <PAST MEDICAL HISTORY> PNC: *) ___ ___ by LMP c/w 7wk U/S *) Labs: A+/Ab-,RI,GC/CT-,RPRnr,HbsAg-,HIV-,GBS unk *) nl FFS, anterior placenta, nl sequential screen, per pt nl, fetal echo at 23 weeks at CHB *) s/p flu and Tdap ISSUES: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p lap appendectomy *) T1DM: (dx'd at ___ - s/p multiple admissions for DKA in past (most recent ___ - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, has not done 24hr urine yet - ___ 1911g(68%); AC 84% - HbA1C ~13% at conception per pt (according to PN records) - ___ 8% - ___ 1.78 - UTI in early pregnancy treated ObHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMH: T1DM dx age ___, on inulin pump ___ year SurgHx: lap appendectomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother and father with T2DM <PHYSICAL EXAM> Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, +1 edema FHR: present at a normal rate <PERTINENT RESULTS> ___ 09: 15AM BLOOD WBC-6.0 RBC-4.03 Hgb-11.3 Hct-34.2 MCV-85 MCH-28.0 MCHC-33.0 RDW-12.9 RDWSD-39.9 Plt ___ ___ 12: 08AM BLOOD WBC-7.7 RBC-3.77* Hgb-10.5* Hct-31.7* MCV-84 MCH-27.9 MCHC-33.1 RDW-12.7 RDWSD-38.6 Plt ___ ___ 10: 14AM BLOOD WBC-6.7 RBC-3.69* Hgb-10.3* Hct-31.0* MCV-84 MCH-27.9 MCHC-33.2 RDW-12.6 RDWSD-38.2 Plt ___ ___ 01: 30AM BLOOD WBC-8.4 RBC-4.19 Hgb-11.6 Hct-35.6 MCV-85 MCH-27.7 MCHC-32.6 RDW-12.6 RDWSD-38.5 Plt ___ ___ 01: 38AM BLOOD ___ PTT-25.7 ___ ___ 09: 15AM BLOOD Glucose-73 UreaN-3* Creat-0.4 Na-138 K-3.6 Cl-109* HCO3-18* AnGap-15 ___ 12: 08AM BLOOD Glucose-92 UreaN-5* Creat-0.4 Na-136 K-3.7 Cl-108 HCO3-15* AnGap-17 ___ 03: 25PM BLOOD Glucose-112* UreaN-5* Creat-0.4 Na-138 K-3.7 Cl-111* HCO3-15* AnGap-16 ___ 10: 14AM BLOOD Glucose-106* UreaN-6 Creat-0.4 Na-137 K-3.7 Cl-109* HCO3-16* AnGap-16 ___ 05: 23AM BLOOD Glucose-119* UreaN-6 Creat-0.4 Na-136 K-3.6 Cl-110* HCO3-15* AnGap-15 ___ 01: 30AM BLOOD Glucose-211* UreaN-7 Creat-0.5 Na-131* K-3.7 Cl-100 HCO3-15* AnGap-20 ___ 01: 30AM BLOOD ALT-12 AST-13 Amylase-16 ___ 01: 30AM BLOOD Lipase-28 ___ 09: 15AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.8 ___ 12: 08AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.9 ___ 03: 25PM BLOOD Calcium-7.5* Phos-2.3* Mg-1.9 ___ 10: 14AM BLOOD Calcium-7.4* Phos-1.9* Mg-1.5* ___ 05: 23AM BLOOD Calcium-7.2* Phos-1.8* Mg-1.4* ___ 01: 30AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.7 UricAcd-5.6 ___ 05: 23AM BLOOD Acetone-NEGATIVE Osmolal-279 ___ 01: 30AM BLOOD Acetone-NEGATIVE Osmolal-284 ___ 01: 30AM BLOOD TSH-6.6* ___ 01: 30AM BLOOD Free T4-1.1 ___ 05: 23AM BLOOD RedHold-HOLD ___ 06: 40AM BLOOD Type-ART pO2-102 pCO2-26* pH-7.39 calTCO2-16* Base XS--7 ___ 06: 44AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03: 01AM URINE Color-Yellow Appear-Clear Sp ___ ___ 08: 44PM URINE Color-Straw Appear-Clear Sp ___ ___ 06: 44AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM ___ 03: 01AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 08: 44PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 06: 44AM URINE RBC-2 WBC-7* Bacteri-NONE Yeast-NONE Epi-10 ___ 03: 01AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-2 ___ 08: 44PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-1 ___ 06: 44AM URINE CastHy-2* ___ 03: 01AM URINE CastHy-1* ___ 03: 01AM URINE Hours-RANDOM Creat-115 TotProt-46 Prot/Cr-0.4* ___ 03: 01AM URINE Osmolal-1042 ___ 3: 01 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> Humalog pump, PNV, ASA 81mg daily <DISCHARGE MEDICATIONS> 1. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0200: 1.05 Units/Hr 0200 - 0600: 1.3 Units/Hr 0600 - 1200: 2.4 Units/Hr 1200 - 1500: 2 Units/Hr 1500 - 1800: 1.9 Units/Hr 1800 - 2100: 2.4 Units/Hr ___ - 0000: 1.65 Units/Hr Meal Bolus Rates: Breakfast = 1: 2 Lunch = 1: 4 Dinner = 1: 2 Snacks = 1: 2 High Bolus: Correction Factor = 1: 12 Correct To ___ mg/dL MD acknowledges patient competent MD has ordered ___ consult 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> DKA T1DM 34 weeks gestational age <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for DKA and management of your T1DM. Your diabetes control was improved and you are now safe to be discharged home.
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On ___, Ms. ___ G1P0 at 34wks, was admitted to the anteapartum service with concern for diabetic ketoacidosis in the setting of T1DM with insulin pump. Workup was negative for infectious process and presentation likely secondary to pump failure. She was initiated on an insulin drip and received IVF hydration with subsequent normalization of blood glucose and resolution of anion gap. Her diet was advanced and she was transitioned to her insulin pump. She continued to have fasting blood sugars at goal. On HD#2, her insulin pump fell out and she again received insulin drip until her pump was replaced and she was able to be transitioned. By hospital day 3, she was on her insulin pump regularly with controlled blood glucose levels. She was then discharged in stable condition with appropriate pump settings. Of note, she had an ultrasound on ___ with BPP ___ and AFI within normal limits.
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10030852-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Elevated BPs <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vacuum-assisted vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 36w3d with poorly controlled ___ transferred from ___ with elevated BPs. She had BPs 172/101 and 164/80 at ___ followed by mild range BPs and did not receive IV antihypertensive medications. She had PIH labs that were wnl except for urine P: C of 0.47. Her FSG were well controlled there. She was given magnesium 6g bolus and transferred to ___. Late preterm betamethasone was deferred given h/o poorly controlled T1DM. On admission, she reports feeling well other than cold symptoms that she has had for a few days. She reports a moderate HA and has not taken Tylenol. Denies vision changes or epig pain. Denies ctx, VB, LOF, reports AFM. Denies nausea, vomiting, abdominal pain. Of note, she was admitted to ___ twice during this pregnancy for poorly controlled diabetes and concern for DKA. She reports her pump has been working well recently. ROS: Denies fevers/chills. Denies vision changes. Denies chest pain/shortness of breath/palpitations. Denies abdominal pain. Denies recent falls or abdominal trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. PNC: - ___ ___ by LMP c/w 7wk U/S - Labs: A+/Ab-,RI,GC/CT-,RPRNR,HbsAg-,HIV-,GBS pnd (collected ___ - Screening: low risk sequential screen - FFS: wnl, anterior placenta - Vaccines: s/p flu and Tdap - Ultrasound ___ (at ___: 2181g, 59%, mildly increased AFI, MVP 8.6cm - Ultrasound ___ (at ___: 2777gm, 74%, AFI 16.9, BPP ___ - Issues: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p LSC appendectomy *) UTI in early pregnancy, treated *) ? Polyhydramnios: MVP 8.6cm on ___, but normal AFI 16.9 on ___ *) T1DM: - diagnosed at ___ - s/p multiple admissions for DKA in past (most recent ___ pre-pregnancy, ___ in pregnancy) - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, 24hr urine 231mg (___) - s/p optho c/s ___, no e/o diabetic retinopathy - HbA1C ~13% at conception per pt (according to ___ records) - ___ 8% - ___ 1.78 *) ___ ante admission ___ and ___: ___ consult, insulin pump adjusted, s/p pump teaching. s/p optho consult, no e/o diabetic retinopathy. s/p nutrition consult. <PAST MEDICAL HISTORY> OBHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMHx: - T1DM dx age ___, on inulin pump ___ year - Obesity PSHx: lsc appendectomy (___) Meds: Humalog pump, PNV, ASA 81mg daily <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother and father with T2DM <PHYSICAL EXAM> VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 10: 23PM BLOOD WBC-9.0 RBC-3.50* Hgb-9.5* Hct-28.7* MCV-82 MCH-27.1 MCHC-33.1 RDW-12.7 RDWSD-38.1 Plt ___ ___ 07: 57PM BLOOD WBC-8.1 RBC-3.53* Hgb-9.2* Hct-29.1* MCV-82 MCH-26.1 MCHC-31.6* RDW-12.7 RDWSD-38.4 Plt ___ ___ 10: 15AM BLOOD WBC-8.5 RBC-3.67* Hgb-9.9* Hct-30.1* MCV-82 MCH-27.0 MCHC-32.9 RDW-12.6 RDWSD-38.0 Plt ___ ___ 01: 55AM BLOOD WBC-7.9 RBC-3.50* Hgb-9.3* Hct-28.6* MCV-82 MCH-26.6 MCHC-32.5 RDW-12.7 RDWSD-38.3 Plt ___ ___ 06: 49PM BLOOD WBC-7.0 RBC-3.54* Hgb-9.6* Hct-29.2* MCV-83 MCH-27.1 MCHC-32.9 RDW-12.6 RDWSD-38.5 Plt ___ ___ 12: 18PM BLOOD WBC-7.4 RBC-3.71* Hgb-10.0* Hct-30.5* MCV-82 MCH-27.0 MCHC-32.8 RDW-12.6 RDWSD-37.7 Plt ___ ___ 04: 15AM BLOOD WBC-7.3 RBC-3.57* Hgb-9.7* Hct-29.5* MCV-83 MCH-27.2 MCHC-32.9 RDW-12.4 RDWSD-38.0 Plt ___ ___ 09: 00PM BLOOD WBC-8.2 RBC-3.75* Hgb-10.1* Hct-31.1* MCV-83 MCH-26.9 MCHC-32.5 RDW-12.5 RDWSD-38.4 Plt ___ ___ 10: 23PM BLOOD Creat-0.6 ___ 07: 57PM BLOOD Creat-0.5 ___ 10: 15AM BLOOD Creat-0.5 ___ 01: 55AM BLOOD Creat-0.5 ___ 06: 49PM BLOOD Creat-0.5 ___ 12: 18PM BLOOD Creat-0.5 ___ 04: 15AM BLOOD Glucose-111* UreaN-6 Creat-0.5 Na-133 K-3.7 Cl-101 HCO3-18* AnGap-18 ___ 09: 00PM BLOOD Glucose-148* UreaN-7 Creat-0.5 Na-132* K-6.1* Cl-103 HCO3-16* AnGap-19 ___ 10: 23PM BLOOD ALT-7 AST-13 ___ 07: 57PM BLOOD ALT-7 AST-13 ___ 10: 15AM BLOOD ALT-8 AST-15 ___ 01: 55AM BLOOD ALT-8 AST-13 ___ 06: 49PM BLOOD ALT-8 AST-13 ___ 12: 18PM BLOOD ALT-8 AST-15 ___ 04: 15AM BLOOD ALT-8 AST-13 ___ 09: 00PM BLOOD ALT-11 AST-43* ___ 10: 23PM BLOOD UricAcd-6.6* ___ 10: 15AM BLOOD UricAcd-5.5 ___ 01: 55AM BLOOD UricAcd-5.3 ___ 12: 18PM BLOOD Mg-4.9* UricAcd-4.7 ___ 04: 15AM BLOOD Mg-4.3* UricAcd-4.2 ___ 09: 00PM BLOOD Calcium-8.1* Phos-4.2 Mg-3.5* UricAcd-3.9 ___ 10: 04AM BLOOD Type-ART pO2-23* pCO2-53* pH-7.27* calTCO2-25 Base XS--3 Comment-CORD ___ ___ 10: 02AM BLOOD ___ pO2-80* pCO2-39 pH-7.32* calTCO2-21 Base XS--5 Comment-CORD VEIN <DISCHARGE INSTRUCTIONS> Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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On ___, Ms. ___ was transferred from ___ at 36w3d with elevated BPs to the 170s/100s and P:C of 0.47. She was given a 6g Magnesium bolus at ___. Late preterm betamethasone was deferred given history of poorly controlled T1DM. Upon arrival, she was continued on magnesium infusion and reported a ___ HA treated with tylenol. For her T1DM, ___ was consulted and recommended transition from humalog pump to insulin gtt. Pt was then counseled and started on induction of labor for pre-eclampsia with severe features by blood pressure. *) Pre-eclampsia, severe by BPs Pt was continued on magnesium infusion. Her BPs ranged from normotensive to intermittently in the severe range. She was given an additional 2g bolus of Mag when Mag level returned subtherapeutic. PEC labs were trended q8 hours. She was continued on labetalol 200mg BID and uptitrated to TID. She was also kept on subcutaneous heparin for VTE prophylaxis. Her headache was treated with tylenol and compazine. During the second stage of labor, she was noted to have hematuria with adequate urine volume likely due to obstruction from fetal head. Cr was normal at 0.6. She was continued on magnesium for 24 hours postpartum and did not require continuation of labetalol in the postpartum period for BP control. *) T1DM Pt's insulin gtt and D10 were titrated per protocol during the intrapartum period. During the postpartum period, pt was transitioned from gtt to pump once taking PO. Pt was followed by ___ throughout her hospital course. *) Induction of labor She received 6 doses of PV cytotec and started on pitocin which was uptitrated per protocol. She then had a foley bulb placed and declined a second placement. Pitocin was uptitrated to 20units per protocol and maintained from ___ at 1100 to ___ at 0430. Pitocin was turned off then restarted on ___ at 0600. She was then AROM'ed at 1315. On ___ at 0030, pt was fully dilated at +1 station. She labored down for an hour, after which she pushed for 20 minutes with good effort. She then labored down again for one hour, after which she resumed pushing with variable intensity. After prolonged second stage and maternal exhaustion, pt was counseled on and underwent a vacuum assisted delivery at 0937 of a viable baby girl, complicated by shoulder dystocia x 2 minutes that resolved with McRobert's maneuver, suprapubic pressure, ___ maneuver. *) Bilateral groin pain - pt complained of bilateral groin pain in the postpartum period, likely musculoskeletal in origin due to prolonged labor course. She was seen and evaluated by physical therapy after pain was adequately controlled. She was able to ambulate without assistance upon discharge. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled. Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 2. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*1 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Moderate to Severe Pain RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 4. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0600: .7 Units/Hr 0600 - 0000: .8 Units/Hr Meal Bolus Rates: Breakfast = 1:8 Lunch = 1:8 Dinner = 1:8 High Bolus: Correction Factor = 1:30 Correct To ___ mg/dL Discharge Disposition: Home Discharge Diagnosis: 36 week gestation, type 1 diabetes, preeclampsia with severe features, prolonged second stage, shoulder dystocia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10030937-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Dyspnea on exertion <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ s/p pLTCS for arrest of dilation on ___ presents with two days of worsening shortness of breath. She describes onset of symptoms two nights ago, which she noticed as she was trying to lie down to go to bed and couldn't take a deep breath. Her SOB has gotten progressively worse over the last two days, making it difficult for her to walk more than a few feet without being symptomatic. She cannot lie flat. She is short of breath when trying to speak multiple sentences. This does not feel like her SOB associated with her asthma in the past. She has been using her inhaler excessively with no relief. She intermittently feels as if her heart is racing. Denies chest pain. Has intermittent abdominal cramping, however denies significant abdominal pain or incisional pain. Only taking Tylenol and motrin for pain; never needed oxycodone. Has had a BM. Voiding without issue; previously bloody urine has resolved. She did have a mild HA on presentation to the ED, which resolved with Tylenol. She is breastfeeding and the baby has been doing really well. <PAST MEDICAL HISTORY> OBHx: ___ - s/p pLTCS on ___ for arrest of dilation at 8cm after prolonged augmentation of labor with Pitocin following SROM GYNHx: - previously normal menstrual cycles - denies hx of abnormal Pap testing (last Pap ___ - denies hx of STIs - denies hx of GYN surgeries or procedures, aside from recent primarly LTCS - has small posterior fibroid (2z2x2cm) PMHx: - migraine HA - asthma PSHx: - pLTCS Medications: albuterol inhaler All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies hypertensive disease in her family, bleeding disorders or history of blood clots. <PHYSICAL EXAM> Physical Exam on Admission: 98.7 HR83 BP149/95 RR20 O2sat 100% RA 97.81 HR74 BP 148/100 RR16 O2sat 100% RA 98.1 HR86 BP151/89 RR22 O2sat 100% RA Gen: NAD CV: mild tachycardia, regular rhythm Pulm: mild increased work of breathing, tachypneaic at rest; mildly decreased breath sounds at bilateral bases, no wheezes appreciated, no crackles appreciated Abd: softly distended, appropriately mildly TTP, fundus firm, incision c/d/I, no drainage or bleeding GU: pad w/mild spotting Ext: WWP, no edema or tenderness appreciated of ___ _ ________________________________________________________________ Physical Exam on Discharge: 24 HR Data (last updated ___ @ 315) Temp: 99.7 (Tm 100.8), BP: 149/90 (127-152/79-99), HR: 87 (71-90), RR: 18, O2 sat: 95% (95-97), O2 delivery: Ra Fluid Balance (last updated ___ @ 2305) Last 8 hours No data found Last 24 hours Total cumulative -345ml IN: Total 840ml, PO Amt 840ml OUT: Total 1185ml, Urine Amt 1185ml General: Sitting up in bed in no acute distress, A&Ox3 Breasts: soft, non-tender, no erythema, soft, no focal areas of induration, fluctuance, or tenderness, nipples intact Lungs: Lungs clear to auscultation bilaterally, no wheezes or crackles Abd: soft, nontender, fundus firm below umbilicus Incision: clean, dry, intact, no erythema/induration, dressed in steri-strips stained with serosanguinous fluid Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 11: 12AM BLOOD WBC-7.9 RBC-3.55* Hgb-9.4* Hct-29.5* MCV-83 MCH-26.5 MCHC-31.9* RDW-14.4 RDWSD-42.9 Plt ___ ___ 12: 20PM BLOOD Neuts-72.5* ___ Monos-4.8* Eos-0.8* Baso-0.3 NRBC-0.4* Im ___ AbsNeut-5.50 AbsLymp-1.52 AbsMono-0.36 AbsEos-0.06 AbsBaso-0.02 ___ 05: 10AM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-141 K-3.9 Cl-106 HCO3-20* AnGap-15 ___ 11: 12AM BLOOD ALT-59* AST-26 ___ 12: 20PM BLOOD cTropnT-<0.01 ___ 12: 20PM BLOOD cTropnT-<0.01 ___ 12: 20PM BLOOD proBNP-631* ___ 02: 22PM BLOOD pO2-22* pCO2-37 pH-7.40 calTCO2-24 Base XS--1 Comment-ABG ADDED CTA Chest (___): 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral multifocal nodular ground-glass opacities likely represents moderate pulmonary edema, in the setting of cardiomegaly and bilateral pleural effusions. CXR ___, prelim read): Right greater than left bilateral perihilar opacities are worrisome for asymmetric pulmonary edema, moderate to severe on the right and moderate on the left. Pulmonary hemorrhage not excluded. Trace right greater than left pleural effusions. EKG (___): Normal sinus rhythm ___ (___): No evidence of deep venous thrombosis in the right lower extremity veins. Transthoracic Echocardiogram (___): Normal global and regional biventricular systolic function. Mild mitral and tricuspid regurgitation. Mild pulmonary hypertension. <MEDICATIONS ON ADMISSION> Albuterol inhaler Ibuprofen Acetaminophen <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth q 6 hours prn pain Disp #*40 Tablet Refills: *0 2. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 3. Ferrous Sulfate 325 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ___ s/p pLTCS ___ re-admitted with dyspnea on exertion, orthopnea, dx w GHTN (started labetolol) and seen by cardiology and cleared. Fever from engorgement <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see ob sheet
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Ms. ___ was readmitted to the Postpartum service after she presented to the Emergency Department with dyspnea on exertion. Thorough workup in the ED found mild pulmonary edema on chest x-ray, and was otherwise negative for acute cardiac or pulmonary etiology. For this, she was given one dose of IV furosemide which helped relieve her symptoms before readmission. On the Postpartum floor, she was comfortable on exam, though still with symptoms of dyspnea on exertion. She complained of a mild headache improved with ibuprofen and acetaminophen and eating, and was well overnight. Two times over the course of her admission, Ms. ___ had a fever, to 101.1 and 100.8, respectively. Thorough evaluation for fever etiology was negative, though Ms. ___ had been breast pumping and feeding intermittently since undergoing CT in the ED, making engorgement the most probable etiology. On night 2 of her admission, Ms. ___ received a second dose of IV furosemide for further improved symptoms, and the next day received a transthoracic echocardiogram without evidence of peripartum cardiomyopathy. By hospital day 3, she was symptomatically improved and continuing to meet all postpartum and self-care milestones, and was deemed safe for discharge with plan for follow up with peripartum cardiology.
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10033159-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> LLQ pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound guided tuboovarian absess drainage <HISTORY OF PRESENT ILLNESS> This is a ___ G0 with no significant PMH presenting with 10 days of LLQ pain, fever and chills. The pain began 10 days PTA. It is a crampy intermittent pain localized to the LLQ, ranging in severity from ___. It does not radiate, and is partially relieved by tylenol. She has noted fevers, with a temperature of 103.8 9d PTA and readings around 101 over the past several days. She also complains of chills, night sweats, decreased appetite and constipation. Last bowel movement today. She denies lightheadedness, blood in her bowel mvts, dysuria, hematuria, or increased frequency. She denies changes in her menstrual periods, her LMP was ___. She is sexually active with one partner and uses condoms. No abnl vaginal discharge or spotting. <PAST MEDICAL HISTORY> PMHx: Trichilomania (diagnosed as a child, not very active at present) PSHx: Wisdom teeth several years ago. PGYNHx: - LMP ___. Regular 30 day cycle, no dysmenorrhea. - Last pap ___. No history of abnormal paps. - No hx of chlamydia, gonorrhea, HSV. - Currently sexually active with 1 partner, monogamous, uses condoms, together for several months. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No known history of gynecologic or obstetric disease. <PHYSICAL EXAM> (done by Dr ___ Tmax 99.4, 84, 107/64, 18, 100% RA HEENT: Moist mucous membranes. Pulm: CTAB CV: RRR, no m/r/g. Abd: Nondistended, +BS, tender to deep palpation over the LLQ. No CVA tenderness. No guarding or rebound tenderness. No stool in the rectal vault. Guiac negative. Pelvic: Normal external genitalia. Speculum exam is unremarkable. No cervical motion tenderness. Midline uterine fundus. Fullness in the left adnexa. Ext: Warm and well perfused. <PERTINENT RESULTS> ___ CBC: 12.9>35.7<556 Lytes: ___ CRP: 155 ___ 10: 30AM BLOOD ___ PTT-35.1* ___ ___ 11: 45AM BLOOD ALT-30 AST-28 AlkPhos-132* Amylase-22 TotBili-0.2 ___ 07: 25AM BLOOD HBsAg-NEGATIVE ___ 07: 25AM BLOOD HIV Ab-NEGATIVE ___ 07: 25AM BLOOD HCV Ab-NEGATIVE ___ 11: 45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ GC/CT: negative RPR: negative cyst fluid culture: pending ___ PUS 1. Enlargement of the left ovary with hyperemia and dilation of the adherent left fallopian tube. Small cul-de-sac collection. These findings in accordance with CT raise suspicion for tubo-ovarian abscess. Followup ultrasound is recommended post- treatment. 2. Mild left hydronephrosis, which likely occurs secondary to mild compression at the left distal ureter from the left adnexal process. ___ CT 1. Large complex cystic left adnexal lesion which most likely represents tubo- ovarian abscess. Correlation with ultrasound is recommended. Followup imaging (US) is advised following treatment. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp: *28 Tablet(s)* Refills: *0* 2. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp: *28 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> tuboovarian absess <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your physician if you experience severe abdominal pain, nausea, vomitting, fevers, or any other concerning symptoms. Please use protection while having sexual intercourse.
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___ G0 with 10 days of LLQ pain and fevers, without PMH or PGYNHx, with fullness in the L adnexa and evidence of a L adnexal cystic lesion seen on CT, and cul-de-sac collection on US admitted to the inpatient gynecology service. Patient's CRP was elevated at 155. The likely diagnosis is PID with tuboovarian abscess. Infected endometrioma may also be in the differential although the patient denies any history of dysmenorrhea. Patient was started on IV ampicillin, gentamicin, and flagyl for empiric for PID with ___. Patient underwent US-guided drainage of left cyst ___. Approximately 10 cc of clear fluid were aspirated and sent for culture and gram stain. As the aspiration did not reveal pus, the procedure was terminated. The procedure was uncomplicated. At the time of this report, the final cyst fluid culture result is pending. The patient remained afebrile throughout the hospitalization. Sexually transmitted infection panel was pan negative. In light of elevated CRP, patient was discharged home with a 2 week Doxycycline and Flagyl. She will follow up in ___ clinic and repeat imaging in ___ weeks.
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10033760-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus, right ovarian cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy, right oophorectomy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 1, para 1, who is status post imaging studies that show a large fibroid uterus. She is status post endometrial biopsy on ___, which showed secretory endometrium. She presents today for further discussion of treatment options. The patient has done much research and presents today requesting multiple myomectomy with the knowledge that because of the size and multiplicity of her uterine fibroid, she could end up with a supracervical hysterectomy. She also has a right ovarian cyst and is requesting right ovarian cystectomy, but understands that she might end up with a right oophorectomy. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 12. She cycles monthly, last menstrual period she believes was ___. She notes her menses are heavy with clots. The patient's last Pap smear is unknown. Therefore, Pap will be updated today. She denies any history of abnormal Paps. She is not sexually active. She has used oral contraceptive pills in her remote past for approximately a year. She does have a history of cyst in her ovaries and clearly as stated above. She has had one pregnancy, vaginal delivery, ___, no complications. She denies ever having sexually transmitted infections. PAST MEDICAL HISTORY: Childhood anemia, cholecystitis, overactive bladder, PTSD, hemorrhoids, intermittent unusual foot pains. OPERATIVE HISTORY: In the ___, she had appendix out in ___ as a child and in the 1990s, gallbladder out here at the ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: Negative for any female cancers. <PHYSICAL EXAM> INITIAL PHYSICAL EXAMINATION: GENERAL: This is a well-developed, well-nourished woman in no apparent distress. VITAL SIGNS: Blood pressure 116/62, weight 183. ABDOMEN: Soft, nondistended, palpable mass approximately 18 cm in maximum vertical dimension and there certainly was a softer palpable mass to the patient's right consistent with that described dumbbell-shaped cystic structure on ultrasound. PELVIC: Normal female external genitalia. Bartholin, urethral, and Skene's glands were normal. The vaginal vault did have a watery discharge. Cultures were done for BV and yeast. Cervix without cervical motion tenderness. Pap smear was updated including HPV testing. Uterus approximately 18 cm in maximum vertical dimension with again that softer larger 12 cm cystic-appearing mass in the mid lateral right aspect of the patient's abdomen. ON DAY OF DISCHARGE GEN: NAD CV: RRR LUNGS: CTABL ABD: NT/ND INCISIONS C/D/I EXT: WNL <MEDICATIONS ON ADMISSION> MVI <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h: prn Disp #*80 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain DO NOT: drive or take with alcohol/sedatives *contains tylenol RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4h: prn Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus, dermoid cyst (final pathology pending) <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___-
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On ___, Ms. ___ was admitted to the gynecology service after undergoing abdominal myomectomy and right oophorectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to ibuprofen and percocet. By post-operative day #3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10037313-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Abdominal multiple myomectomy <PHYSICAL EXAM> Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 10: 00AM WBC-3.0* RBC-3.59* HGB-10.6* HCT-34.5 MCV-96# MCH-29.5# MCHC-30.7* RDW-16.1* RDWSD-48.3* ___ 10: 00AM WBC-3.0* RBC-3.59* HGB-10.6* HCT-34.5 MCV-96# MCH-29.5# MCHC-30.7* RDW-16.1* RDWSD-48.3* <MEDICATIONS ON ADMISSION> Norethindrone 5mg QD <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ , You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing and abdominal multiple myomectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid/toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oxycodone/acetaminophen/ibuprofen(pain meds). By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10039110-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Diflucan <ATTENDING> ___ <CHIEF COMPLAINT> Vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Patient is a ___ y/o G6P2 with a history of known fibroid uterus, history of anemia, history of PE on Eliquis (___), who presents with vaginal bleeding. LMP started ___ - has been much heavier than her prior periods. Changing "more than one pad" per hour, having dizziness, palpitations, SOB as well. Mild cramping. She is followed by Dr. ___ office for her fibroid uterus. Started Lupron (test dose ___, first dose ___ - 11.25 mg with plan for Q3 month injections). Had been advised to get ferraheme injections for anemia, baseline Hct ___, but did not keep appointments. She underwent an endometrial biopsy in ___, which returned as proliferative endometrium and benign endocervix. Patient states she has discussed hysterectomy with Dr. ___ but was "waiting for her blood counts to come up." <PAST MEDICAL HISTORY> OB History: - TAB x 4 - LTCS x 2 GYN History: - LMP ___ - last pap smear ___ NILM HPV- - fibroid uterus, as per above PMH: - anemia - "fatty liver" - PE (___) on Eliquis Surgical History: - (___) prim LTCS - (___) open MMY - (___) rpt LTCS - (___) laparoscopic hiatal hernia repair, Roux-En-Y, LOA <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of ovarian, uterine, breast, or colon cancer. <PHYSICAL EXAM> Vitals: Stable and within normal limits General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, non-tender, uterus palpable ~5 cm above umbilicus GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 05: 00AM BLOOD WBC-8.1 RBC-4.42 Hgb-7.1* Hct-26.1* MCV-59* MCH-16.1* MCHC-27.2* RDW-22.2* RDWSD-43.2 Plt ___ ___ 11: 02AM BLOOD WBC-6.3 RBC-3.47* Hgb-5.6* Hct-20.5* MCV-59* MCH-16.1* MCHC-27.3* RDW-21.9* RDWSD-43.4 Plt ___ ___ 12: 35AM BLOOD WBC-6.0 RBC-3.99 Hgb-8.4* Hct-27.6* MCV-69* MCH-21.1* MCHC-30.4* RDW-29.4* RDWSD-67.8* Plt ___ ___ 05: 00AM BLOOD Neuts-66.9 Lymphs-18.9* Monos-7.6 Eos-5.3 Baso-0.9 Im ___ AbsNeut-5.45 AbsLymp-1.54 AbsMono-0.62 AbsEos-0.43 AbsBaso-0.07 ___ 07: 25AM BLOOD Neuts-60.0 ___ Monos-9.7 Eos-4.9 Baso-0.5 Im ___ AbsNeut-3.29 AbsLymp-1.34 AbsMono-0.53 AbsEos-0.27 AbsBaso-0.03 ___ 05: 00AM BLOOD Glucose-74 UreaN-13 Creat-1.1 Na-139 K-4.1 Cl-107 HCO3-20* AnGap-12 <MEDICATIONS ON ADMISSION> Apixaban 5 mg PO BID <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever 2. MedroxyPROGESTERone Acetate 10 mg PO BID RX *medroxyprogesterone [Provera] 10 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 3. Apixaban 5 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal bleeding secondary to known fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service to manage your vaginal bleeding. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * You may eat a regular diet. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain, headache, or difficulty breathing To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after presenting with vaginal bleeding secondary to known fibroid uterus, with possible additional Lupron effect. Her Hct on initial presentation was 20.5. On HD#1 she received 2 units packed RBCs with a rise in her Hct to 23.7. She was also started on Provera 10 mg daily. ___ was consulted and planned for uterine artery embolization. On HD#2 her Hct was 22.1 and she received an additional two units packed RBCs with appropriate response of her hematocrit to 27.6 and subjective improvement in her symptoms. Her Provera was also increased to 10 mg twice daily. By HD #3, she had minimal ongoing vaginal bleeding and was overall feeling better. She elected to defer UAE during this admission and requested to be discharged home. Her foley catheter was removed and she voided spontaneously. She had minimal pain, was ambulating independently, and continued on regular diet. She was discharged home in stable condition with outpatient follow-up scheduled.
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10039110-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, Bilateral salpingectomy <HISTORY OF PRESENT ILLNESS> ___ is a ___ gravida 7 ___ who returns to discuss further future hysterectomy and bilateral salpingectomy. On ___, endometrial biopsy showed proliferative endometrium and benign endocervix. She has a history of an enlarged uterus, excessive uterine bleeding. And chronic/acute blood loss anemia for which she has received IV iron therapy. In addition, in efforts to decrease her uterine fibroid burden and decrease her excessive bleeding she has been on IM Lupron therapy. Since initiating Lupron therapy she has had no further vaginal bleeding. She will get a 3-month dose today. She has a history of thrombosis/pulmonary embolism and has been treated with Eliquis. She has an appointment with Dr. ___ ___, heme-onc for recommendations in regard to perioperative anticoagulation therapy. <PAST MEDICAL HISTORY> OB History: - TAB x 4 - LTCS x 2 GYN History: - LMP ___ - last pap smear ___ NILM HPV- - fibroid uterus, as per above PMH: - anemia - "fatty liver" - PE (___) on Eliquis Surgical History: - (___) prim LTCS - (___) open MMY - (___) rpt LTCS - (___) laparoscopic hiatal hernia repair, Roux-En-Y, LOA <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of ovarian, uterine, breast, or colon cancer. <PHYSICAL EXAM> On day of discharge: <PERTINENT RESULTS> ___ 10: 25AM BLOOD WBC-7.1 RBC-5.03 Hgb-11.0* Hct-36.1 MCV-72* MCH-21.9* MCHC-30.5* RDW-16.6* RDWSD-42.7 Plt ___ <MEDICATIONS ON ADMISSION> Apixaban 2.5mg BID Leuprolide <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hrs RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *2 2. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth Two times per day Disp #*56 Tablet Refills: *2 3. Docusate Sodium 100 mg PO BID Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice per day Disp #*60 Capsule Refills: *0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate ___ cause sedation. Do not drink or drive. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___ ___ were admitted to the gynecology service after your procedure. ___ have recovered well and the team believes ___ are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking opioids (e.g. oxycodone, hydromorphone) * Take a stool softener such as colace while taking opioids to prevent constipation. * Do not combine opioid and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet. * ___ may walk up and down stairs. Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Leave the steri-strips in place. They will fall off on their own. If they have not fallen off by 7 days post-op, ___ may remove them. * If ___ have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where ___ are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if ___ are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing the procedures listed below. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and a TAP block. She was transitioned to lovenox 12 hours post-operatively given her history of provoked PE. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, tylenol. By post-operative day 2 she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10040768-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilation and Curettage <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ s/p TAB at 16 weeks on ___ who presents with heavy vaginal bleeding. She reports that she has had daily spotting since she had the TAB. However, she was a party around midnight and had heavy bleeding more than 3 cups into the toilet followed by passage of clots. She denies any fevers, chills, abdominal pain, chest pain or shortness of breath. She had complained of lightheaded on presentation to the ED but feels better now. Denies nausea, vomiting or abnormal vaginal discharge. Denies intercourse since procedure and has not been on birth control. <PAST MEDICAL HISTORY> Gyn Hx: - Unknown LMP - remote h/o genital herpes - last Pap in system ___ wnl, due for follow up - current contraception: condoms - past contraception: OCPs, depoprovera, condoms, reports spotting with all past contraceptives. OBHx: G1: SVD 8# term female (___) G2: pLTCS twins female (___) G3-G8: TAB (D+C) PAST MEDICAL HISTORY: pancreatitis, recurrent UTIs PAST SURGICAL HISTORY: TAB x 6 with D&C's <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Physical Examination Upon Presentation Time Pain Temp HR BP RR Pox Glucose + Triage 00: 37 5 98.8 108 156/96 18 99% ra Today 02: 37 0 86 108/62 18 100% RA Today 03: 21 87 121/67 18 99% RA No acute distress Abdomen soft, non-tender and non-distended Pelvic exam: On insertion of speculum, cervix is visualized and appears parous, vaginal vault was cleaned out with 1 scopette and there was no active bleeding. There was no CMT and no uterine tenderness or adnexal tenderness to palpation. Ext non-tender and non-distended. Physical Examination Upon Discharge Vital signs stable Well appearing, no acute distress Abdomen soft, nontender Vaginal bleeding minimal <PERTINENT RESULTS> ___ 12: 55AM PLT COUNT-327# ___ 12: 55AM NEUTS-62.0 ___ MONOS-4.2 EOS-3.2 BASOS-0.5 ___ 12: 55AM WBC-8.1 RBC-3.42* HGB-9.5* HCT-30.6* MCV-90 MCH-27.7# MCHC-30.9*# RDW-14.1 ___ 12: 55AM HCG-10 ___ 12: 55AM estGFR-Using this ___ 12: 55AM GLUCOSE-88 UREA N-10 CREAT-0.8 SODIUM-139 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16 Intraoperative Findings: 1. Exam under anesthesia: Small anteverted uterus. Cervix 1 cm dilated. 2. Products of conception and clot. <MEDICATIONS ON ADMISSION> denies <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Retained products of conception <DISCHARGE CONDITION> Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call the office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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The patient was admitted overnight on ___ to the gynecology service for retained products of conception diagnosed by pelvic ultrasound in the setting of vaginal bleeding following an elective termination on ___. Her hematocrit was 30.6 on presentation. She was taken to the operating room for a dilation and curretage. Her operative course was uncomplicated. Please see report for full details. She recovered well and was discharged home later that day in stable condition with follow up scheduled with Dr. ___ on ___.
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10041339-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> pprom <MAJOR SURGICAL OR INVASIVE PROCEDURE> exam under anesthesia s/p vaginal delivery, bakri placed postpartum, removed <PHYSICAL EXAM> On discharge: Vitals: 24 HR Data (last updated ___ @ 018) Temp: 97.5 (Tm 98.1), BP: 101/67 (97-131/61-77), HR: 99 (94-99), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA Fluid Balance (last updated ___ @ 020) Last 8 hours Total cumulative -900ml IN: Total 0ml OUT: Total 900ml, Urine Amt 900ml Last 24 hours Total cumulative -2600ml IN: Total 1000ml, PO Amt 1000ml OUT: Total 3600ml, Urine Amt 3600ml General: NAD, A&Ox3 CV: RRR Lungs: No respiratory distress Abd: soft, overall nontender excepting some mild tenderness over umbilicus, fundus firm below umbilicus Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 03: 05AM BLOOD WBC-17.2* RBC-2.59* Hgb-8.6* Hct-25.2* MCV-97 MCH-33.2* MCHC-34.1 RDW-15.1 RDWSD-52.8* Plt Ct-81* ___ 01: 18AM BLOOD WBC-16.9* RBC-2.67* Hgb-9.0* Hct-25.3* MCV-95 MCH-33.7* MCHC-35.6 RDW-14.6 RDWSD-50.4* Plt Ct-83* ___ 08: 45PM BLOOD WBC-16.2* RBC-2.54* Hgb-8.9* Hct-26.7* MCV-105* MCH-35.0* MCHC-33.3 RDW-14.1 RDWSD-53.8* Plt ___ ___ 03: 10PM BLOOD WBC-10.1* RBC-3.07* Hgb-10.7* Hct-31.0* MCV-101* MCH-34.9* MCHC-34.5 RDW-14.2 RDWSD-52.0* Plt ___ ___ 10: 40AM BLOOD WBC-8.2 RBC-2.82* Hgb-9.9* Hct-29.3* MCV-104* MCH-35.1* MCHC-33.8 RDW-14.2 RDWSD-53.3* Plt ___ ___ 12: 30PM BLOOD WBC-11.2* RBC-2.98* Hgb-10.5* Hct-30.4* MCV-102* MCH-35.2* MCHC-34.5 RDW-13.8 RDWSD-50.6* Plt ___ ___ 01: 18AM BLOOD Glucose-92 UreaN-9 Creat-0.4 Na-133* K-3.7 Cl-107 HCO3-17* AnGap-9* <DISCHARGE INSTRUCTIONS> pelvic rest for 6 weeks, rest
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ANTEPARTUM She was admitted to antepartum after it was confirmed that her amniotic membranes ruptured. She was given latency antibiotics, underwent a NICU consult, and received betamethasone. She remained stable until 34 weeks gestational age and underwent induction of labor. POST PARTUM On ___, patient had a spontaneous vaginal delivery. This was complicated by post partum hemorrhage and chorioamnionitis. Regarding her postpartum hemorrhage, her total estimated blood loss was 2400mL due to uterine atony and a posterior cervical laceration. She necessitated an OR takeback for improved visualization and repair of the cervical laceration. She received pitocin, cytotec, methergine, TXA. A Bakri balloon balloon for 240mL was placed as well as vaginal packing. She received 2 units of packed RBCs. Her hematocrit was obtained and noted to be 25.3 (___) with platelets of 83. Her fibrinogen was 180. Her INR was 1.3 over two measurements (___). Her vitals remained stable and her vaginal packing and bakri balloon were removed on ___. Regarding her chorioamnionitis, patient received 2g of ancef in the OR. She had a fever of approximately ___ on ___ at 2145. She received ampicillin and gentamicin for 24 hours first afebrile ___ afebrile 0300 ___. For her GDMA1, patient's fingersticks were not followed. On post partum day 3, ___, patient had stable vitals and accomplished all her post partum milestones. Her bleeding was stable and she was thus discharged to home in stable condition. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) 5. Levothyroxine Sodium 25 mcg PO 2X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: s/p vaginal delivery postpartum hemorrhage Discharge Condition: stable Followup Instructions: ___
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10041958-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic Fibroid Uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy Bilateral salpingectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G4, P3, Term3, Preterm0, Abt1, Sab0, Tab1, Ect0, Live3. Patient's last menstrual period was ___. She presents for pre-op visit for planned surgery, Total Abdominal Hysterectomy at ___ on ___ for large fibroid uterus. Progressively increasing myoma causing abdominal discomfort, urinary frequency. Pt has been referred by Dr ___ hysterectomy. <PAST MEDICAL HISTORY> PMH: migraine, low back pain, iron deficiency anemia, H pylori, colonic adenoma, fibroid, elevated A1c, DJD of knee PSH: laparoscopic tubal ligation, excision vaginal cyst, D&C, LEEP ObHx: G4P3, Term#, Preterm0, Abt1, Sab0, Tab1, Ect0, Live 3. GynHx: fibroid Uterus <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father with DMT2 and hypertension Mother with breast cancer and hypertension <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, nondistended, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> None. **Pathology Pending <MEDICATIONS ON ADMISSION> Ibuprofen <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4,000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *2 2. Docusate Sodium 100 mg PO BID Take while taking pain meds RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *2 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking medication RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*30 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN pain Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Symptomatic Fibroid Uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a total abdominal hysterectomy, bilateral salpingectomy for symptomatic fibroid uterus. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, ibuprofen, and acetaminophen. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10042315-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Large symptomatic fibroid uterus. <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy, lysis of adhesions, partial omentectomy, and drainage of a left ovarian cyst <HISTORY OF PRESENT ILLNESS> ___ ___ who on ___, underwent a bilateral uterine fibroid embolization. Again, she presents to discuss further the requested operative management. She continues to have pelvic pain, fullness, constipation, increased urinary frequency. On ___, she had an MR of her pelvis, which showed large fibroid uterus extending to the upper abdomen. The uterus including fibroids measured 30 x 18 x 24 cm, minimally decreased in size prior to examination on ___, when it measured 30 x 18 x 26 cm. The endometrium was somewhat distorted by the fibroids. The largest intramural fibroid was at the uterine fundus, minimally decreased in size and measured 17.6 x 15.6 x 16.2 cm, previously measured 18.3 x 17.9 x 18 0.6 cm. This fibroid subserosal less than 50% intramural and did not abut the endometrium. An additional large fibroid was subserosal pedunculated fibroid on the right which measured 11.2 x 11.3 x 8.6 cm, previously measured 9.1 x 12.7 x 13.2 cm, minimally decreased in size. Two additional large subserosal pedunculated fibroids arise from the anterior lower uterus measuring 6.5 x 3.9 x 5.1 cm, previously measured 5.8 x 8.4 x 5.6 cm and last 7.6 x 6.7 x 8.5 cm, previously 10.7 x 7.9 x 8.9 cm. Both of these fibroids were minimally decreased in size from prior examination. The ovaries were normal in appearance, trace pelvic free fluid was in physiologic limits. These findings were discussed with the patient and her questions were answered. Her ___ Pap was negative for intraepithelial lesion or malignancy and she tested negative for the high-risk HPV. She also had a negative endometrial biopsy. ___ her Hct was 36.3%. She continues to eat Iron rich food and supplement with daily po Iron. Of note, she continues to have decreased platelets and is being seen by her hematologist. I am waiting for intraoperative and post-operative recommendations. <PAST MEDICAL HISTORY> Ob/Gyn hx: G0, would like to keep future childbearing options open, if possible. Menarche 10 x 28 x 5, hx of heavy menses with no clots, no metrorraghia, no post coital bleeding, absent dyspareunia, no dysmenorrhea. Problems: FIBROIDS, UTERUS KERATITIS OVERWEIGHT PHARYNGITIS Surgical History: none <SOCIAL HISTORY> <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> MGM HYPERTENSION denies family hx of GYN malignancies, DM, CAD <PHYSICAL EXAM> Pre-Admission Physical Exam WDWN obese woman in NAD BP: 138/98. Weight: 287 (With Clothes; With Shoes). Height: 67. BMI: 44.9. LMP: ___. ABDOMEN: Soft, obese, nondistended, nontender. There was a large palpable mass 5 fingerbreadths above the umbilicus, from the pubic symphysis to the top of the uterine fundus is 34 cm. There was no inguinal lymphadenopathy and again no tenderness on palpation of this mass which was c/w a large uterus. PELVIC: Deferred secondary to the patient having no complaints. Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 12: 19PM WBC-12.2* RBC-4.51 HGB-13.8 HCT-38.2 MCV-85 MCH-30.6 MCHC-36.1 RDW-13.7 RDWSD-42.5 ___ 12: 19PM PLT COUNT-117* <MEDICATIONS ON ADMISSION> Medications - Prescription IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth Q6 hours as needed for pain/cramping - (Not Taking as Prescribed) Medications - OTC MULTIVITAMIN [DAILY MULTI-VITAMIN] - Daily Multi-Vitamin tablet. 1 (One) tablet(s) by mouth once daily - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild no more than 4g in 24hrs RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hrs Disp #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild take with food, no more than 2400mg in 24hrs RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hrs Disp #*40 Tablet Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate don't drink alcohol and don't drive on this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing abdominal myomectomy, lysis of adhesions, partial omentectomy, and drainage of a left ovarian cyst. During her procedure 11 fibroids were removed, the largest being 20cm. Notably there were multiple adhesions concerning for previous PID. Immediately post-op, her pain was controlled with IV Dilaudid/Toradol. Please see the operative report for full details. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her post-operative course was complicated by persistant tachycardia and development of a post-operative ileus. She had symptomatic tachycardia to the 110-120s. EKG showed sinus tachycardia. Her hematocrit was trended. Her pre-op HCT (___) of 38.2 and remained stable at an appropriate decrease to 33, after an intraoperative EBL 500cc. Her urine output remained adequate. Tachycardia was not responsive to a fluid bolus. A CTA was ordered to rule out a thromboembolic event which was significant for no segmental PE and showed only bilateral atelectasis, and a fluid filled gastric lumen consistent with an ileus. She was started on subcutaneous heparin prophylactically. She had a leukocytosis with a max of 30.3 with no other accompanying symptoms such as fever or chill or other localizing symptoms such as severe abdominal pain, dysuria, cough/sputum production. Of note, the patient has had an elevated heart rates since her uterine artery embolization ___ during which time she was extensively worked up and thought to be secondary to post-embolization syndrome. On POD 2, she had an episode of 600cc of emesis. She was made NPO overnight. The following day her diet was advanced without incident with no additional episodes of emesis. She was transitioned to PO oxycodone/ibuprofen/acetaminophen for pain control. By post-operative day 4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient cardiology and gynecology follow-up scheduled.
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10043622-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> ___ 05: 44PM WBC-9.3 RBC-4.38 HGB-12.9 HCT-37.9 MCV-87 MCH-29.5 MCHC-34.0 RDW-13.4 RDWSD-41.7 ___ 05: 44PM NEUTS-59.2 ___ MONOS-10.3 EOS-0.9* BASOS-0.2 IM ___ AbsNeut-5.53# AbsLymp-2.67 AbsMono-0.96* AbsEos-0.08 AbsBaso-0.02 ___ 05: 44PM PLT COUNT-253 ___ 10: 00PM ___ PO2-28* PCO2-42 PH-7.41 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA ___ 10: 00PM LACTATE-1.6 ___ 09: 21PM GLUCOSE-254* UREA N-17 CREAT-0.6 SODIUM-136 POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-24 ANION GAP-19 ___ 09: 21PM estGFR-Using this ___ 09: 21PM WBC-15.9* RBC-4.26 HGB-13.0 HCT-37.1 MCV-87 MCH-30.5 MCHC-35.0 RDW-13.3 RDWSD-41.5 ___ 09: 21PM PLT COUNT-269 ___ 08: 20PM URINE HOURS-RANDOM ___ 08: 20PM URINE UCG-NEGATIVE ___ 08: 20PM URINE UHOLD-HOLD ___ 08: 20PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 08: 20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08: 20PM URINE RBC-6* WBC-<1 BACTERIA-NONE YEAST-MOD EPI-3 ___ 08: 20PM URINE MUCOUS-RARE <MEDICATIONS ON ADMISSION> Lantus 20 QHS, pioglitazone, glimpiride <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H Do not exceed 4,000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Take with food or milk. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abdominal pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the gynecology service. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___ MS. ___ was admitted to the Gynecology service from the Emergency Department. She received IV morphine in the ED for pain control. A UA was negative for infection however showed red blood cells. An initial pelvic ultrasound showed "Impression: Asymmetric enlargement of the left ovary compared to the right without detection of vascular flow, concerning for ovarian torsion. Small amount of simple left adnexal free fluid." A chest Xray showed was negative. A CT scan showed "Impression: 1. No nephrolithiasis or ureterolithiasis. 2. Asymmetric enlargement and hypodensity of the left ovary is also seen on pelvic ultrasound from the same day, and may reflect non vascularity seen on that exam." A repeat pelvic ultrasound on ___ showed "Impression: Essentially unchanged exam compared to the pelvic ultrasound from 6 hours prior, with asymmetry of the ovaries. No detectable left ovarian vascularity. Given no interval change, suspicion for torsion is low. Additionally, the ovary does not look particularly edematous, and decreased or undetectable ovarian blood flow can be seen in postmenopausal woman. I think that torsion is unlikely though not entirely excluded." Her WBC count was initial 15.9, however downtrended to 9.3. For her diabetes, she was placed on an insulin sliding scale and her blood glucose was monitored. Her pain was controlled with Tylenol and toradol. She was initially kept NPO for possible procedure, however her vital signs remained stable and her pain remained well controlled. On hospital day 1 her diet was advanced and she tolerated this well. She was discharged to home in stable condition with outpatient follow-up as scheduled.
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10044439-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Cipro / Ceclor / Reglan / Toradol / morphine <ATTENDING> ___ <CHIEF COMPLAINT> pre-term labor/abruption <MAJOR SURGICAL OR INVASIVE PROCEDURE> Low transverse c/section <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm, incision c/d/i Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 09: 22AM WBC-13.4* RBC-3.30* HGB-9.6* HCT-28.7* MCV-87 MCH-29.1 MCHC-33.4 RDW-13.5 RDWSD-42.1 ___ 09: 22AM PLT COUNT-352 ___ 09: 22AM ___ PTT-24.6* ___ ___ 09: 22AM ___ ___ 12: 14AM WBC-12.3* RBC-3.29* HGB-9.6* HCT-28.1* MCV-85 MCH-29.2 MCHC-34.2 RDW-13.4 RDWSD-41.1 ___ 12: 14AM PLT COUNT-331 ___ 10: 38PM OTHER BODY FLUID FETALFN-POSITIVE ___ 10: 15PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 10: 15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 10: 15PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 10: 15PM URINE AMORPH-RARE ___ 10: 15PM URINE MUCOUS-RARE <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Buprenorphine 4 mg SL DAILY 2. Prenatal Vitamins 1 TAB PO DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 2. HYDROmorphone (Dilaudid) 2 mg PO Q6H: PRN Pain - Severe pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q 6 hr Disp #*25 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H RX *ibuprofen 600 mg 1 tablet(s) by mouth Q 6 hours Disp #*40 Tablet Refills: *0 4. LORazepam 1 mg PO Q6H: PRN muscle spasm RX *lorazepam [Ativan] 1 mg 1 by mouth Q 8 Disp #*20 Tablet Refills: *0 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pregnancy delivered Hypothyroid H/O opiate abuse Anxiety <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Routine post partum Pt was given post op narcotics and told she cannot get refills except from ___
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On ___, Ms. ___ was admitted to Antepartum service for pre-term labor and placental abruption. She underwent a low transverse cesarean section, with an estimated blood loss and her hematocrit was monitored closely. Post-operatively her pain was controlled with Dilaudid PCA, which was transitioned to oral Dilaudid, acetaminophen and ibuprofen. She was also seen by the chronic pain service during her hospitalization. She was continued on her home levothyroxine during her hospitalization. She was offered her home Subutex but declined. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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10044439-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Cipro / Ceclor / Reglan / Toradol / morphine <ATTENDING> ___ <CHIEF COMPLAINT> pelvic cramping, rule out reterm labor, rule out short cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ ___ @ 19w2d with prior history of preterm delivery at 29w3d due to abruption presents with irregular contractions. Patient states that she has been experiencing irregular contractions, lasting one minute for one week. The contractions are associated w/ back pain and pelvic pain which subsides once contractions. This morning she noted pink spotting, thus she decided to present. She denies any recent vaginal intercourse, abdominal trauma, changes in vaginal discharge. Of note, her last TVUS was on ___ which showed a CL=3.3 cm. She endorses +FM and denies VB, LOF. She feels nervous that her cervix is shorter and she is having preterm labor. She denies any HA, F/C, n/v, abdominal pain, rashes. Last meal 2 hours ago All: - Celcor (childhood) - Cipro (itching, throat swelling) - Toradol (rash) - Morphine (choking sensation) <PAST MEDICAL HISTORY> PNC: ___ ___ by IVF dating Labs: A+/Rh neg/RI/RPR neg/HBsAg neg/HIV neg/GBS unk Screening: low risk ERA FFS: N/A GLT: N/A US: N/A Issues: - small subchorionic hematoma noted on 510/19 U/S at 6w5d. No vaginal bleeding. Plan follow up with NT U/S. - Hx preterm delivery with repeat LTCS at 29 weeks for twins. Followed for short cervix, preterm contractions. Both babies are doing very well and meeting milestones. s/p ___ consult. IM Progesterone week ___ for prevention of recurrent preterm birth. However pt opted to start vaginal progesterone @ 12weeks - hx opioid use: on buprenorphine ___ QD - hypothyroidism: levothyroxine 75mcg QD; last TSH 1.96 on ___ - gHSV: [ ] suppression @ 36wks OB: G1 - SAB G2 - C/S at term 38w0d G3 - C/S at 29w3d, abruption, mono-di twins PMH: - Opiate dependence - Anxiety - Hypothyroidism PSH: - c/s x 2 - LSC x 6 (ovarian cystectomy, appendectomy, LOA) - Exploratory laparotomy, ruptured hemorrhagic cyst - Cholecystectomy - Mini laparotomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Gen: A&O, NAD CV: RRR Resp: CTAB Abd: +BS, soft, NT/ND, no rebound or guarding. Ext: calves nontender bilaterally, no c/c/e Pelvic: normal vulva anatomy, vagina w/ normal discharge, no bleeding noted. Cervix appears visually closed. SVE: pt declined FHT 140s. Bedside TVUS: Cervical length measuring 2.1 cm, unchanged w/ fundal pressure <PERTINENT RESULTS> ___ 06: 08PM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG <MEDICATIONS ON ADMISSION> Meds: - Levothryxoine 100mcg daily - Subtex 8mg TID - PNV - Vaginal progesterone BID <DISCHARGE MEDICATIONS> 1. Buprenorphine 8 mg SL TID 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm contractions <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per instruction sheet
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admitted for observation. lower abdominal cramping resolved. ___ U/S cephalic, normal fluid, cervical length 3.4cm, no evidence abruption ___ follow up U/S prelim read CL 3.7cm per review with Dr ___. discharge instructions reviewed. d/c home with follow up on ___ with primary ___ MD ___ and with ___ U/S.
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10049377-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Celexa / Zoloft / bupropion HCl / lisinopril / Bentyl <ATTENDING> ___ <CHIEF COMPLAINT> pelvic organ prolapse & incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> robot-assisted supracervical hysterectomy, right salpingo-oopherectomy, sacrocolpopexy, TVT and cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ patient who presents with vaginal dryness and vaginal bulge symptoms. She has had vaginal atrophy symptoms for many years; however, the bulge again becoming noticeable this ___. She notes increased vaginal dryness and discomfort when walking. She has a palpable bulge when she wipes. She has been on Vagifem for several years. When the increased vaginal dryness started, she was switched to Estrace, which helped for a little while, but then became ineffective. She has gone back to Vagifem, which she uses twice a week. She states that she was diagnosed with a prolapse by an urologist as well as her gynecologist. She spends six months in ___ and six months in ___. She is leaving to go back to ___ in the first week of ___. She denies any urinary incontinence. She goes to bathroom every three or more hours. Sometimes she feels the urge to urinate, but cannot void. She gets up once at night to urinate. She denies problems with fecal incontinence. She has occasional constipation. She denies recurrent bladder infections, hematuria or dysuria. She does state that her urine flow is normal flow. She is sexually active and her problems with the prolapse or urination do not interfere with intercourse. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Positive for hypercholesterolemia, hypertension, irritable bowel, osteoporosis, thyroid disorder and vaginal atrophy. Past Surgical History: Tubal ligation in ___, appendectomy in ___, cholecystectomy in ___ via a right paramedian laparotomy. Past OB History: Two pregnancies, two vaginal deliveries, two children. Birth weight of largest baby delivered vaginally 7 pounds 13 ounces. Positive for forceps, negative for vacuum-assisted vaginal delivery. Past GYN History: Menopause at age ___. Up-to-date with preventative screening Pap, last Pap ___, no history of abnormal Paps. Last mammogram ___ was negative. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother, stroke. Father, heart disease. <PHYSICAL EXAM> On admission: General: Well developed, well groomed, normal weight. Psych: Oriented x3, affect is normal. Skin: Warm and dry, no atypical lesions or rashes. Neck: Trachea midline. Pulmonary: Normal respiratory effort. No use of accessory muscles. Abdomen: Soft, nontender. No masses, no guarding, no rebound. No hepatosplenomegaly. There is a long right paramedian scar from cholecystectomy in ___. Lymph Nodes: No inguinal lymphadenopathy. Cardiovascular: Pulse normal rate and rhythm. No pedal edema or varicosities in the lower extremities. Neurologic: The bulbocavernosus reflex is positive. The anal wink is negative bilaterally. Grossly normal sensation to light touch. Genitourinary: External Genitalia: Normal, no lesions or discharge. Urethral Meatus: No caruncle, no prolapse. Urethra: Nontender. External urethral meatus is small. Posterior urethral caruncle, no prolapse. Urethra: Nontender, no masses or exudate. Bladder is nonpalpable, nontender. Vagina is moderately atrophic, stage III cystocele, stage II uterine prolapse, see POP-Q below. Cervix: Grossly normal. Uterus small, mobile, postmenopausal. Adnexa: No masses or tenderness. Anus and Perineum: No masses or tenderness. POP-Q: Aa -1, Ba +3, C -2. ___ 3.5, PB 3, TVL 8. Ap -2.5, Bp -2.5, D -5. <PERTINENT RESULTS> No lab results for this admission. <MEDICATIONS ON ADMISSION> DICYCLOMINE - 10 mg capsule - 1 Capsule(s) by mouth 3 times daily as needed for stomach spasm ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit capsule - 1 Capsule(s) by mouth every other week If diarrhea, poke hole in capsule and take liquid. ESTRADIOL [VAGIFEM] - 10 mcg tablet - 1 per vagina twice weekly HYDROCHLOROTHIAZIDE - 12.5 mg tablet - 1 Tablet(s) by mouth once a day IBUPROFEN - 600 mg tablet - 1 Tablet(s) by mouth 4 times daily as needed for pain LEVOTHYROXINE - 75 mcg tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 25 mg tablet extended release 24 hr - 1 Tablet(s) by mouth in AM PRAVASTATIN - 20 mg tablet - 1 Tablet(s) by mouth once a day ASPIRIN - (OTC) - 81 mg tablet, chewable - 1 Tablet(s) by mouth CALCIUM CARBONATE [TUMS ULTRA] - 1,000 mg tablet, chewable - 1 Tablet, Chewable(s) by mouth twice a day DOCUSATE SODIUM - (OTC) - 100 mg capsule - 1 Capsule(s) by mouth once a day LACTASE [LACTAID] LACTOBACILLUS RHAMNOSUS GG [PROBIOTIC] PSYLLIUM HUSK [METAMUCIL] <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 2. Ibuprofen 600 mg PO Q6H: PRN pain do not overlap with toradol RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Metoprolol Tartrate 25 mg PO DAILY 5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 - 2 tablet(s) by mouth every 4 hours Disp #*45 Tablet Refills: *0 6. Calcium Carbonate 500 mg PO QID: PRN indigestion <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse and incontinence now s/p robot-assisted supracervical hysterectomy, right salpingo-oopherectomy, sacrocolpopexy, TVT and cystoscopy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a robot-assisted suprcervical hysterectomy, right salpingo-oopherectomy, sacrocolpopexy, TVT, cysto for pelvic organ prolapse and incontinence. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. A voiding trial was performed on post-op day 1 with the following results: 200 mL instilled, voided 150 mL, PVR 25 mL; 200 mL instilled, voided & missed hat, PVR 0 mL. She did not require a Foley catheter to go home. Her diet was advanced without difficulty and she was transitioned to oral percocet and motrin. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10049736-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> RLQ pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic paratubal cystectomy detorsion <HISTORY OF PRESENT ILLNESS> ___ yo G4P4 dx with R ovarian vs paratubal cyst after presenting to ___ with RLQ pain ~1 mo ago. She had severe pain which improved after narcotics and rest. Was back to her usual state of health until last night. Began having dull RLQ pain @ 1030pm, subsequently had severe pain beginning @ 130am. Presented to ___ initially and was transferred ___ concern for torsion. On arrival to ___, she was very uncomfortable. Vital signs were normal. Got 2x morphine 5mg IV and had a pelvic US. Ate crackers at 930am. Currently states pain is ___, achy, RLQ, non-radiating <PAST MEDICAL HISTORY> OB/GYN Hx: - LTCS x 4 - denies h/o pelvic infections - remote h/o cervical dysplasia, nl f/u - diagnosis of R adnexal cyst ~1mo ago - no current contraception PMH: Denies PSH: - LTCS x4 - LSC appy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> T 97.3, HR 57, BP 100/52, RR 20 100% NAD Abd soft, ND, +TTP RLQ/suprapubic region, no r/g Pelvic: small av uterus with limited mobility. + soft, moblie mass appreciated post to uterus, fairly uncomfortable with palpation of the mass. Discomfort on R with mvmt of cervix ext NT, NE <PERTINENT RESULTS> ___ 05: 40AM BLOOD WBC-9.2 RBC-4.03* Hgb-12.2 Hct-35.2* MCV-87 MCH-30.3 MCHC-34.7 RDW-12.8 Plt ___ ___ 05: 40AM BLOOD Neuts-85.5* Lymphs-11.0* Monos-3.1 Eos-0.2 Baso-0.3 ___ 05: 40AM BLOOD Glucose-122* UreaN-14 Creat-0.7 Na-140 K-3.9 Cl-106 HCO3-25 AnGap-13 ___ 07: 00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 07: 00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 07: 00AM URINE UCG-NEG PELVIC ULTRASOUND ___: Transabdominal and transvaginal examinations performed, the latter to further evaluate the endometrium and adnexal structures. The uterus is anteverted and retroflexed and measures 10.8 x 4.4 x 6.0 cm. The endometrium is homogeneous in echogenicity measuring 8 mm. A C-section scar is noted. Within the right adnexa, there is a large simple cyst measuring 6.4 x 5.0 x 6.6 cm. This likely represents a paraovarian cyst. The adjacent ovary appears slightly edematous and measures 2.6 x 3.2 x 3.3 cm. The left ovary measures 2.6 x 2.2 x 3.1 cm. Small follicles are noted. There is normal arterial and venous Doppler waveforms within both ovaries. There is trace pelvic free fluid. IMPRESSION: 1. Slightly edematous right ovary with normal arterial and venous Doppler waveforms. Findings are indeterminate with ovarian torsion not excluded. Gynecologic consultation with clinical correlation is recommended. 2. Large 6.6 cm right paraovarian cyst. Follow-up pelvic ultrasound in 3 months is recommended. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain: do not administer more than 4000mg acetaminophen in 24 hrs. Disp: *30 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> paratubal cyst adnexal torsion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication
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Ms. ___ presented to the emergency department with RLQ pain. Ultrasound was performed showing a large 6.6 cm right paraovarian cyst and slightly edematous right ovary. Due to concern for torsion, patient was taken to the operating room. She was found to have a 10cm paratubal necrotic cyst causing adnexal torsion and underwent laparascopic paratubal cyst excision after adnexal detorsion. She had an uncomplicated recovery and was discharged home on postoperative day #0 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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10050785-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> nausea/vomiting, left flank pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G5P3 at 7w4d by LMP presented with left flank pain and nausea. Pt went to ___ and reported severe left flank pain since 2 days ago, ___. Of note she was started on an antibiotic ___ (pt do not know name of ___ UTI, however she was not able to keep the antibiotic down because she was nauseous and vomiting for the past 2 days as well. She can't keep food or fluid down at all, and urinate twice per day only. She had subjective fever, but never took her temperature. She alsp had chills. On Ros: she denied dizziness, headache, shortness of breath, chest pain, cough, diarrhea, constipation, or abdominal pain. <PAST MEDICAL HISTORY> PNC if pregnant: -___ ___ by LMP ___ -Labs: O+/Ab-/RPRNR/RI/HBsAg-/HIV- -US ___: No ___. OB Hx: G5P3, TAB x1, SVD x2, c/s x1 GYN Hx: denied hx of abnl pap; hx of chlamydia Meds: Wellbutrin, Trazadone, Visitril PMH: depression PSH: c/s x1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 99.8, HR 97, BP 103/45, RR 18, O2 Sat 97%RA GENERAL: NAD, but uncomfortable HEART: RRR; no murmurs appreciated LUNGS: CTAB ABDOMINAL: soft, none tender, none distended BACK: positive left CVA tenderness, no right CVA tenderness EXTREMITIES: NT Bedside US: +FHR 132 BPM, CRL = 6w1d <PERTINENT RESULTS> ___ WBC-20.7 RBC-4.14 Hgb-12.9 Hct-37.9 MCV-92 Plt-330 ___ Neuts-88.4 ___ Monos-5.4 Eos-0.3 Baso-0.3 ___ WBC-16.5 RBC-3.80 Hgb-11.9 Hct-33.5 MCV-88 Plt-293 ___ Neuts-84.7 ___ Monos-7.1 Eos-0.1 Baso-0.2 ___ Glu-101 BUN-4 Cre-0.6 Na-135 K-3.8 Cl-99 HCO3-25 AnGap-15 ___ Calcium-9.2 Phos-3.1 Mg-2.0 ___ URINE Blood-SM Nitrite-POS Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ URINE RBC-1 WBC-95 Bacteri-FEW Yeast-NONE Epi-3 URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML. SENSITIVITIES: MIC expressed in MCG/ML _______________________________________ ESCHERICHIA COLI AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R <MEDICATIONS ON ADMISSION> Wellbutrin Trazadone Visitril <DISCHARGE MEDICATIONS> 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. 3. bupropion HCl 100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 4. Macrobid ___ mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp: *20 Capsule(s)* Refills: *0* 5. Macrobid ___ mg Capsule Sig: One (1) Capsule PO once a day: Please start once twice daily regimen for macrobid is complete. Disp: *30 Capsule(s)* Refills: *2* 6. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day for 60 days. Disp: *60 Capsule(s)* Refills: *3* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pyelonephritis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call for fevers, chills, back pain, pain with urination, nausea, vomiting, vaginal bleeding, or any other questions or concerns. . Please complete your antibiotics. Take 2 pills daily for another 10 days, then one pill daily until instructed to stop.
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___ y/o G5P3 admitted at 7w4d with pylonephritis. . Although Ms ___ initially only had a low grade temperature, she had left flank pain, tenderness, elevated white blood cell count, and urinalysis suspicious for infection. Given the high suspicion for pyelonephritis, she was admitted to the antepartum floor and treated with IV Ceftriaxone. Overnight, she developed a fever to 101. She was continued on IV fluids. Her pain was controlled with po meds and she was tolerating a regular diet. Her urine culture grew >100,000 EColi. She remained on IV antibiotics until afebrile for 48hrs, then transitioned to po antibiotics (Macrobid). She will continue a 14 day course, then continue daily suppression for the remainder fo the pregnancy. . *)Dating: Bedside ultrasound in triage revealed a 10 day discrepancy from her LMP. A formal ultrasound was not obtained during this admission, therefore, should be arranged as an outpatient. . *)Depression: Ms ___ was continued on Wellbutrin and social services was consulted. She was encouraged to followup with Behavioral Health at ___.
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10053697-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> s/p fall <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ ___ yrs. G1, P0, Term0, Preterm0, Abt0, Sab0, Tab0, Ect0, Live0 at 33w3d presented to ___ for evaluation after fall. HPI: She was walking her dog this morning with a hot cocoa in her hand and tripped over uneven sidewalk. She landed on her right hand, right wrist and flank. She is not sure if she hit her abdomen, but doesn't think so. She was seen in ER and diagnosed with Boxer's fracture of ___ metacarpal. Her hand was splinted and she was transferred to L and D for further evaluation. She denies ctx, LOF, VB, abdominal pain. +FM. <PAST MEDICAL HISTORY> PMH: ADHD PSH: Wisdom teeth removal <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory. <PHYSICAL EXAM> On admission: VSS Constitutional: Gravid well developed, well nourished female, appearing in no acute distress Abdomen: no tenderness and no masses Fundus: size equals dates, nontender and not irritable EFW: Average Sterile speculum exam: Dilation: Closed Effacement: Long Extremity: Hand wrapped per ortho <PERTINENT RESULTS> ___ 01: 04PM FETAL HGB-0 ___ 01: 02PM WBC-10.1* RBC-3.67* HGB-12.0 HCT-35.3 MCV-96 MCH-32.7* MCHC-34.0 RDW-13.1 RDWSD-46.1 ___ 01: 02PM PLT COUNT-191 ___ 01: 02PM ___ PTT-27.2 ___ ___ 01: 02PM ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> PNV <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right hand fracture Pregnancy at 33 weeks <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please keep appointments with Dr. ___ orthopedics as scheduled.
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Ms. ___ was transferred from the ED to Labor and Delivery. Given significant fall and ongoing contractions, decision made to monitor x 24 hours on L&D. This was uneventful. At the end of this period, she was discharged home with close OB and ortho follow-up.
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| 60
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10053980-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 32w6d presents to OB triage with painful contractions since 1am. No vaginal bleeding. No LOF. + AFM. Patient had intercourse last night around 11pm. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ by second tri U/S Labs: A+/Ab neg/RI/RPR NR/HepBsAg neg/ U/S: 1. normal FFS, post placenta 2. ___: EFW 1451g, 25% Testing: GLT 119, quad low risk Issues: 1. anorexia/poor weight gain, s/p nutrition consult, ensure BID 2. seen in OB triage in ___ tri, "hit in abd with doorknob" 3. recurrent UTIs, on macrobid ppx 4. h/o syncope, s/p cards consult, ECHO nl 5. teen pregnancy, s/p SW consult PAST OBSTETRIC HISTORY G1P0 PAST GYNECOLOGIC HISTORY Denies abnl pap/STIs. Regular cycles. PAST MEDICAL HISTORY 1. Syncopal episodes, s/p cards consult, ECHO nl, likely secondary to low caloric intake 2. Anorexia/poor weight gain, s/p nutrition consult, ensure BID, monitor lytes PAST SURGICAL HISTORY denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: AFVSS GENERAL: NAD, cachetic, uncomfortable ABDOMEN: Soft, NT, gravid EXTREMITIES: NT NE SVE: ___ FHT: baseline 125, mod LTV, +accels, no decels TOCO: q2mins BPP ___, AFI 11cm, vertex <PERTINENT RESULTS> ___ WBC-8.5 RBC-3.54 Hgb-10.5 Hct-30.0 MCV-85 Plt-275 ___ Neuts-62.4 ___ Monos-4.6 Eos-1.7 Baso-0.4 ___ Glu-82 BUN-7 Cre-0.5 Na-135 K-3.4 Cl-108 HCO3-20 ___ Glu-90 BUN-8 Cre-0.5 Na-137 K-4.1 Cl-106 HCO3-20 ___ Calcium-8.3 Phos-2.3 Mg-6.2 ___ Albumin-3.3 Calcium-8.4 Phos-2.9 Mg-1.8 ___ Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ URINE CULTURE neg ___ GBS neg <MEDICATIONS ON ADMISSION> prenatal vitamins iron supplement <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp: *60 Capsule(s)* Refills: *0* 2. Ensure Liquid Sig: One (1) can PO three times a day. Disp: *1 case* Refills: *2* 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp: *30 Cap(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 33+4 weeks gestation preterm contractions <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> continue modified bedrest at home. call your doctor with any leaking of fluid, vaginal bleeding, regular or painful contractions, or decreased fetal movement. Try to follow nutrition recommendations, including ensure shakes ___ times/day.
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___ G1P0 admitted at 32w6d with preterm labor. . Ms ___ was contracting every 2 minutes on arrival to triage. Her cervix was 1-2/50/-2. Fetal testing was reassuring and she had no signs or symptoms of abruption of infection. Due to her gestational age and cervical dilation, she was started on magnesium tocolysis. She was given a course of betamethasone (complete on ___ for fetal lung maturity and the NICU was consulted. Her contractions spaced out significantly on magnesium, however, she developed acute onset of shortness of breath after approximately 10 hours and the magnesium was discontinued. Her magnesium level was found to be 7.4 at that time. Her shortness of breath resolved quickly after stopping the magnesium. Her contractions were minimal and she made no further cervical change. After prolonged monitoring on labor and delivery, she was transferred to the antepartum floor. She underwent close fetal surveillance with daily NSTs. She has been followed by social services as an outpatient and they were able to see her during this admission. Due to the ongoing concern of her poor weight gain, pyschology was consulted to evaluate her for a possible eating disorder. They did not find any evidence of any eating disorder, and feel that her poor weight gain appears to be more related to the stress of the pregnancy. Recommendations included close followup with social services and nutrition. Please see pychiatry consult note in OMR for details. On hospital day #3, she continued to have no contractions off tocolysis and was discharged home.
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10053980-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> - painful contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> - s/p normal spontaneous vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 presenting with painful ctx ___ min. apart at 36w6d. No VB/LOF. +AFM. Admitted to L&D for mgmt of labor. <PAST MEDICAL HISTORY> - anorexia - h/o syncope, s/p Cards consult, nml ECHO, ___ low caloric intake - frequent UTIs <SOCIAL HISTORY> ___ <FAMILY HISTORY> - non-contributory <PHYSICAL EXAM> On admission: Vitals - T: 97.7 HR: 84 RR: 16 BP: 124/88 Gen: NAD, uncomfortable with ctx Abd: soft, gravid, non-tender ___: no edema or calf TTP SVE: ___ <PERTINENT RESULTS> ___ WBC-10.4 Hgb-9.9 Hct-28.4 Plt ___ ___ WBC-11.4 Hgb-9.3 Hct-27.7 Plt ___ ___ WBC-15.6 Hgb-9.8 Hct-27.9 Plt ___ ___ WBC-10.4 Hgb-10 Hct-28.3 Plt ___ . ___ Neuts-69.7 ___ Monos-4.7 Eos-2.6 Baso-0.2 ___ Neuts-78.4 Bands-0 ___ Monos-3.5 Eos-2.2 Baso-0.1 ___ Neuts-71 Bands-11 ___ Monos-3 Eos-0 Baso-1 . ___ URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-<1 . ___ 10: 02 pm URINE Source: ___ **FINAL REPORT ___ Negative for Chlamydia trachomatis by PCR. . ___ 6: 50 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH . ___ 11: 15 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH . ___ 9: 55 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH . ___ 8: 50 pm BLOOD CULTURE Source: Venipuncture **FINAL REPORT ___ Blood Culture, Routine (Final ___: VIRIDANS STREPTOCOCCI. OF TWO COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET ONLY. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. <MEDICATIONS ON ADMISSION> - PNV - iron supplement <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp: 30 Capsule(s) Refills: 0 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: 30 Tablet(s) Refills: 0 3. Prenatal Vitamin 60-0.8 mg Tablet Sig: One (1) Tablet PO once a day. Disp: 30 Tablet(s) Refills: 2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - intrauterine pregnacy at 36wks delivered - preterm labor - chorioamnionitis <DISCHARGE CONDITION> - good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - see discharge sheet
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1. Postpartum fever Uneventful SVD without complications. On PPD #2 became febrile to 102.5F associated with chills. CBC drawn at that time showed a WBC of 15.2 with a left shift and 11 bands. Blood cultures were drawn, with 1 out of 2 sets positive for gram positive cocci in chains and pairs that on final report was noted to be Strep. viridans. Urine cx was negative. She was initially started on ampicillin and gentamicin, but was noted to be persistently febrile on PPD #3, with a max temp of 103.4F, when clindamycin was added. On evaluation, she noted no focal sx of infection. An infectious disease consultation was obtained on PPD #3; please see note in OMR for full details. Urine GC/CT was negative by PCR. CXR was WNL. CT of the abd/pelvis was negative for intra-abdominal fluid collection/abscess. On amp/gent/clinda she gradually defervesced, and repeat CBC with diff showed no bands. Her WBC trended down over the remainder of her hospitalization, normalizing to 10.4 on the day of discharge. Repeat blood cx showed no bacterial growth. On discharge home she was afebrile and in good condition.
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10054622-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> NSAIDS (Non-Steroidal Anti-Inflammatory Drug) <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic cramping <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilation and curettage <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> LABS -=== ___ 03: 15AM BLOOD WBC-5.5 RBC-3.07* Hgb-8.7* Hct-26.0* MCV-85 MCH-28.3 MCHC-33.5 RDW-13.8 RDWSD-42.3 Plt Ct-87* ___ 07: 16AM BLOOD WBC-6.1 RBC-2.90* Hgb-8.3* Hct-24.5* MCV-85 MCH-28.6 MCHC-33.9 RDW-13.6 RDWSD-42.4 Plt Ct-74* ___ 07: 50PM BLOOD WBC-8.8 RBC-3.22* Hgb-9.3* Hct-27.0* MCV-84 MCH-28.9 MCHC-34.4 RDW-13.5 RDWSD-41.2 Plt Ct-64* ___ 02: 25PM BLOOD WBC-13.5* RBC-3.51* Hgb-10.1* Hct-30.0* MCV-86 MCH-28.8 MCHC-33.7 RDW-13.5 RDWSD-41.6 Plt Ct-75* ___ 08: 50AM BLOOD WBC-18.5* RBC-3.94 Hgb-11.4 Hct-33.6* MCV-85 MCH-28.9 MCHC-33.9 RDW-13.5 RDWSD-41.7 Plt Ct-86* ___ 07: 00PM BLOOD WBC-14.9*# RBC-3.88* Hgb-11.4 Hct-32.9* MCV-85 MCH-29.4 MCHC-34.7 RDW-13.2 RDWSD-40.3 Plt Ct-92* ___ 07: 16AM BLOOD Neuts-78.7* Lymphs-12.0* Monos-8.2 Eos-0.3* Baso-0.3 Im ___ AbsNeut-4.80 AbsLymp-0.73* AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02 ___ 07: 50PM BLOOD Neuts-73* Bands-21* Lymphs-5* Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.27* AbsLymp-0.44* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* ___ 07: 00PM BLOOD Neuts-84.2* Lymphs-8.7* Monos-6.1 Eos-0.3* Baso-0.2 Im ___ AbsNeut-12.52*# AbsLymp-1.29 AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03 ___ 07: 50PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-NORMAL ___ 07: 50PM BLOOD Plt Smr-VERY LOW Plt Ct-64* ___ 03: 15AM BLOOD Plt Ct-87* ___ 07: 16AM BLOOD Plt Ct-74* ___ 02: 25PM BLOOD Plt Ct-75* ___ 08: 50AM BLOOD Plt Ct-86* ___ 08: 50AM BLOOD ___ PTT-27.1 ___ ___ 07: 00PM BLOOD Plt Smr-LOW Plt Ct-92* ___ 07: 00PM BLOOD Glucose-83 UreaN-7 Creat-0.4 Na-135 K-3.5 Cl-99 HCO3-24 AnGap-16 ___ 07: 00PM BLOOD Genta-<0.2* ___ 07: 50PM BLOOD Lactate-1.5 ___ 09: 00AM BLOOD Lactate-1.3 ___ 09: 00AM BLOOD Hgb-12.3 calcHCT-37 ___ 08: 30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06: 35PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08: 30PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 06: 35PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 08: 30PM URINE RBC->182* WBC-6* Bacteri-FEW Yeast-NONE Epi-<1 MICROBIOLOGY -=== ___ 9: 50 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 8: 30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL. ___ 7: 50 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): ___ 6: 35 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING -=== ___ Pelvic Ultrasound Final Report EXAMINATION: EARLY OB US <14WEEKS INDICATION: ___ G2P0 @ 12w p/w abdominal pain// eval for ___ trimester pregnancy LMP: ___ TECHNIQUE: Transabdominal and transvaginal examinations were performed. Transvaginal exam was performed for better visualization of the embryo. COMPARISON: None. FINDINGS: An intrauterine gestational sac is seen and a single living embryo is identified with a crown rump length of 62 mm representing a gestational age of 12 weeks 5 days. This corresponds satisfactorily with the menstrual dates of 12 weeks 2 days. The uterus is normal. The ovaries are normal. There is funnel shaped dilation of the cervix measuring 7 mm at its widest point, at the internal os. IMPRESSION: 1. Single live intrauterine pregnancy with size = dates. 2. Cervical dilation measuring up to 7 mm at its widest point, at the internal os. ___ Pelvic Ultrasound Final Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ w/ SAB. Evaluate for retained placenta. Most fetal tissue has passed.// ___ w/ SAB. Evaluate for retained placenta. Most fetal tissue has passed. TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: Pelvic ultrasound ___. FINDINGS: The uterus is anteverted. Previously noted gestational sac and fetus are no longer present. The endometrial cavity is distended with heterogeneous echogenic material, with vascularized products seen posteriorly at the level of the uterine body, measuring at least 5.3 x 3.8 cm in transverse ___, compatible with vascularized retained products of conception. In addition, there is heterogeneous echogenic material without vascularity in the endocervical canal concerning for blood products. Small amount of free fluid in the pelvis. Normal ovaries bilaterally. IMPRESSION: Findings consistent with vascularized retained products of conception measuring at least 5.3 x 3 8 cm in transverse ___ with additional echogenic blood products in the endocervical canal. Small amount of free fluid. <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * Please avoid NSAIDs (ex. ibuprofen) in the setting of your low platelet counts * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) until your post-operative appointment * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ yo G3P0 who presented to the ED at 12weeks gestational age with cramping. She underwent a pelvic ultrasound on ___ which demonstrated a live single intrauterine pregnancy. While in the ED, she developed worsening cramping and vaginal bleeding, and she passed fetal tissue. Repeat pelvic ultrasound revealed retained products of conception. In the ED, pt was noted to be tachycardic (HR max 117) with Tmax 100.2. Her labs were notable for increasing leukocytosis (14 -> 18), thought to be secondary to an inflammatory reaction to her miscarriage (differential included uterine infection i.e. endometritis). The decision was made to proceed with a dilation and curettage for complete removal of pregnancy tissue. On ___ Ms. ___ underwent an uncomplicated ultrasound-guided dilation and curettage. Please refer to the operative note for full details. She had an estimated blood loss of 350mL and received methergine and cytotec intraoperatively. She was continued on PO methergine for 24 hours post-operatively. She also received IV doxycycline intra-operatively due to concern for developing endometritis. Her hematocrit was trended: 33.6 (pre-operative) -> 30.0 (PACU) -> 24.5 (post-operative day #1)-> 26 (post-operative day #2 am). Her post-operative course was complicated by fever and thrombocytopenia: - Fever: Pt spiked a fever to 103.1 on post-operative day #1. Her CBC at the time was notable for WBC 8.8 with 21 bands. UA was negative for UTI. She was treated for presumed endometritis, and received IV gentamicin and IV clindamycin for 24 hours (___). She was then transitioned to PO doxycycline and PO flagyl. - Thrombocytopenia: Pt was noted to have downtrending platelets, with nadir of 64 (___), thought due to ITP vs. gestational thrombocytopenia. Her vaginal bleeding was minimal following the procedure, and her platelet count improved prior to discharge (platelet=87 on ___. NSAIDs were held during this admission in the setting of thrombocytopenia. Thee remainder of her post-operative course was uncomplicated. She received PO Tylenol and oxycodone prn pelvic pain. Her diet was advanced without difficulty. She voided spontaneously on post-operative day #0. By hospital day #2, pt was tolerating a regular diet, voiding spontaneously, ambulating independently, and her pain was well-controlled with oral medications. She was discharged to home with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*1 3. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 4. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate [___] 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 5. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Retained products of conception Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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| 902
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10056202-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Active labor at ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> Low Transverse Cesarean Section. <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ G4P0 at ___ with history of HepB (HBSAG Negative ___, history of hip replacement in ___ secondary to aseptic necrosis of head and neck of R femur, osteopenia, presents in active labor. Presents w/ lower abdominal pain that became more progressively more frequent and intense. At this time, the patient endorses crampy, sharp abdominal pain located over pubic region, lasting 10 mintes, with 5 minute intervals. Also had loss of fluid and vaginal spotting around 7 o'clock pm. Continued to feel fetal movement. <PAST MEDICAL HISTORY> OBHx: - G4P0, G1 TAB, G2TAB, G3 SAB, G4 current GynHx: - denies abnormal Pap, history of STIs PMH: - avascular necrosis of the right hip, s/p THA, recent AVN of the medial aspect of the left knee. L hip revision ___. - crohn's disease currently managed with diet - Osteopenia PSH: - right hip arthroplasty <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Physical Exam on Discharge: VSS Gen: NAD CV: RRR Pulm: CTAB Abd: Soft, nontender Ext: Warm well perfused, nontender <PERTINENT RESULTS> ___ 05: 20PM BLOOD WBC-17.5* RBC-2.61* Hgb-8.0* Hct-23.6* MCV-90 MCH-30.7 MCHC-33.9 RDW-14.6 Plt ___ ___ 07: 20PM BLOOD WBC-15.7* RBC-2.81* Hgb-8.7* Hct-25.4* MCV-90 MCH-30.9 MCHC-34.2 RDW-14.1 Plt ___ ___ 02: 35PM BLOOD WBC-14.3* RBC-2.31*# Hgb-7.0*# Hct-21.3*# MCV-92 MCH-30.3 MCHC-32.9 RDW-14.0 Plt ___ ___ 10: 46PM BLOOD WBC-10.3 RBC-4.28 Hgb-12.7 Hct-38.1 MCV-89 MCH-29.8 MCHC-33.4 RDW-14.2 Plt ___ ___ 07: 20PM BLOOD ___ 02: 35PM BLOOD ___ 03: 13PM BLOOD Lactate-3.3* Na-133 K-3.2* Cl-106 ___ 03: 13PM BLOOD Hgb-6.7* calcHCT-20 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q3H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every ___ hours Disp #*25 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary cesarean section at 38 weeks. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Postpartum care per printed RN discharge sheet.
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Ms ___ is a ___, G4, P0 who presented at 37 weeks 6 days, in active labor. She progressed to fully dilated, and began to push. She pushed for a total of 3hours 15min with minimal decent of the vertex. Fetal status is reassuring prior to surgery. All consents were reviewed, signed in the chart prior to proceeding to the operating room. A viable male infant, weight 2900 g Apgars 9 and 9 was delivered from the vertex presentation. There was bilateral extension into the broad ligaments, and L uterine artery with an EBL of 1500. Patient was transfused 2 units PRBC post op and HCT rose from 21.3 to 25.4. Post partum patient recovered well and was discharged home in stable condition on POD 4.
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10056833-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Amoxicillin / Penicillin G <ATTENDING> ___. <CHIEF COMPLAINT> induction of labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ gestational age presents with fetus with trisomy 18 now with IUGR. She is here for IOL. Of note, pt is also Je___'s Witness and declines blood transfusion even if it would be a life-saving procedure. She has signed JW papers. +FM, no vb/lof/ctx <PAST MEDICAL HISTORY> PNC: xfer from ___ ___: ___ PNL: O pos, ab neg, RPRNR, RI, HepB neg PGYN: denies PMH: ADD, depression, previously on Adderall/Zoloft, on no meds during pregnancy PSH: breast augmentation, liposuction <SOCIAL HISTORY> ___ <FAMILY HISTORY> not relevant to current presentation <PHYSICAL EXAM> Physical: afebrile, VS wnl comfortable CTAB NL S1S2 RRR Abd soft, gravid, NT SVE: FT/long/closed/firm <PERTINENT RESULTS> ___ 06: 39PM BLOOD WBC-9.7 RBC-4.64 Hgb-13.9 Hct-40.5 MCV-87 MCH-29.9 MCHC-34.3 RDW-14.0 Plt ___ ___ 06: 39PM BLOOD Creat-0.8 ___ 06: 39PM BLOOD ALT-13 AST-32 ___ 06: 39PM BLOOD UricAcd-7.7* <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pregnancy delivered IUFD-Trisomy 18 <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Given
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Ms ___ was admitted to Labor and Delivery on ___ for induction of labor given known trisomy 18 fetus with severe IUGR and low HR on office ultrasound (per patient, FHR 68 at office visit prior to arrival at L&D). After discussion with the patient and her primary OB, Dr ___ fetal monitoring was not performed as it was expected that the fetus would not survive labor given multiple cardiac abnormalities seen previously on ultrasound. Ms ___ received 6 doses of 50mcg vaginal misoprostol and had cervical change to ___. She did not report any symptoms of labor. After a discussion of the risks and benefits of continued induction given her refusal of blood products the patient was discharged home on ___. Late that evening she reported a gush of fluid and subsequent onset of regular painful contractions. She returned to Labor and Delivery and spontaneously delivered a stillborn female infant on ___. She was seen by Social Work postpartum. Ms ___ had an uncomplicated postpartum course and was discharged home in good condition on postpartum day #1.
| 457
| 217
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10063680-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfonamides <ATTENDING> ___. <CHIEF COMPLAINT> Painful ctx w/ SROM <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1P0 @ ___ presents with ctx q5mins since ___ with SROM, light mec per RN. +AFM, no VB. PNC: EDC ___ by u/s B-/Ab-/RPRNR/RI/HBSAg-/GBS- FFS nl, GLT 114. Declined ERA/quad Rhogam @ 28wks <PAST MEDICAL HISTORY> OBHx: Primagravida GynHx: Denies abnl Paps/STIs. MedHx: Depression SurgHx: none Meds: Prozac 40mg daily, PNV <ALLERGIES> Sulfa-->rash <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> PE 98.7 77 18 130/80 NAD, intermittent ctx CTAB, RRR Abd soft, NT, gravid Ext WWP, no C/C/E SVE (by RN) 5-6/100/-1 Toco Palpable q5mins FHT 125/mod var/+accels/no decels <PERTINENT RESULTS> CBC 13.3>12.7/36.2<84->86->71->64->54->60->133 ALT 283->257->311->226 AST 160->260->92 Uric acid 4.1->4.8->4.7->4.0 Pro/cr 0.2 UA w/ trace protein <MEDICATIONS ON ADMISSION> Prozac, PNV <DISCHARGE MEDICATIONS> 1. Breast pump Hospital grade Electric Breast pump <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Normal pregnancy, complicated by Hellp syndrome on day of delivery <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> follow detailed discharge planning instruction sheet. Call for fever, heavy bleeding, bad headache, mastitis or depression
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___ G1P0 presented with painful ctx and SROM. Had elevated BPs of 130/80 and 140/76 in triage. PIH labs obtained; pt found to have pattern consistent with HELLP syndrome (elevated LFTs, decreased platelets). Pt had no symptoms of preeclampsia. Delivered female infant by uncomplicated spontaneous vaginal delivery. Pt tolerated 30 hours of magnesium postpartum well. Labs began trending appropriately on PPD#1. Blood pressures continued to be within normal range. Pt was discharged on PPD#3 in stable condition to follow up with Dr. ___.
| 494
| 131
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10065035-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain, nausea, vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic right oophorectomy <HISTORY OF PRESENT ILLNESS> ___ yo G1P1 PMHx TLH for fibroids presents with RLQ pain since ___. Patient reports pain started acutely and woke her from sleep. Had initial nausea with pain and presented to outside ED. At OSH had continued RLQ pain despite morphine and moderate relief with subsequent dilaudid. In ED here continues to report RLQ pain. Has received dilaudid 0.5mg IV x2. Denies fever, chills, dysuria, lightheaded, dizziness, constipation, diarrhea. <PAST MEDICAL HISTORY> OB/GYN Hx: - ___- s/p SVD at term - TLH for fibroid uterus ___ - Denies hx abnl pap/STI - ? hx of endometriosis PMHx: - Plantar fasciitis - Denies hx asthma, HTN, clotting disorders PSHx: - laparscopic TLH <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: Gen: NAD, mildly uncomfortable Abd: soft, voluntary guarding, tender RLQ Pelvic: tender in right adnexa, unable to tolerate pelvic exam Ext: warm well perfused On day of discharge: VS 97.8 45 109/59 14 97% Gen: well appearing, NAD Abd: soft, mild tenderness at incision sites, nondistended, incisions intact with dermabond Ext: no erythema, tenderness or edema <PERTINENT RESULTS> ___ 07: 00PM BLOOD WBC-7.6 RBC-3.98* Hgb-12.0 Hct-36.1 MCV-91 MCH-30.1 MCHC-33.1 RDW-13.7 Plt ___ ___ 07: 00PM BLOOD Neuts-59.4 ___ Monos-8.2 Eos-0.7 Baso-0.3 ___ 07: 00PM BLOOD ___ PTT-29.2 ___ ___ 07: 00PM BLOOD Glucose-90 UreaN-12 Creat-0.9 Na-139 K-3.9 Cl-104 HCO3-27 AnGap-12 ___ 01: 24PM PLT COUNT-170 ___ 01: 24PM WBC-10.2 RBC-3.79* HGB-11.5* HCT-34.3* MCV-91 MCH-30.4 MCHC-33.5 RDW-13.2 ___ 01: 24PM UREA N-13 CREAT-0.9 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours Disp #*60 Tablet Refills: *0 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not exceed 4000mg acetaminophen in 24 hours RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Every 4 hours Disp #*25 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right ovarian torsion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing right oophrectomy for R ovarian torsion. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate, her foley was removed and she was able to void spontaneously. Her diet was advanced without difficulty and she was transitioned to percocet and ibuprofen for pain. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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| 151
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10066767-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain, nausea and constipation <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old G6P2 with PMH significant for Stage III Ovarian Cancer s/p Ex-Lap, TAH/BSO/LND/omentectomy in ___ and s/p 6 cycles ___ Taxol currently on Avastin who presented to ED with ___ day history of progressive nausea, abdominal pain and constipation. Patient recently arrived from ___. and over past two days had noticed bilateral lower abdominal pain (L>R) which initially started as a sharp pain and had become a intermittent ache which she rated as a ___. This was associated with decreased PO intake and progressively worsening nausea. She denied any emesis, but stated that she had not had a BM for ___ days and last flatus was the morning of admission. Her last PO intake was the afternoon of admission with 6 tablespoons of gatorade and 2 small bites of bread. She denied any fever, chills, dysuria or vaginal bleeding. Initially on arrival to ED, nausea improved with Zofran. However, then worsened and she began to experience belching. <PAST MEDICAL HISTORY> GYNECOLOGIC HISTORY: Stage III Ovarian Cancer (Unknown Type) s/p Ex Lap/TAH/BSO/LND/omentectomy in ___. Subsequent ___ x 6 cycles. Currently on Avastin since ___. Heme-Onc: ___ ___ OBSTETRIC HISTORY: G6P2 SAB x 3 PTD @ 7 months LTCS x 2 PAST MEDICAL HISTORY: Hyperlipidemia PAST SURGICAL HISTORY: - TAH/BSO/staging - Open Appendectomy - LTCS x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Significant for CAD. No history of malignancies per patient <PHYSICAL EXAM> 98.2 72 133/77 16 99%RA General: NAD, appears mildly uncomfortable CV: RRR Pulm: CTAB Abd: Soft, + BS, minimally distended, TTP in bilateral lower quadrants, no guarding and no rebound Pelvic: Deferred <PERTINENT RESULTS> ___ CT ABDOMEN/PELVIS FINDINGS: LUNG BASES: There is minimal bibasilar atelectasis, without pleural effusion. ABDOMEN: The liver contains a 9-mm hypodensity within segment VIII, which is too small to characterize. The hepatic and portal veins are patent. The spleen is normal in appearance. The pancreas is somewhat atrophic, but otherwise normal appearing. The adrenals are normal bilaterally. The kidneys demonstrate symmetric contrast enhancement and brisk bilateral excretion. Multiple hypodensities seen within the upper, mid, and lower poles of the left kidney are too small to characterize, but likely also represent cysts. The gallbladder is normal in appearance. There is studding of the anterior surface of the liver, concerning for peritoneal carcinomatosis. A small amount of fluid is seen anterior to the right lobe of the liver. The stomach is collapsed and therefore not well evaluated. Starting in the left mid abdomen and extending to the left lower quadrant, there are distended (though less than 3-cm in diameter) loops of small bowel, which progressively become fecalized in the left lower pelvis, where a transition point is evident (601B: 33). Distal loops are decompressed. Stool is seen throughout the colon. There is no intraperitoneal free air. There is diffuse stranding of the small bowel mesentery. PELVIS: The bladder is collapsed. There is free fluid seen within the pelvis. BONE WINDOWS: There is no concerning lytic or blastic osseous lesion. IMPRESSION: 1. Prominent loops of small bowel extending to the left lower quadrant where they become fecalized adjacent to an apparent transition point, suggesting partial or early complete small bowel obstruction. Please note, malignant obstruction not excluded. 2. Studding seen along the anterior capsule of the liver, where there is a small amount of focal fluid, concerning for peritoneal carcinomatosis. ___ CXR FINDINGS: There is a right chest MediPort in place with tip at the cavoatrial junction. The lungs are clear. There is no pleural effusion, or pneumothorax. The cardiac silhouette is normal in size, and the mediastinal contours are normal. Contrast excretion is seen within the left renal collecting system. IMPRESSION: No acute chest abnormality. ___ 09: 50PM BLOOD WBC-3.3* RBC-4.25 Hgb-12.6 Hct-39.1 MCV-92 MCH-29.6 MCHC-32.2 RDW-13.5 Plt ___ ___ 09: 30AM BLOOD WBC-2.9* RBC-3.61* Hgb-11.0* Hct-33.8* MCV-94 MCH-30.6 MCHC-32.7 RDW-13.7 Plt ___ ___ 04: 57AM BLOOD WBC-3.2* RBC-3.34* Hgb-10.6* Hct-30.8* MCV-92 MCH-31.6 MCHC-34.3 RDW-13.5 Plt Ct-91* ___ 11: 55AM BLOOD WBC-3.1* RBC-3.61* Hgb-11.1* Hct-33.3* MCV-92 MCH-30.6 MCHC-33.2 RDW-13.5 Plt Ct-94* ___ 09: 50PM BLOOD Neuts-71.5* ___ Monos-7.8 Eos-0.7 Baso-0.5 ___ 09: 50PM BLOOD Glucose-110* UreaN-30* Creat-1.1 Na-143 K-4.1 Cl-104 HCO3-25 AnGap-18 ___ 09: 30AM BLOOD Glucose-102* UreaN-23* Creat-1.0 Na-141 K-4.6 Cl-105 HCO3-28 AnGap-13 ___ 04: 57AM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-141 K-3.5 Cl-105 HCO3-28 AnGap-12 ___ 11: 55AM BLOOD Glucose-153* UreaN-6 Creat-0.7 Na-142 K-3.7 Cl-107 HCO3-25 AnGap-14 ___ 09: 50PM BLOOD ALT-12 AST-26 AlkPhos-55 TotBili-0.6 ___ 09: 50PM BLOOD Lipase-30 ___ 09: 50PM BLOOD Albumin-4.6 ___ 09: 30AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.9 ___ 04: 57AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9 ___ 11: 55AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.6 ___ 09: 30AM BLOOD CA12___-61* ___ 09: 58PM BLOOD Lactate-1.2 ___ 01: 10AM URINE Color-Straw Appear-Clear Sp ___ ___ 01: 10AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 01: 10AM URINE RBC-9* WBC-2 Bacteri-NONE Yeast-NONE Epi-1 <MEDICATIONS ON ADMISSION> Avastin Q3 weeks (Last dose ___ Pravachol 10mg <DISCHARGE MEDICATIONS> 1. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp: *60 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Small bowel obstruction Ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology for a small bowel obstruction. You were able to pass gas, have a bowel movement and tolerate a light regular diet without surgery or a ___ tube prior to being discharged. Your CA-125 was 61. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity * You may eat a light regular diet as tolerated To reach medical records to get the records including CT of imaging from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the Gynecology service for management of presumed small bowel obstruction in the setting of known ovarian cancer. For her SBO, she was conservatively managed and never experienced any emesis. She was made NPO and given IV fluids. She began passing flatus on hospital day #2 and her diet was advanced slowly without difficulty. She was noted to be thrombocytopenic on admission, and her platelets remained stable in the 90k-100k range. The thrombocytopenia was presumed to be chronic, related to her malignancy and possibly chemotherapy. Ms. ___ was discharged home in stable condition on hospital day #3.
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10071611-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> hot pepper <ATTENDING> ___. <CHIEF COMPLAINT> acute situational anxiety to pregnancy, hemorrhagic shock <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and evacuation complicated by intraoperative hemorrhage requiring exploratory laparotomy, total abdominal hysterectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___, otherwise healthy, now s/p elective ___ week D&C c/b intraoperative bleeding requiring urgent ex lap and TAH. Pt was referred from Plant Parenthood to our ob/gyn department for elective abortion at ___ week. There was concern for placenta previa. Elective D&C was complicated by EBL ~ 2.0L, requiring ex lap TAH through midline incision. Intraoperative H&H was ___ initially. Repeat H&H ___ after 1U pRBC. She has received 4U of pRBC. Access includes PIV's x2 (16 and 18 gauge) and A-line. She's on phenylephrine gtt peripherally and maintaining her BP. <PAST MEDICAL HISTORY> None <SOCIAL HISTORY> ___ <FAMILY HISTORY> Unknown <PHYSICAL EXAM> ADMISSION Vitals: 85 105/67 12 100% GENERAL: sedated and intubated HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, midline incision with e/o bleeding on dressing EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rash NEURO: deferred . DISCHARGE Gen: NAD Resp: CTAB CV: RRR Abd: soft, midline incision clean/dry/intact with Steri strips Ext: no tenderness to palpation <PERTINENT RESULTS> ADMISSION ___ 11: 17AM BLOOD WBC-14.6* RBC-3.82* Hgb-11.5 Hct-34.4 MCV-90 MCH-30.1 MCHC-33.4 RDW-15.5 RDWSD-49.3* Plt Ct-93* ___ 11: 17AM BLOOD ___ ___ 11: 17AM BLOOD Glucose-155* UreaN-10 Creat-0.3* Na-136 K-3.8 Cl-113* HCO3-20* AnGap-7* ___ 11: 28AM BLOOD D-Dimer-7391* ___ 11: 17AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.2* ___ 09: 28AM BLOOD Type-ART pO2-283* pCO2-36 pH-7.28* calTCO2-18* Base XS--8 . Pertinent: ___ 03: 20PM BLOOD WBC-13.3* RBC-2.91* Hgb-8.8* Hct-25.7*# MCV-88 MCH-30.2 MCHC-34.2 RDW-16.1* RDWSD-50.5* Plt Ct-75* ___ 07: 01PM BLOOD WBC-12.2* RBC-2.71* Hgb-8.1* Hct-23.4* MCV-86 MCH-29.9 MCHC-34.6 RDW-16.4* RDWSD-51.1* Plt Ct-71* ___ 01: 43AM BLOOD WBC-9.3 RBC-2.41* Hgb-7.3* Hct-20.9* MCV-87 MCH-30.3 MCHC-34.9 RDW-16.5* RDWSD-51.9* Plt Ct-70* ___ 06: 00AM BLOOD WBC-9.0 RBC-2.83* Hgb-8.5* Hct-25.1* MCV-89 MCH-30.0 MCHC-33.9 RDW-15.9* RDWSD-50.8* Plt Ct-70* ___ 03: 18PM BLOOD WBC-9.6 RBC-2.72* Hgb-8.4* Hct-24.0* MCV-88 MCH-30.9 MCHC-35.0 RDW-16.0* RDWSD-51.6* Plt Ct-82* ___ 06: 35AM BLOOD WBC-9.2 RBC-2.67* Hgb-8.1* Hct-23.9* MCV-90 MCH-30.3 MCHC-33.9 RDW-16.0* RDWSD-52.7* Plt Ct-86* ___ 07: 01PM BLOOD ___ 01: 43AM BLOOD ___ 01: 43AM BLOOD Glucose-109* UreaN-7 Creat-0.4 Na-134 K-3.8 Cl-107 HCO3-20* AnGap-11 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain do not take more than 4000mg per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 4. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN severe pain do not drive or drink alcohol while taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Acute anxiety to pregnancy, placenta previa, intraoperative hemorrhage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___, otherwise healthy, now status post dilation and curettage complicated by intraoperative bleeding requiring urgent TAH. *FICU Course ___ # Hemorrhagic shock: s/p elective ___ week D&C c/b intraop bleeding (ESBL ~ 2.0L), requiring ex-lap TAH. She has received 4U pRBC per mass transfusion protocol. In the FICU she was given 2 units FFP per mass transfusion protocol. Platelets held due to level of 71. Also given additional dose of Ancef. Levophed weaned in FICU. Also in FICU H/H trended to 7.3/20.9 from 8.1/23.4 so she was given another unit ___ total) with repeat H/H showing 8.5/25.1. She remained hemodynamically stable and thus was transferred to OBGYN service. # Concern for DIC: D/t recent obstetrical complications. Fibrinogen level obtained which was 115. Dx likely based on low fibrinogen (115), INR 1.2, plt 93. Supported by acute significant bleeding and shock. # Respiratory failure: Pt intubated for procedure. Currently on CMV mode. Current barrier to extubation is hemodynamic stability. Pt was paralyzed in OR. Ventilation quickly weaned upon arrival to FICU and she was extubated. # Hyponatremia: Low 130's. Baseline unknown. Volume status currently hypovolemic to euvolemic. SIADH has been associated with pregnancy but may be due to poor po intake. Serum osm 272, consistent with hypotonic hyponatremia. Urine lytes obtained show Urine Na 219. Picture most consistent with volume loss. # Leukocytosis: most likely reactive. # Electrolyte abnormalities: Notable for low Mg and phos. Repleted. *End of FICU Course* Patient was transferred to the OBGYN service on post operative day 1. She remained hemodynamically stable with stable hematocrit and hemoglobin, electrolytes within normal range. She was tolerating a regular diet, pain was controlled on oral ibuprofen and Tylenol with IV dilaudid for breakthrough pain. Her urine output was adequate and foley catheter was removed on post operative day 2. . By post-operative day 3, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10071795-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Latex / Percocet / Neosporin / Levaquin / Bacitracin / oxycodone / levofloxacin / Dilaudid <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain, fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ aspiration of tubo-ovarian abscess <HISTORY OF PRESENT ILLNESS> ___ ___ presenting with 10 day history of abdominal pain as well as fever at home to 101 a week ago. She states she first noted left-sided cramping about 10 days ago, and then developed a sharper right-sided pain a week ago. She feels pain has been constant. She was evaluated by her PCP and diagnosed with a UTI based on U/A, and was treated with course of Bactrim. She also reports increased vaginal discharge recently. She had a PUS done with her OBGYN which was suspicious for a right-sided ___, and was instructed to present to ___ for IV antibiotic treatment. However, she preferred to be treated her and was transferred to our ED. Here, she reports feeling intermittent nausea but has not vomited today or in past week. She denies urinary symptoms. Having regular BMs. No current fevers or chills. No CP, SOB. Continues to feel she is having increased vaginal discharge. She has had recent unprotected sex with a new male partner. <PAST MEDICAL HISTORY> OB History: - ___&C at age ___ GYN History: Menarche age ___. LMP ___, regular menses every 21 days with 8 days of very heavy flow, significant pelvic pain.Denies a history of abnormal Pap smears. Uses condoms for birth control, no hormonal methods. Reports history of self-aborting fibroid at age ___ and history of ovarian cysts. Has genital herpes diagnosed at age ___, infrequent outbreaks, not on suppression. H/o trichomonas, no other STIs. Medical Problems: - Asthma, denies intubations or hospitalizations - Liver injury s/p laparoscopic cholecystectomy Surgical History: 1. ___, tonsillectomy. 2. ___, left knee arthroscopy. 3. ___ TAB with D&C 4. In ___, laparoscopic cholecystectomy at ___. 5. In ___, repeat surgery, laparoscopy converted to open surgery for repair of liver injury associated with laparoscopic cholecystectomy by Dr. ___ at ___. 6. ___, Operative HSC and myomectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On day of discharge: T 98.8 PO 101 / 64 70 16 98 `BP `HR `RR`O2 UOP: multiple voids, not measured PE: General: NAD, A&Ox3 Lungs: No respiratory distress, normal work of breathing Abd: soft, nontender, minimally distended, improved from last exam. no rebound or guarding. +BS Extremities: no calf tenderness <PERTINENT RESULTS> ___ 07: 10AM HIV Ab-NEG ___ 07: 10AM WBC-8.5 RBC-3.61* HGB-10.5* HCT-31.7* MCV-88 MCH-29.1 MCHC-33.1 RDW-14.4 RDWSD-46.0 ___ 07: 10AM NEUTS-65.4 ___ MONOS-7.4 EOS-2.6 BASOS-0.5 IM ___ AbsNeut-5.56 AbsLymp-2.01 AbsMono-0.63 AbsEos-0.22 AbsBaso-0.04 ___ 07: 10AM PLT COUNT-305 ___ 07: 10AM ___ PTT-32.0 ___ ___ 07: 10AM ___ ___ 04: 59AM OTHER BODY FLUID CT-NEG NG-NEG ___ 12: 20AM URINE HOURS-RANDOM ___ 12: 20AM URINE UCG-NEG ___ 12: 20AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12: 20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR* ___ 12: 20AM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-2 ___ 10: 46PM LACTATE-1.0 ___ 10: 30PM GLUCOSE-83 UREA N-9 CREAT-1.0 SODIUM-138 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15 ___ 10: 30PM estGFR-Using this ___ 10: 30PM ALT(SGPT)-18 AST(SGOT)-23 ALK PHOS-99 TOT BILI-0.2 ___ 10: 30PM LIPASE-25 ___ 10: 30PM ALBUMIN-3.6 ___ 10: 30PM WBC-9.7 RBC-3.61* HGB-10.6* HCT-32.0* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.2 RDWSD-46.0 ___ 10: 30PM NEUTS-67.6 ___ MONOS-6.2 EOS-1.9 BASOS-0.4 IM ___ AbsNeut-6.52* AbsLymp-2.28 AbsMono-0.60 AbsEos-0.18 AbsBaso-0.04 ___ 10: 30PM PLT COUNT-300 <MEDICATIONS ON ADMISSION> 1. Zyrtec p.r.n. 2. Albuterol inhaler p.r.n., asthma attacks. 3. Concerta <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4gm per day. RX *acetaminophen 500 mg ___ capsule(s) by mouth every six (6) hours Disp #*30 Capsule Refills: *1 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 12 Days RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*24 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *1 4. Metoclopramide 10 mg PO Q8H: PRN nausea RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 5. MetroNIDAZOLE 500 mg PO BID do not drink alcohol while on this medication RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #*24 Tablet Refills: *0 6. Cetirizine 10 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> tubo-ovarian abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the gynecology service for your abdominal pain and fever and was found to have a tubo-ovarian abscess. You were started on antibiotics and had ___ drainage of the abscess with improvement in your symptoms. Please complete the 2 week course of antibiotics to ensure that the infection completely resolves. Please call the office at ___ with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks until your follow-up appointment * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after presenting to the ED with fever and abdominal pain, found to have right-sided ___. On admission, she was started on IV gentamicin and clindamycin. Her post-operative course was uncomplicated. On hospital day 1 she had ultrasound guided pelvic aspiration of the pelvic collection with drainage of 17 mL of complex fluid. Her diet was advanced without difficulty and her pain was controlled with PO dilaudid/Tylenol/ibuprofen. On hospital day2, she was transitioned to PO doxycycline and flagyl. By hospital day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, afebrile and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10071795-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Latex / Percocet / Neosporin / Levaquin / Bacitracin / oxycodone / levofloxacin / Dilaudid <ATTENDING> ___. <CHIEF COMPLAINT> lower abdominal pain/bloating <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <PHYSICAL EXAM> Gen NAD, comfortable CV regular rate Pulm nl respiratory effort Abd soft, nondistended, minimally TTP in RLQ. no R/G Extrem no edema, no TTP <PERTINENT RESULTS> ___ 07: 31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 07: 31PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09: 40PM PLT COUNT-266 ___ 09: 40PM NEUTS-56.5 ___ MONOS-8.5 EOS-2.0 BASOS-0.8 IM ___ AbsNeut-3.65 AbsLymp-2.06 AbsMono-0.55 AbsEos-0.13 AbsBaso-0.05 ___ 09: 40PM WBC-6.5 RBC-3.79* HGB-10.9* HCT-33.4* MCV-88 MCH-28.8 MCHC-32.6 RDW-14.6 RDWSD-46.9* ___ PUS IMPRESSION: 1. Persistent, thick-walled complex right adnexal collection however, decreased in size and complexity with less demonstrated vascularity when compared to prior examination which was performed prior to drainage of the right ___. This could represent pus or blood. The appearance of the right adnexa by ultrasound should be correlated with the current clinical scenario and patient's symptoms in order to determine if residual infection persists. 2. Numerous intramural uterine fibroids. 3. Normal left ovary. <MEDICATIONS ON ADMISSION> Medications - Prescription ALBUTEROL - Dosage uncertain - (Prescribed by Other Provider) CETIRIZINE [ZYRTEC] - Dosage uncertain - (Prescribed by Other Provider) METHYLPHENIDATE HCL [CONCERTA] - Dosage uncertain - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin XR] 1,000 mg-62.5 mg 2 tablets by mouth every 12 hours Disp #*56 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> recurrent tubo-ovarian abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after presenting with abdominal pain, bloating, and US consistent with a right adnexal collection concerning for persistent tubo-ovarian abscess. The team now believes you have recovered well and are ready to be discharged home. Please complete the full course of antibiotics as prescribed. Please call Dr. ___ office with any questions or concerns. General instructions: * Take your medications as prescribed. * Please complete the full course of antibiotics as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to gynecology service after presenting with lower abdominal pain and bloating, in the setting of a recent admission for ___ and drainage of same, and after the completion of a course of augmentin. She underwent a PUS and found persistent, thick walled complex right adnexal collection, decreased in size and complexity with less demonstrated vascularity when compared to prior examination. However, given recurrent lower abdominal pain and bloating, patient was admitted for IV antibiotics. She was began on IV gent/clinda for 24 hours. She had a CBC/diff wnl limits. She had adequate pain control. On HD2, she remained afebrile, her pain was well controlled and she was transitioned to oral augmentin (patient unable to tolerate flagyl/doxy due to GI upset). She was thus discharged home in stable condition.
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10071795-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Latex / Percocet / Neosporin / Levaquin / Bacitracin / levofloxacin / Dilaudid / paper tape / shellfish derived / tree nuts / environmental <ATTENDING> ___ <CHIEF COMPLAINT> Uterine fibroids and right ovarian mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Abdominal myomectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ gravida 1 para 0010 with a last menstrual period of ___ who has a known fibroid uterus, history of tubo-ovarian abscess and right adnexal mass who would like the removal of her multiple fibroids and right adnexal mass. Status post endometrial biopsy on ___ which showed proliferative endometrium and was negative for chronic endometritis or endometrial hyperplasia. Prior to today's visit, I saw this patient on ___ after she had undergone drainage of a right sided tubo-ovarian abscess. She was discharged home from the ___ GYN service on ___. At our ___ visit, it was decided that it would be important for her body to fully recover from that medical challenges before having a major operative procedure. On ___, she had a repeat ultrasound at the ___ which showed an anteverted uterus that measured 11.3 by a 6.9 x 7.9 cm. The endometrial stripe was normal for the patient's age measuring 9 mm. There was a 3.1 cm posterior mid body, 2.8 cm left fundal, 3.7 cm mid fundal and 4.1 cm right fundal fibroids. The right and left ovaries were normal in size measuring 2.9 x 2.3 x 3 cm and 4.1 x 1.9 x 2.6 cm. A homogenous hypoechoic 2.9 x 2.3 x 3 cm unchanged endometrium was present on the right ovary. There was no free fluid. These findings were all reviewed with the patient and her questions were answered to her satisfaction. On ___ she had an MRI which showed an anteverted uterus that measured 10.9 x 6.3 x 9.6 cm, larger compared to prior to CT from ___. At least 7 intramural fibroids were identified in the uterus, many of them centrally nonenhancing and larger compared to the CT from ___ the largest fibroid measures 3.9 x 3.9 x 4.0 cm and located at the left anterior fundus. There was a 2.1 x 1.9 cm structure with fluid level identified in the right ovary consistent with hemorrhagic material. The left ovary was visualized and appeared normal. Of note, she has a history of a vaginal myomectomy. OB/GYN history: Menarche age ___, menses every 21 days with 8 days of very heavy flow. During her heaviest bleeding. She change the pad or tampon every 1.5 hours. She endorses dysmenorrhea, intermenstrual bleeding, postcoital bleeding and dyspareunia. She states that she had an abnormal Pap in the past requiring no treatment. Last Pap was ___ and normal. She is heterosexual and not sexually active at this time. Reports history of an aborting fibroid at age ___ and history of ovarian cysts. Has genital herpes diagnosed at age ___, infrequent outbreaks, not on suppression. H/o trichomonas, no other STIs. TAB via D&C at age ___ Medical history: RIGHT TUBO-OVARIAN ABSCESS UTERINE FIBROIDS Surgical History: US-GUIDED ASPIRATION OF A RIGHT TUBO-OVARIAN ABSCESS. ___ 17 CC OF ___ TISSUE: ENDOMETRIAL BIOPSY ___ ___ ___ FINAL Endometrium, biopsy: Fragments of early secretory endometrium. Surgical History: 1. ___, tonsillectomy. 2. ___, left knee arthroscopy. 3. ___, ? TAB vs ectopic pregnancy surgery (pt uncertain of side or location or if she underwent medical treatment). 4. ___, laparoscopic cholecystectomy at ___ ___. 5. ___, repeat surgery, laparoscopy converted to open surgery for repair of liver injury associated with laparoscopic cholecystectomy by Dr. ___ at ___. 6. Vaginal Myomecomy @ 21 <FAMILY HISTORY> Comments: <FAMILY HISTORY> Denies a family history of any GYN or female cancers such as breast, ovarian, uterine, cervical, vaginal, or colon cancer. She reports mother with skin cancer, diabetes, hypertension, heart disease, and hypercholesterolemia. She also reports two brothers with hypertension and grandparents with heart disease. <SOCIAL HISTORY> Marital status: Single Children: No Work: ___ Sexual orientation: Male Domestic violence: Denies Contraception: None Contraception would like pregnancy/has had evaluation and comments: was told was "not ovulating" but has regular menses Tobacco use: Never smoker --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription ALBUTEROL - Dosage uncertain - (Prescribed by Other Provider) CETIRIZINE [ZYRTEC] - Dosage uncertain - (Prescribed by Other Provider) MEDROXYPROGESTERONE - medroxyprogesterone 10 mg tablet. One tablet(s) by mouth Daily METHYLPHENIDATE HCL [CONCERTA] - Dosage uncertain - (Prescribed by Other Provider) VITAMIN D - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC BIOTIN - Dosage uncertain - (OTC) BUDESONIDE-FORMOTEROL [SYMBICORT] - Dosage uncertain - (OTC) VITAMIN B - Vitamin B . - (OTC) --------------- --------------- --------------- --------------- <ALLERGIES> Bacitracin Dilaudid Latex Levaquin levofloxacin Neosporin (Neomycin Sulfate/Bacitracin/Polymyxin B) oxycodone Percocet (Oxycodone Hcl/Acetaminophen) <PHYSICAL EXAM> General: NAD, comfortable CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, dressing removed, incision w/ steri strips clean/dry/intact, superficial ecchymosis along superior aspect of incision Extremities: no edema, no TTP, pneumoboots in place bilaterally <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication
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On ___, Ms. ___ was admitted to the gynecology service after undergoing EXAM UNDER ANESTHESIA and MULTIPLE MYOMECTOMIES. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with morphine and tordal. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, she was ambulating, and she was transitioned to PO oxycodone/ibuprofen/acetaminophen. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*9 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe do not drink alcohol or drive while taking oxycodone RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 6. Sertraline 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Uterine fibroids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10074649-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total vaginal hysterectomy, bilateral partial salpingectomy, cystoscopy <PHYSICAL EXAM> Gen: NAD CV: RRR Pulm: breathing comfortably on RA Abd: soft, appropriately mildly TTP, no rebound or guarding GU: minimal staining on pad, foley in place Ext: WWP, mild TTP on lateral dorsal aspect of right ankle and foot, no erythema or edema <PERTINENT RESULTS> ___ 03: 30AM BLOOD WBC-15.0* RBC-3.34* Hgb-9.6* Hct-29.8* MCV-89 MCH-28.7 MCHC-32.2 RDW-14.1 RDWSD-46.1 Plt ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing transvaginal hysterectomy, bilateral salpingectomy and cystoscopy for abnormal uterine bleeding. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. Her Foley was removed and she was voiding independently. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth Every 6 hours as needed Disp #*40 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Can take while using oxycodone to prevent severe constipation. RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice per day as needed Disp #*28 Tablet Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN Pain Please take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #*40 Tablet Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Do not operative heavy machinery or drink while using. RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #*12 Tablet Refills:*0 5. Amitriptyline 25 mg PO QHS 6. Gabapentin 100 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: excessive menstruation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10074863-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine <ATTENDING> ___ <CHIEF COMPLAINT> bulk symptoms from fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic myomectomy <HISTORY OF PRESENT ILLNESS> This is a ___ G0, P0 premenopausal Caucasian female in same-sex marriage sent from Dr. ___ office (PCP/PNP) for GYN consultation regarding worsening symptomatic fibroid uterus. The patient complained predominately of bladder pressure, urinary frequency and incomplete voiding. Pelvic exam confirmed a large dominant anterior fibroid compressing on the bladder. PUS (___) revealed an enlarged anteverted uterus measuring 13.5 x 8.3 x 4 cm with a 7.9-cm left fundal subserosal fibroid and an additional 2.8-cm right exophytic fibroid. Normal right ovary. Left ovary was not seen. Normal endometrial stripe 3 mm. . All the treatment options were discussed with the patient in detail and she opted for surgical management with a laparoscopic myomectomy. The patient did desire future fertility and specifically declined definitive surgical treatment such as hysterectomy. <PAST MEDICAL HISTORY> OB History: G0. GYN History: Menarche at age ___. LMP ___. Regular menses every 28 days, four days of moderate flow. She does report some increasing dysmenorrhea for the last few months. The patient denies history of abnormal Pap smears. Last Pap smear on ___ reportedly negative. The patient is sexually active, prefers the same sex, reports six sexual partners throughout life. She does not require any contraception. She denies history of any STDs. Medical Problems: 1. Hypothyroidism. 2. Uterine fibroids, newly diagnosed. Surgical History: Negative. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal grandmother with breast cancer diagnosed in postmenopausal state. The same maternal grandmother with diabetes and hypertension. Mother with hypertension and hypercholesterolemia. No other family medical conditions. Denies any other GYN cancers in the family. <PHYSICAL EXAM> On postoperative exam: 98.6 93/60 82 1897% RA I/O 120 PO + 3175 IVF / 120 UOP + 200 EBL A+O, NARD RRR, CTAB Abd soft, appr TTP, no R/G, +BS Incisions: periumbilicus with ___ dark nearly dried blood blotted with gauze, no active bldg, no hematoma/fluctuance, + ecchymosis, no further bleeding expressed Other 4 lateral incisions with intact ___ surrounding erythema, no fluctuance/exudate <PERTINENT RESULTS> Intraoperatively morcellated uterine fibroid pending pathology <MEDICATIONS ON ADMISSION> levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily) <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *50 Tablet(s)* Refills: *1* 2. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *0* 3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please follow the postoperative instructions you have from Dr. ___. Please remove your umbilical dressing in 3 days. If you have steri-strips over your incisions, allow them to fall off on their own. For any issues, you may call Dr. ___ office at ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit.
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Ms. ___ underwent an uncomplicated robotic myomectomy; please see the operative report for full details. Following the procedure, her umbilical incision was noted to be oozing minimally. The incision was intact and the oozing resolved spontaneously. A pressure dressing was applied without further evidence of bleeding or hematoma. She was instructed to remove the dressing after 3 days. Her postoperative course was otherwise uncomplicated, and she was discharged on postoperative day 1 in good condition, having met all postoperative milestones and with follow-up scheduled.
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10078770-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> "Abdominal pain and vaginal bleeding" <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnostic Laparascopy with lysis of Adhesion <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ year old nulligravid at 6weeks and 3days by Last Menstrual period of ___ who presented with abdominal pain and vaginal bleeding. She reported that the pain had been ongoing for two weeks and became ___ on ___. She initially presented to ___ where she was told that she had a serum quantitative HCG of 72. She was then sent home. She began to bleed at 10am on ___, which orginally started as pink spotting and then got heavier. She then presented again to the ___ at 2am on ___ morning. Her repeat HCG on return to ___ was 39. Given no ob/gyn there, she was transferred here. <PAST MEDICAL HISTORY> She denied any significant past medical history <SOCIAL HISTORY> She is originally from ___ and lived in ___ until ___. She currently lives in ___ with her husband. She denies alcohol, tobacco and drug use. <PHYSICAL EXAM> Physical Examination was completed by Dr. ___. Vitals: 98, 68, 110/70, 18, 100% RA Gen: uncomfortable, nauseated and vomitting clear material CV: RRR lungs: CTAB abd: soft, TTP BLQ, ND, no rebound, +bs pelvic: nl ext genitalia. Vaginal vault with blood. Cx normal appearing, + pain with bimanual exam. No certain palpable masses. <PERTINENT RESULTS> ___ 07: 25PM WBC-9.3 RBC-4.52 HGB-9.8* HCT-32.5* MCV-72* MCH-21.8* MCHC-30.3* RDW-17.2* ___ 07: 25PM NEUTS-79.6* LYMPHS-15.5* MONOS-3.7 EOS-0.8 BASOS-0.4 ___ 07: 25PM PLT COUNT-232 ___ 07: 25PM ___ PTT-24.1 ___ ___ 05: 25PM HCG-34 Tranvaginal and Transabdominal Ultrasound Findings: There is no visualized intrauterine gestational sac. A 1.6 x 1.6 x 1.4 fibroid is identified in the anterior uterus. The endometrium is slightly heterogeneous. The ovaries are normal in size bilaterally. An avascular rounded 1.0 x 1.0 x 1.2 cm echogenic focus in noted in the left ovary, likey representing a fat containing dermoid. There is a right adnexal dilated tubular structure extending to the right ovary with avascular internal debris, without evidence of peristalsis on real-time imaging. No adnexal mass is seen bilaterally. There is no free fluid. <MEDICATIONS ON ADMISSION> Prematal Vitamins <DISCHARGE MEDICATIONS> 1. Colace 50 mg Capsule Sig: One (1) Capsule PO four times a day as needed for constipation. Disp: *30 Capsule(s)* Refills: *0* 2. Zofran 4 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for nausea. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Laparascopic Lysis of Adhesion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms ___, you were admitted for overnight observation following a laparascopic procedure for concern for tubal pregnancy. * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit.
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The decision was made to operate on Ms ___ based on the ultrasound findings and her clinical presentation. She was taken to the operating room on ___ where an examimination under anasthesia was performed, a diagnostic laparascopy and lysis of adhesion. The examination under anasthesia showed an 8cm anteverted uterus without any palpable masses and laparascopy showed no evidence of tubal dilation or hematosalpinx, no evidence of ectopic pregnancy in the tubes, ovaries or cornua. No hematoperitoneum. There was an incidental finding of adhesions, which were lysed and a small fundal fibroid. Patient tolerated the procedure well and was transferred to the recovery in good condition. Patient was admitted overnight for observation and adequate pain management.Her foley was discontinued and she passed a trial of void prior to being discharge with appropriate pain medication, counseling and a follow up visit scheduled with Dr. ___.
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10078892-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ceclor / Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P1 ___ s/p pLTCS after IOL for cholestasis presents with fevers. Patient states she was feeling well until ___ when she started having urinary frequency and dysuria. She spoke to her physician and was given a rx for macrobid. She was counseled not to breastfeed while on medication therefore did not use it. However, her symptoms worsened despited increased PO hydration and she began taking medicine ___ ___ after having Tm 102 at home. She has taken a total of 4 doses to date. Her urinary symptoms have resolved and she does not have frequency or dysuria at this time. However, today she had a temperature of 100.0 that increased to 101 despite taking Tylenol. She last took 500mg Tylenol and 500mg of ibuprofen at 1330 today. She denies cough, sneezing, congestion. She denies pain in her breast; she breastfeeds/pumps ___ per day. She denies abdominal pain or discomfort. She has some constipation which improves with Colace use. She denies swelling or pain in her calves. She has not had recent sick contacts. Of note, her labor course was notable for a six hour push and development of chorioamnionitis prior to cesarean. She received a 24 hours course of clindamycin and gentamicin for coverage. <PAST MEDICAL HISTORY> PMH: rhabdo after ___ ___ PSH: T&A, ACL reconstruction, sinusectomy, rhinoplasty, IVF egg retrieval <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Lungs: breathing comfortably on room air Abdomen: soft, non tender Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 04: 46PM BLOOD WBC-8.2 RBC-3.38* Hgb-8.8* Hct-27.5* MCV-81* MCH-26.0 MCHC-32.0 RDW-13.1 RDWSD-39.0 Plt ___ ___ 01: 06AM BLOOD WBC-8.5# RBC-3.30* Hgb-8.5* Hct-26.5* MCV-80* MCH-25.8* MCHC-32.1 RDW-13.1 RDWSD-38.3 Plt ___ ___ 04: 46PM BLOOD Neuts-65.4 ___ Monos-6.3 Eos-0.9* Baso-0.5 Im ___ AbsNeut-5.35 AbsLymp-2.16 AbsMono-0.51 AbsEos-0.07 AbsBaso-0.04 ___ 01: 06AM BLOOD Neuts-65.0 ___ Monos-7.3 Eos-0.5* Baso-0.5 Im ___ AbsNeut-5.52 AbsLymp-2.22 AbsMono-0.62 AbsEos-0.04 AbsBaso-0.04 ___ 08: 19PM URINE Color-Straw Appear-Clear Sp ___ ___ 08: 19PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 08: 19PM URINE RBC-1 WBC-34* Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 RenalEp-<1 ___ 08: 19PM URINE Mucous-RARE <MEDICATIONS ON ADMISSION> PNV, Zantac 150mg BID <DISCHARGE MEDICATIONS> 1. Sulfameth/Trimethoprim DS 1 TAB PO Q12H Duration: 12 Days you should pump and dump breast milk while you are taking this medication. RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth every 12 hours Disp #*24 Tablet Refills: *0 2. Acetaminophen ___ mg PO Q6H: PRN Mild Pain 3. Docusate Sodium 100 mg PO BID: PRN Constipation 4. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pyelonephritis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with fever and infection concerning for pyelonephritis (urinary/kidney infection). You were treated with IV antibiotics, and your symptoms improved. We transitioned you to oral antibiotics (Bactrim) at the time of discharge. The team feels it is now safe for you to be discharged home. * Bactrim is not safe for breast feeding in infants less than 2 months of age. You should pump and dump on this medication. * Please call Dr. ___ office with any questions or concerns! It was a pleasure taking care of you during your stay. Sincerely, Your ___ Ob/Gyn care team
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On ___, Ms. ___, who had undergone primary low transverse cesarean section on ___, was readmitted to the post partum service with fevers urinary tract infection, concerning for pyelonephritis. Initial labs were notable for a normal white count without bandemia. Her urine cultures (___) grew E. Coli. Blood cultures were also drawn (and were pending at the time of discharge). She was started on IV aztreonam on ___ for 24 hours afebrile. Her symptoms and vital signs had improved by ___, and at that time she was discharged on a 12 day course of Bactrim. She was told to discard her breast milk during this time, given the studies of increased risk of jaundice in newborn infants who are exposed to Bactrim through breast milk.
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10079632-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> D&C <HISTORY OF PRESENT ILLNESS> CC: bleeding, abdominal pain HPI: ___ yo F G1P0010 presenting with vaginal bleeding, abdominal pain S/p med AB ___ at PP, did well initially. Yesterday started having heavy vaginal bleeding soaking 10 ___ pads. Feeling a little light-headed. Also passed a couple baseball size clots. Mild abdominal pain. Vomited once yesterday. No other N/V. No issues with urination. No fevers, chills. ROS: negative except as above <PAST MEDICAL HISTORY> PMH: denies PSH: denies OBHx: G1 - med AB GYNHx: - LMP currently having bleeding s/p med ab - denies h/o STIs MEDS: none ALL: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Discharge physical exam Vitals: stable and within normal limits Gen: no acute distress; alert and oriented to person, place, and date CV: regular rate and rhythm; no murmurs, rubs, or gallops Resp: no acute respiratory distress, clear to auscultation bilaterally Abd: soft, no rebound/guarding Ext: no tenderness to palpation <PERTINENT RESULTS> ___ 12: 24AM BLOOD WBC-21.6* RBC-3.81* Hgb-11.2 Hct-31.6* MCV-83 MCH-29.4 MCHC-35.4 RDW-12.9 RDWSD-38.6 Plt ___ ___ 12: 24AM BLOOD Neuts-80.5* Lymphs-13.9* Monos-4.8* Eos-0.1* Baso-0.2 Im ___ AbsNeut-17.39* AbsLymp-3.01 AbsMono-1.04* AbsEos-0.03* AbsBaso-0.05 ___ 06: 52AM BLOOD WBC-6.7 RBC-2.86* Hgb-8.3* Hct-25.1* MCV-88 MCH-29.0 MCHC-33.1 RDW-13.4 RDWSD-42.6 Plt ___ ___ 06: 52AM BLOOD Neuts-48.6 ___ Monos-6.1 Eos-1.0 Baso-0.4 Im ___ AbsNeut-3.27 AbsLymp-2.95 AbsMono-0.41 AbsEos-0.07 AbsBaso-0.03 ___ 12: 24AM BLOOD Glucose-149* UreaN-10 Creat-0.7 Na-141 K-3.2* Cl-102 HCO3-24 AnGap-15 ___ 06: 52AM BLOOD Glucose-110* UreaN-7 Creat-0.5 Na-142 K-4.0 Cl-108 HCO3-27 AnGap-7* ___ 06: 52AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.9 ___ 12: 55PM BLOOD HIV Ab-NEG ___ 02: 25AM URINE Color-Amber* Appear-Hazy* Sp ___ ___ 02: 25AM URINE Blood-LG* Nitrite-NEG Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD* ___ 02: 25AM URINE RBC->182* WBC-28* Bacteri-FEW* Yeast-NONE Epi-<1 ___ 02: 25AM URINE AmorphX-RARE* ___ 02: 25AM URINE Mucous-OCC* ___ 10: 05AM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not exceed 4000mg in a day RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6H PRN Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID constipation Please take while taking iron supplements to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *0 3. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*18 Capsule Refills: *0 4. Ferrous Sulfate 325 mg PO DAILY anemia Please do not take at the same time as antibiotics. RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth Daily Disp #*50 Tablet Refills: *0 5. Ibuprofen 600 mg PO Q6H: PRN Pain Take with food. Do not exceed 2400mg in a day. RX *ibuprofen 600 mg 1 tablet(s) by mouth Q6H PRN Disp #*50 Tablet Refills: *0 6. MetroNIDAZOLE 500 mg PO BID Duration: 9 Days RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #*18 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> retained products of conception endometritis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for medical care. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ ___ with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your follow up appointment. * Nothing in the vagina (no tampons, no douching, no intercourse) for 2 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower * No tub baths for 2 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring more than 1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing ultrasound-guided D&C for retained products of conception. Please see the operative report for full details. *)retained products of conception s/p D&C Her post-operative course was uncomplicated. Her pre-procedure Hct was 31.6 and stabilized at 25.1 post-procedure. She was started on PO iron supplementation for management of her anemia. As her blood type was Rh positive, Rhogam was not indicated. *) Endometritis She presented with fundal tenderness and a leukocytosis to 21.6 with left shift. She was treated with IV ampicillin/gentamicin/clindamycin for 24 hours ___ for empiric coverage of endometritis. Her leukocytosis resolved, and her WBC count wsa 6.1 on day of discharge. Patient was transitioned to PO antibiotics (Doxycycline and Flagyl). Her workup for vaginal infections was negative. *) Hypokalemia Her labs were notable for asymptomatic hypokalemia with K 3.2. Her potassium was repleted with appropriate rise to normal level. She clinically improved after her D&C and antibiotic treatment and was then discharged home in stable condition with outpatient follow-up arranged.
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10081067-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> chronic hypertension with superimposed severe pre-eclampsia spontaneous vaginal delivery at 31 weeks 6 days <MAJOR SURGICAL OR INVASIVE PROCEDURE> spontaneous vaginal delivery placement of ___ IUD <HISTORY OF PRESENT ILLNESS> ___ yo G3P1 at 31.1 with cHTN sent in from office for ___ evaluation. Elevated BPs in office with systolic BP 170s. Not on medications in this pregnancy. Denies HA, CP, SOB, RUQ pain, change in vision. <PAST MEDICAL HISTORY> OB: G3P1 G1: SVD, c/b severe PEC required magnesium G2: TAB, D&C G3: current GYN: None PMH: Denies PSH: - D&C - Wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: BPs 165/94, 149/102, 154/97, 161/87, 152/88, 162/96, 173/107 Resp 18, T 98.1 Gen: NAD, comfortable CV: RRR Resp: CTAB Abd: soft, non-tender Ext: non-tender no edema TAUS: vtx, MVP ___ FHT: 145/mod var/+accels/-decels Toco: flat Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Mild Pain Do not exceed 4000 mg in 24 hour hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily. Disp #*60 Tablet Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *1 4. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice per day Disp #*60 Tablet Refills: *1 5. NIFEdipine CR 60 mg PO BID RX *nifedipine 60 mg 1 tablet(s) by mouth every 12 hours. Disp #*60 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic hypertension with superimposed severe pre-eclampsia spontaneous vaginal delivery at 31 weeks 6 days <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___, Congratulations on the birth of your daughter! You were admitted to the hospital and induced after developing chronic hypertension with superimposed pre-eclampsia. You underwent an uncomplicated vaginal delivery at 31 weeks 6 days. You required blood pressure medication to control your blood pressure. You should continue your medication (Nifedipine ER 60mg twice daily and Labetalol 200mg twice daily). You will have close outpatient follow-up and may require adjustments to your medication. Please follow the below instructions: -Nothing in the vagina for 6 weeks (No sex, douching, tampons) -Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs -Do not take more than 2400mg ibuprofen in 24 hrs -Please call the on-call doctor at ___ if you develop a headache, chest pain, vision changes, shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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___ yo G3P1 with cHTN admitted at 31w1d with severe preeclampsia. On admission, she had multiple severe range blood pressures. Preeclampsia labs were normal with the exception of an increase in proteinuria (920mg). She was started on po Nifedipine CR, which was quickly uptitrated to 60mg BID. Fetal testing was reassuring. She received a course of betamethasone (complete ___ and the NICU was consulted. On HD#3, a second agent was added to her regimen (Labetolol 200mg TID) due to persistently elevated blood pressures. She otherwise remained clinically stable until 31w5d when she had routine fetal testing in the ___ and was noted to have oligohydramnios and an elevated s/d (4.9). Delivery was recommended. She was transferred to labor and delivery for induction of labor. She received Magnesium for neuroprotection and seizure prophylaxis intrapartum. She had a spontaneous vaginal delivery on ___ and delivered a liveborn female weighing 1310 grams with Apgars of ___. Neonatology staff was present for delivery and transferred the neonate for prematurity. ------------------ She was continued on Magnesium for 24 hours postpartum, and her blood pressures were controlled with oral labetolol and nifedipine. Her pain was treated with oral pain medications. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced without incident. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. Her anti-hypertension regimen was Labetolol 200mg BID and Nifedipine CR 60mg BID. She was discharged home in stable condition with postpartum outpatient follow-up scheduled.
| 991
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10082132-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> PPROM <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary classical cesarean section <HISTORY OF PRESENT ILLNESS> ___ yo G4P2 25w1d GA here after SROM at 6pm today. Currently denies cxns. +AFM. Feeling intermittent crampiness, not painful. Pt states she has been in her usual state of health and was not doing anything different from her usual routine today. Denies any recent infections or VB. <PAST MEDICAL HISTORY> PNC: EDC ___ by first trimester u/s O+/Ab-/HBsAg neg/RPR NR/ Rubella ___ normal FFS denies any issues during this pregnancy has not yet had GLT OBHx: SVD x 2, full term largest baby 7#6oz SAB x 1 GYNHx: denies h/o abnormal Paps or STIs PMH: denies PSH: tonsillectomy breast reduction oophorectomy (pt unsure of laterality, but thinks L side) for benign ovarian cyst D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS- 98.3 89 20 135/77 comfortable, in NAD RRR abd obese, nontender SSE: grossly ruptured with +pooling, cervix appears long SVE: 2cm external os, 1cm internal os, long FHT: ___ 160/+acc/+occ var decels/mod var toco: flat TAUS: vtx, +FHR 162 bpm by mmode, no fluid pockets visible, R lateral placenta, good fetal movement visualized <PERTINENT RESULTS> ___ WBC-11.2 RBC-4.01 Hgb-10.3 Hct-30.9 MCV-77 Plt-201 ___ Neuts-77.3 ___ Monos-3.9 Eos-2.6 Baso-0.2 ___ WBC-12.9 RBC-3.85 Hgb-9.7 Hct-29.6 MCV-77 Plt-222 ___ Neuts-79.6 ___ Monos-4.8 Eos-0.9 Baso-0.1 ___ WBC-13.2 RBC-4.17 Hgb-10.4 Hct-32.1 MCV-77 Plt-238 ___ Neuts-78.7 ___ Monos-3.0 Eos-1.4 Baso-0.2 ___ WBC-17.7 RBC-4.19 Hgb-10.5 Hct-32.6 MCV-78 Plt-215 ___ Neuts-84.8 ___ Monos-3.5 Eos-0.8 Baso-0.1 ___ Hct-30.2 ___ ___ PTT-30.9 ___ ___ ___ PTT-29.2 ___ ___ GLT-182 ___ ___ ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD ___ URINE RBC-1 WBC-84 Bacteri-FEW Yeast-NONE Epi-4 URINE CULTURE (Final ___: NO GROWTH URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> prenatal vitamins zantac <DISCHARGE MEDICATIONS> 1. Percocet ___ mg Tablet Sig: ___ Tablets PO four times a day as needed for pain. Disp: *45 Tablet(s)* Refills: *0* 2. Motrin 600 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Disp: *40 Tablet(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm premature rupture of membranes <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> rest. no heavy lifting, exercise, baths for 4 weeks
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___ yo G4P2 admitted at 25+1 weeks with PPROM. She was initially afebrile and without any evidence of chorioamnionitis or preterm labor. Fetal testing was reassuring. She was started on latency antibiotics and given a course of betamethasone for fetal lung maturity (complete on ___. The NICU was consulted. She was admitted to the antepartum service for close maternal and fetal surveillance. She remained clinically stable until 26+4 weeks gestation when she developed fetal tachycardia and had an elevated white blood cell count. Further fetal testing revealed a biophysical profile of ___. Given the concern for chorioamnionitis and nonreassuring fetal testing, delivery was recommended. She underwent a primary classical cesarean section on ___. Liveborn female infant from breech, apgars 8 and 8. NICU staff was present for delivery and transferred the neonate immediately for prematurity. Please see operative report for details. . Postoperatively, she was continued on Gentamycin and Clindamycin for 24 hours. She remained afebrile and otherwise had an uncomplicated postoperative course.
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10084394-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Erythromycin Base / Lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Transabdominal hysterectomy, right ovarian cystectomy, right paratubal cystectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> Pt is a ___ gravida 0, who presented to the office experiencing irregular menses with heavy flow. The patient also complained of symptoms of pelvic pressure and pain. An ultrasound done in ___ revealed an enlarged uterus measuring 12.1 x 10.2 x 9.6 cm with multiple fibroids, the largest measuring 8.1 x 7.6 x 7.5 cm posteriorly. The patient desired definitive therapy and in the form of a total abdominal hysterectomy with possible bilateral salpingo-oophorectomy. She was counseled in the office about her other options and expressed the desire to proceed with hysterectomy, for symptomatic fibroid uterus. An endometrial biopsy in the office was obtained, which was negative for malignancy. Informed consent was obtained prior to proceeding to the operating room. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 13. She is cycling regularly with menorrhagia. She notes that when she has her menses, her pain can be ___. She denies any history of sexually transmitted diseases or abnormal Pap smears. PAST MEDICAL HISTORY: Significant for arthritis, hypertension, gastric reflux, T2DM, and hypercholesterolemia. OPERATIVE HISTORY: D&C x2 for regular prolonged vaginal bleeding in ___ and ___, polyp removal in ___, tonsillectomy and adenoidectomy in ___, carpal tunnel release in ___ and ___, and multiple myomectomy on ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> None contributory <PHYSICAL EXAM> GENERAL: Well-developed, well-nourished, obese woman, in no apparent distress. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Conjunctivae pink. Oropharynx clear. NECK: Supple, without increased thyroid. LYMPH SYSTEM: Negative. LUNGS: Clear to auscultation bilaterally. COR: Regular rate. ABDOMEN: Obese, soft, nondistended, and nontender. Negative hepatosplenomegaly, negative palpable masses. PELVIC: Difficult secondary to the patient's body habitus. Vaginal vault, normal appearing discharge, no lesions. Cervix without cervical motion tenderness. Uterus approximately 16 cm in maximal vertical dimension. Again, difficult to appreciate secondary to the patient's size. Adnexa, there were no obvious masses. She was nontender bilaterally. <PERTINENT RESULTS> ___ 09: 00 HCT 40.8 ___ 09: 05 WBC 11.0 HGB 9.9 HCT 28.8 PLT 188 <MEDICATIONS ON ADMISSION> Medications - Prescription ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth once daily HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - one Tablet(s) by mouth once daily HYDROCORTISONE - 2.5 % Cream - Apply to rash for 7 days twice a day After 7 days, use only as needed, not daily METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - one Tablet(s) by mouth daily METOPROLOL TARTRATE [LOPRESSOR] - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth daily 1 q am and ___ q pm <DISCHARGE MEDICATIONS> 1. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Please take medication with food. Disp: *60 Tablet(s)* Refills: *0* 5. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* 8. Ferrous Gluconate 325 mg (36 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* 9. Zofran 4 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for nausea for 3 days. Disp: *8 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Symptomatic fibroid uterus <DISCHARGE CONDITION> Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 8 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit.
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Pt was admitted after undergoing total abdominal hysterectomy, right paratubal cystectomy, and cystoscopy for symptomatic fibroid uterus. Intra-operative finding included: fibroid uterus with multiple fibroids, largest posterior measuring 8 cm, uterus densely adherent to bowel, right hemorrhagic ovarian cyst, right small paratubal cyst, and bilateral ureteral jets seen but no methylene blue during cystoscopy. Please see operative note by Dr. ___ complete details. During previous surgeries, pt had trouble with getting adequate pain control post operatively, thus acute pain service was consulted and pt had epidural placement immediately after her surgery. On post-op day #2, she was transitioned to PCA, and then transitioned to PO pain medication on post-op day #3. Pt was started on her home medication (Lopressor and HCTZ) for her hypertension. While pt was still recovering and not taking regular PO, she was placed on insulin sliding scale. When pt was able to have a regular diet, her home medication (Metformin) for her T2DM was restarted. Ms ___ was discharged on post-operative day #4 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty.
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10084586-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Zocor <ATTENDING> ___. <CHIEF COMPLAINT> cervical carcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Examination under anesthesia, radical hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy. <HISTORY OF PRESENT ILLNESS> ___ G2, P2 sent by Dr. ___ for consultation regarding a new diagnosis of cervical carcinoma. She saw Dr. ___ recently with a complaint of complete procidentia. Dr ___ a 5 cm irregular lesion on the cervix suspicious for malignancy. A representative biopsy was obtained and this revealed invasive squamous cell carcinoma. The patient has had Pap smears regularly all her life, which have all been normal. She has no history of cervical dysplasia. Her last Pap smear was in ___. She denied any GI or GU complaints. She has had no pain. She denied any lower extremity swelling. Of note, she recently had a urine cytology for microscopic hematuria. This revealed atypical cells suspicious for urothelial dysplasia or neoplasia. She has been wearing a pessary placed by Dr. ___, ___ this has greatly relieved her prolapse symptoms. She is now able to sit comfortably whereas she could not before. She had been suffering prolapse symptoms for at least six months. She also reports that she has had irregular vaginal bleeding for about four months. She denied any GI or GU symptoms. She denied gross hematuria. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, diabetes, diabetic retinopathy, and diabetic nephropathy. PAST SURGICAL HISTORY: Laser surgery for retinal hemorrhage. OB HISTORY: Vaginal delivery x2. GYN HISTORY: Last Pap smear as above. Last mammogram was in ___ and normal. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for malignancies <PHYSICAL EXAM> GENERAL APPEARANCE: Well developed, well nourished. HEENT: Sclerae anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. BREASTS: Without masses. ABDOMEN: Soft and nondistended and without palpable masses. EXTREMITIES: Without edema. PELVIC: The external genitalia were normal. The lower vagina was normal on speculum examination. A pessary was in place. This was not removed. Today's examination revealed smooth vaginal walls, a 5 cm irregular palpable tumor on the exocervix with no vaginal fornix involvement, and no palpable pelvic masses. The rectal examination revealed no parametrial disease or cul-de-sac nodularity. The rectal was intrinsically normal. <PERTINENT RESULTS> ___ 08: 10AM BLOOD WBC-10.9 RBC-2.98* Hgb-9.4* Hct-26.7* MCV-90 MCH-31.6 MCHC-35.3* RDW-12.9 Plt ___ ___ 08: 10AM BLOOD Glucose-143* UreaN-43* Creat-1.9* Na-134 K-4.5 Cl-101 HCO3-26 AnGap-12 ___ 08: 10AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.2* <MEDICATIONS ON ADMISSION> Lipitor, lisinopril, atenolol, calcium, hydrochlorothiazide. <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *30 Capsule(s)* Refills: *1* 4. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Stage IB2 cervical cancer possible COPD <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. Please call if you have redness and warmth around the incision, if your incision is draining pus-like material, or if your incision reopens. - No driving for two weeks and while taking narcotic pain medication as it can make you drowsy. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal adequately. - Nothing per vagina (no tampons, intercourse, douching for 6 weeks. - Please keep your follow-up appointments as outlined below. - Please leave foley in for 1 week.
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___ yo G2P2 with hypertension, type II diabetes mellitus, and nephropathy was admitted ___ status post exploratory laparotomy, radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for Stage Ib2 cervical cancer. Please see operative report for details. The pt was given routine post-op care. She was kept on her home medications for her hypertension and hypercholesterolemia. She was not given NSAIDs given her history of renal insufficiency (baseline Cr ~2.0) and her foley was kept in for one week post-operatively. The pt continued to require oxygen longer than expected post-operatively which was felt to be due to her likely undiagnosed chronic lung disease given her extensive smoking history as well as a recent URI the pt complained of on admission. She had bilateral lower extremity dopplers which did not show evidence of DVT and a CXR did not show any evidence of pneumonia but did show atelectasis and pleural effusions. The pt was able to be weaned off the oxygen and was discharged home in good condition on POD#3.
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10084586-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Zocor <ATTENDING> ___. <CHIEF COMPLAINT> diarrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P2 POD#9 from a radical hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymph node dissection for cervical cancer presents with diarrhea. Pt was started on augmentin for possible vaginal cuff infected seroma on ___ after seeing Dr. ___ in the office with the c/o foul smelling discharge. Pt reports watery, non-bloody diarrhea since starting the abx. Pt denies cramping, blood in stool, nausea, vomiting, fever/chills. Pt reports only mild vaginal discharge now. Incisional pain is minimal and pt feels well aside from the diarrhea. She has been afraid to eat anything because it will go right through her. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, diabetes, diabetic retinopathy, and diabetic nephropathy. PAST SURGICAL HISTORY: Laser surgery for retinal hemorrhage. OB HISTORY: Vaginal delivery x2. GYN HISTORY: Last Pap smear as above. Last mammogram was in ___ and normal. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for malignancies. <PHYSICAL EXAM> 97.1 122/60 64 16 99% RA NAD, sitting up in bed with family members around visiting ___, no murmurs mild expiratory wheeze bilaterally +BS, soft, NT, ND incision: c/d/i, no erythema NT, NE Pelvic deferred. Per Dr. ___ ___: PELVIC: The external genitalia were normal. Speculum examination initially revealed smooth vaginal walls and a normal apex without any discharge or blood. There was a foul odor. Upon opening the speculum valves, there was leakage of a moderate amount of clear brown-stained fluid from the mid aspect of the vaginal apex. Approximately 50 cc total was drained. This was cleared away. A portion of this was sampled for culture. The speculum was kept open until the drainage ceased. Bimanual examination revealed smooth vaginal walls, intact vaginal apex, and no palpable pelvic masses. There was no palpable mass on rectal examination. The rectum was intrinsically normal. There was no tenderness on rectovaginal examination. <PERTINENT RESULTS> ___ WBC-17.8 Hgb-9.2 Hct-28.8 Plt ___ ___ Glucose-143 UreaN-63 Creat-2.2 Na-140 K-3.8 Cl-100 HCO3-30 ___ Glucose-122 UreaN-56 Creat-1.8 Na-134 K-3.6 Cl-98 HCO3-27 CT Abd/pelvis ___: In the mid pelvis, there is decrease of the amount of free air as well as decrease of the air-fluid level seen on the study of ___. <MEDICATIONS ON ADMISSION> Lipitor, lisinopril, atenolol, calcium, hydrochlorothiazide, augmentin day ___ <DISCHARGE MEDICATIONS> 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp: *30 Tablet(s)* Refills: *0* 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp: *14 Tablet(s)* Refills: *0* 3. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal cuff seroma Diarrhea Dehydration <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Drink plenty of fluids Call with any temps >100.4
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Pt was admitted ___ s/p exploratory laparotomy, radical hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection for cervical cancer for diarrhea associated with augmentin use. Pt was placed on augmentin POD#5 for foul smelling vaginal discharge and a likely vaginal cuff infected seroma. Pt was admitted and given IVF and placed on PO cipro/flagyl for the vaginal cuff seroma as well as to cover the possibility of c diff. Pt tolerated POs and her diarrhea improved while she was hospitalized. Pt was discharged home on HD#2/POD#10 continued on the cipro and flagyl. Pt also complained of stress incontinence since her operation. Explained to pt that likely from fixing her prolapse and would likely not improve unless she had some sort of surgery. Suggested that the pt follow up with Dr. ___ her incontinence.
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10085948-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / amoxicillin / tramadol <ATTENDING> ___ <CHIEF COMPLAINT> Gender dysphoria <MAJOR SURGICAL OR INVASIVE PROCEDURE> EXAM UNDER ANESTHESIA, TOTAL LAPAROSCOPIC HYSTERECTOMY, BILATERAL SALPINGOOPHORECTOMY, CYSTOSCOPY WITH REMOVAL OF BLADDER POLYP; REDUCTION AND OPEN REPAIR OF INCARCERATED UMBILICAL HERNIA <HISTORY OF PRESENT ILLNESS> ___ gravida 0, transgender man who presents for gender confirming surgery. ___ states that he has been thinking about this procedure for quite some time. He has been married to his wife for the past ___ years and she is very supportive of his transition. He is not interested in future pregnancy nor harvesting eggs. He started testosterone over ___ years ago and he has had no vaginal bleeding since that time. He is interested in having his female reproductive organs removed e.g. uterus, fallopian tubes and ovaries bilaterally. On ___ an ultrasound which showed an anteverted uterus that measured 7.4 x 3.4 x 3.1 cm. The endometrium was homogenous and measured 2 mm. The right ovary was not visualized. The left ovary was seen and appeared normal. There was no free pelvic fluid. These findings on this normal pelvic ultrasound were discussed and his questions were answered. <PAST MEDICAL HISTORY> <ALLERGIES> Penicillin, amoxicillin, tramadol PMH: -Asthma -Psoriasis -Bipolar -PTSD -Anxiety PSH: -right knee lateral release ___ years ago - Right hand/arm cyst removal and tendon repair ___ years ago - fistulous track removed from right buttock cheek ___ years ago OB/GYN history: Menarche he is not sure, he has had no bleeding for 2+ years. His last Pap smear was ___ and was normal. He denies any history of abnormal Pap smears. He is currently sexually active with his wife of ___ years. Contraception-not needed. He does have a history of ovarian cyst. He has never had a sexually transmitted infection. He has never had a pregnancy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother-diabetes, COPD, hypertension, bipolar melanoma, alcohol abuse and status post MI Maternal grandmother-status post MI, alcohol abuse Maternal grandfather-alcohol abuse ___ <PHYSICAL EXAM> ADMISSION EXAM -= BP: 130/80, HR: 80, O2: 96% on RA, Tcurrent: 97.5, RR: 19 Input/output: IVF- 1747 mL of LR in OR/PACU Urine Output - 533 from OR to current, UOP 325 cc/ 1.5 hr PE Gen: Stable, in no apparent distress Lungs: CTAB Cardiac: RRR Abdominal exam: Bowel sounds present; abdomen soft, non-distended, no rebound tenderness or guarding. Tenderness to palpation in the umbilicus, but no tenderness in LLQ. Incision: Dressing clean, dry, intact. Closed with suture. GU: Minimal staining of vaginal pad, Foley in place draining concentrated yellow urine Ext: Pneumoboots in place bilaterally, BLE nontender, nonedematous DISCHARGE EXAM -= Vitals: T 98.7, BP 158/104, HR 91, RR 18, SpO2 96 % on RA General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, incisions clean/dry/intact GU: no spotting in pad Extremities: no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 07: 16AM BLOOD WBC-7.7 RBC-5.33 Hgb-15.1 Hct-44.7 MCV-84 MCH-28.3 MCHC-33.8 RDW-13.5 RDWSD-41.5 Plt ___ <MEDICATIONS ON ADMISSION> ALBUTEROL SULFATE [VENTOLIN HFA] - Dosage uncertain - (Prescribed by Other Provider) BUPROPION HCL [WELLBUTRIN XL] - Dosage uncertain - (Prescribed by Other Provider) CLONAZEPAM - Dosage uncertain - (Prescribed by Other Provider) CLONIDINE HCL [CATAPRES] - Dosage uncertain - (Prescribed by Other Provider) OXCARBAZEPINE - Dosage uncertain - (Prescribed by Other Provider) TESTOSTERONE CYPIONATE - Dosage uncertain - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Do not exceed 4000 mg in a day RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6HR Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*15 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain Do not exceed 2400 mg in a day. Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth Q6HR Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drink and drive. ___ cause sedation. Partial fill upon request RX *oxycodone 5 mg ___ tablet(s) by mouth Q4HR Disp #*40 Tablet Refills: *0 5. Albuterol Inhaler ___ PUFF IH Q4H: PRN shortness of breath or wheezing 6. BuPROPion XL (Once Daily) 300 mg PO DAILY 7. ClonazePAM 1 mg PO QHS: PRN anxiety 8. OXcarbazepine 600 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> DESIRES GENDER AFFIRMATION SURGERY & INCARCERATED UMBILICAL HERNIA <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Mr. ___ was admitted to the gynecology service after undergoing TLH, BSO, cysto, bladder polyp biopsy/removal, reduction and open repair of incarcerated umbilical hernia for gender affirmation. Please see the operative report for full details. *) Post-op His post-operative course was uncomplicated. Immediately post-op, his pain was controlled with IV Dilaudid/Toradol. On post-operative day 1, his urine output was adequate so his foley was removed and he voided spontaneously. His diet was advanced without difficulty and he was transitioned to PO oxycodone/ibuprofen/acetaminophen By post-operative day 2, he was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. He was then discharged home in stable condition with outpatient follow-up scheduled. ===================== CHRONIC ISSUES ===================== *) h/o bipolar, anxiety: continue home meds *) asthma: albuterol prn
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| 208
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10086122-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal and rectal pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ year-old Gravida 7 Para 3 at 24+2 weeks gestational age presented complaining of vaginal and rectal pressure. She had a history of 3 prior preterm deliveries at 29 weeks, 30 weeks and 34 weeks gestational age. Denied dysuria, hematuria, urgency and frequency. She had a positive fetal fibronectin done in the office on ___ in addition to positive BV and yeast cultures. She denied leakage of fluidl and vaginal bleeding. She endorsed normal fetal movement. <PAST MEDICAL HISTORY> Estimated due date ___ Labs: O+, ab neg, HBsAg neg, RPR NR, RI . Obstetric History: G7P3 - ___ vaginal delivery @ 34wks - ___ vaginal delivery @ 30wks (preterm labor) - ___ primary low transverse c-section @ 29 weeks after PPROM per record (patient reports this delivery was at 26 weeks) - Therapeutic abortion x 2 - Spontaneous abortion x 1 . Gynecologic History: - Last menstrual periods: ___ - Paps: abnormal pap in ___ with colposcopy, normal f/u - STIs: +hx GC/CT with PID - reports that she has a Bartholin's Cyst . Medical History: asthma, no history of intubations . Surgical History: c-section, D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> none <PHYSICAL EXAM> (on admission) VITALS: T 98.6, HR 52, BP 106/59 GENERAL: pleasant woman in NAD CV: NSR w/o m/g/r CHEST: CTA B ABDOMEN: soft, NTND, no palpable masses, gravid SVE: closed, at least 1cm of length palpable. FHT: 150's, mod, AGA TOCO: one possible contraction in ___ hours <PERTINENT RESULTS> Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: REPORTED BY PHONE TO ___ ON ___ @ 15: 47. NEISSERIA GONORRHOEAE. Positive by PCR. Testing confirmed by real-time PCR amplification of an alternative target found in N. gonorrhea. This confirmatory test was developed and its performance . ___ 9: 45 am ANORECTAL/VAGINAL CULTURE Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: BETA STREPTOCOCCUS GROUP B. . ___ 11: 47 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . Urine toxicology negative <MEDICATIONS ON ADMISSION> prenatal vitamins albuterol <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *30 Capsule(s)* Refills: *3* 2. progesterone micronized 100 mg Insert Sig: Two (2) inserts Vaginal QHS (once a day (at bedtime)): in the vagina. Disp: *60 inserts* Refills: *2* 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp: *30 patch* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> shortened cervix <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Remain on modified bedrest. It is okay to get up an walk around your house, but no vigorous activity. Also, continue pelvic rest - this means nothing in the vagina - no intercourse, tampons or douching.
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___ year-old Gravida 7 Para 0,3,3,3 admitted at 24 weeks 2 days gestation with short cervix (1.7cm), pelvic pressure, and positive fetal fibronectin. She had no evidence of preterm labor, infection, or abruption. Urine toxicology screen was negative. Her cervix was closed on digital exam. She was admitted to the antepartum floor for hospitalized bedrest and close observation. She frequently reported pelvic and rectal pressure, however, she only had rare contractions on tocometry and her cervix was unchanged. Maternal fetal medicine consult recommended continued hospitalized bedrest as well as vaginal progesterone, which was initiated at 26 weeks (took some time for insurance to approve and for patient to have it picked up from the compounding pharmacy). Although she wasn't entirely compliant with bedrest (frequently ambulating in room and leaving the floor to smoke) and she often complained of pelvic pressure, she had only rare contractions on tocometry and her cervix remained closed over multiple exams. Cervical length was stable at 1.7cm with no dynamic changes. She was ordered for Nifedipine as needed for contractions but only received one dose. . Ms ___ was diagnosed with Gonorrhea on ___. She was treated with Ceftriaxone on ___, then treated again on ___ given her report of unprotected intercourse while hospitalized. A test of cure will be done in the outpatient setting. . Fetal testing was reassuring. She received a course of betamethasone for fetal lung maturity and the NICU was consulted. She underwent daily NSTs, weekly biophysical profiles, and growth scans every three weeks. She underwent a full fetal survery on ___ which was unremarkable. . Ms ___ remained stable until 28 weeks at which time she was discharged home to continue modified bedrest, pelvic rest, and vaginal progesterone.
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| 405
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10087637-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G2P2 with hx of pelvic pain and dysmenorrhea and known fibroids s/p Mirena IUD placement ___ for management of ___ transferred from ___ with acute worsening of abdominal pain. The patient reports that she recently finised her first menstrual period since placement of the IUD. Her LMP started ___ and lasted until ___, which is significantly longer than her usual periods, and her bleeding was lighter. Towards the end of this period, she developed her usual pelvic pain which is worst on the left side and radiates down into her left leg. She took motrin and tylenol for this. She went to work on ___ and then spent much of the weekend in bed secondary to discomfort, which was all of the same quality as her usual pain. At work today, she experienced sudden onset central lower abdominal pain that felt more like stomach cramps and made her double over. A friend took her to the ED at ___ where she had a hct drawn that was 35, and also had a pelvic u/s and CT. There was noted to be free fluid in the pelvis and the IUD was thought to be malpositioned leading to concern for uterine perforation. The patient was transferred to ___ for further evaluation and management. Of note, at ___ the patient's UCG was negative. She reports that her husand has had a vasectomy and she does not think there is any chance she could be pregnant. The patient has an artificial heart valve due to rheumatic heart disease and is on coumadin for anti-coagulation with a goal INR of 2.5-3.5. She reports that her INR has recently been elevated. INR at ___ 4.4 (4.1 on ___. The patient denies any vaginal bleeding, N/V, fevers/chills, urinary or vaginal sxs. She has not had pain like this before. -Received IV morphine, fentanyl and zofran at ___ -Received fentanyl 0.25mcg IV x 1 at ___ ED <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 12. Cycles q28 days, typically bleeds for three days. She denies abnormal Pap smears. She denies any history of sexually transmitted infections. She has had two vaginal deliveries both without complications. PAST MEDICAL HISTORY: Cardiac valve disease secondary to rheumatic fever w/ prosthetic mitral valve and atrial valve and has had a tricuspid valve repair, all performed in ___. History of migraine headaches, herpes labialis, and colonic polyps. ALLERGIES: No known drug allergies. OPERATIVE HISTORY: Valvular replacement and repair in ___, lsc cholecystectomy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> Exam on admission: O: T 97.0 HR 77 BP 101/57 RR 16 99%RA NAD, well-appearing RRR CTAB Abd soft, ND, TTP in lower quadrants, no rebound or guarding Bimanual: IUD strings palpated at os, no vaginal bleeding, approx. 16cm uterus with irregular contour c/w fibroids, tenderness on palpation of lower abdomen, no CMT, no adnexal masses or fullness Ext without edema, NT Exam on discharge: VS: T 98, BP 92/54, HR 62, RR 18, O2sat 100% on RA Gen: NAD CV: RRR Lungs: CTAB Abd: soft, non-distended, minimally tender to palpation in the lower abdomen with no rebound or guarding Ext: no edema, non-tender to palpation <PERTINENT RESULTS> LABORATORY: At ___, Hct 35, INR 4.4, UCG negative At ___ ED: ___ 09: 55PM BLOOD WBC-11.1*# RBC-3.73* Hgb-12.1 Hct-36.6# MCV-98 MCH-32.5* MCHC-33.1 RDW-12.2 Plt ___ ___ 09: 55PM BLOOD Neuts-83.1* Lymphs-11.8* Monos-3.4 Eos-1.3 Baso-0.5 ___ 09: 55PM BLOOD ___ PTT-46.9* ___ Follow-up labs: ___ 07: 05AM BLOOD WBC-5.5# RBC-3.70* Hgb-12.2 Hct-36.4 MCV-99* MCH-33.1* MCHC-33.5 RDW-12.5 Plt ___ ___ 07: 05AM BLOOD ___ PTT-47.5* ___ RADIOLOGY: Imaging from ___ (reviwed with radiology attending): TVUS & CT: nl ovaries bilat, no cysts seen, nl flow, moderate amt of complex free fluid in pelvis, density c/w blood, multiple fibroids, IUD well positioned at fundus, no evidence of uterine perforation BLOOD BANK: INDICATIONS FOR CONSULT: Difficult crossmatch and/or evaluation of irregular antibody (s) CLINICAL/LAB DATA: Ms. ___ is a ___ year old female admitted with abdominal pain and dysmenorrhea. A blood sample was sent for type and screen. Laboratory Data: Patient ABO/Rh: Group AB, Rh positive Antibody screen: Positive Antibody identity: Anti-K Antigen phenotype: Negative for ___ Transfusion History: ___: 6 non-reactive red blood cell transfusions 6 non-reactive plasma transfusions 3 non-reactive platelet transfusions 1 non-reactive cryoprecipitate transfusion No history of transfusions at ___ they were notified of the anti-K. DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. ___ has a new diagnosis of anti-K antibody. ___ is a member of the Kell blood group system. Anti-K is clnically significant and capable of causing hemolytic transfusion reactions and hemolytic disease of the fetus and newborn. Ms. ___ should receive ___ negative products for all red blood cell transfusions. Approximately 90% of ABO compatible blood will be ___ negative. <MEDICATIONS ON ADMISSION> AMOXICILLIN - amoxicillin 500 mg capsule. 4 Capsule(s) by mouth once as needed for prior to dental work take 4 tablets 1 hour prior to dental procedure - (Prescribed by Other Provider) ENOXAPARIN - enoxaparin 60 mg/0.6 mL Sub-Q Syringe. Inject sq twice a day as needed for low INR or prior to procedure LEVONORGESTREL [MIRENA] - Mirena 20 mcg/24 hour ___ years) Intrauterine Device. inserted one intrauterie device---releiable for ___ years NARATRIPTAN - naratriptan 2.5 mg tablet. 1 (One) tablet(s) by mouth once at onset of migraine ___ repeat after 4 hours if HA continues. OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1 capsule(s) by mouth once every other day - (Prescribed by Other Provider) TOPIRAMATE - topiramate 100 mg tablet. 2 tablet(s) by mouth at bedtime VALACYCLOVIR - valacyclovir 1 g tablet. 2 tablet(s) by mouth bid for one day as needed for onset of cold sores WARFARIN - warfarin 2 mg tablet. 3 tablet(s) by mouth once a day --------------- --------------- --------------- --------------- <DISCHARGE MEDICATIONS> 1. Topiramate (Topamax) 200 mg PO QHS 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *1 4. Warfarin 4 mg PO 3X/WEEK (___) ___ 5. Warfarin 6 mg PO 4X/WEEK (___) <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Hemoperitoneum Possible ruptured ovarian cyst Fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the gynecology service for observation and monitoring of pain control and hematocrit levels. Your pain was controlled with minimal oral pain medication, and your hematocrit levels were stable. We also checked your INR level, which was 3.3 on the day of discharge and you should continue on you home doses of coumadin and follow-up with the doctors who manage your coumadin dosing. In addition, please follow these ___ instructions: *) Do not take more than 2400mg ibuprofen (motrin) in 24 hours *) Do not take more than 4000mg acetaminophen in 24 hours *) Do not drive while taking narcotics *) Take a stool softener while taking narcotics. *) Do not combine narcotic and sedative medications or alcohol *) You may eat a regular diet Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication
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On ___, Ms. ___ was admitted to the gynecology service with acute worsening of abdominal pain and hemoperitoneum, in the setting of supra-therapeutic INR, for pain control and observation. *) Abdominal pain: Given the ultrasound report from ___ ___ (which was reviewed with ___ radiologists), the Mirena IUD appeared to be in good position with no evidence of perforation and there was a moderate amount of free fluid consistent with hemoperitoneum. Given the patient's history of pain, this was thought most consistent with a ruptured hemorrhagic cyst. A urine test for pregnancy was negative and patient's partner has had a vasectomy, making ectopic pregnancy unlikely. Thus, the patient was given percocet for pain control. She required minimal amounts of percocet to achieve good pain control. *) Anticoagulation: Patient's INR was supra-therapeutic in the ___ ED to 4.4, and at ___ at 4.0, with goal 2.5-3.5. She was given 2mg coumadin on ___, instead of 4mg and repeat testing revealed the INR to be within the target range. She remained hemodynamically stable with a stable hematocrit. The Anti-coagulation management service at ___, the service which manages her coumadin dosing, was contacted on hospital day 1, and a plan was made to continue the patient's usual coumadin dosing, with follow-up INR testing on ___. In the afternoon of hospital day 1, the patient remained with minimal abdominal pain and hemodynamically stable, and thus she was discharged home, with outpatient follow-up arranged.
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10091978-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> scheduled primary c/s for twins (breech and vertex) <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p c/s for twins breech/breech <HISTORY OF PRESENT ILLNESS> The patient was diagnosed with diamniotic dichorionic twin. She was followed up with antepartum testing. The estimated fetal weights were in the ___ percentile in concordance with mild-to-moderate oligohydramnios which was followed and was stable. During the pregnancy the fetus' were breech and vertex. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Renal Stones: Right. 2. Bulging disc L4-L5. PAST SURGICAL HISTORY : Tonsillectomy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: Healthy aside from back problems. Living. Father: A&W. Living. ___: 1 healthy. Other: Denies family history of DM, clotting disorders, congenital heart defects or anomalies, neural tube defects, autism, learning disabilities, chromosomal abnormalities. <PHYSICAL EXAM> AF VSS Comfortable RRR CTAB Abd soft, NT, ND, +BS Minimal VB Ext no c/c/e, no TTP <PERTINENT RESULTS> ___ 10: 44AM WBC-14.5* RBC-3.61* HGB-11.6* HCT-32.6* MCV-90 MCH-32.1* MCHC-35.6* RDW-13.5 ___ 10: 44AM PLT COUNT-219 ___ 08: 40AM WBC-14.2* RBC-3.66* HGB-11.7* HCT-33.4* MCV-91 MCH-32.1* MCHC-35.2* RDW-13.8 ___ 08: 40AM PLT COUNT-208 ___ 01: 09PM WBC-20.6* RBC-3.01* HGB-9.8* HCT-27.6* MCV-92 MCH-32.4* MCHC-35.3* RDW-13.6 ___ 01: 09PM PLT COUNT-222 ___ 07: 56PM WBC-20.8* RBC-2.41* HGB-7.7* HCT-22.0* MCV-92 MCH-31.8 MCHC-34.8 RDW-14.5 ___ 07: 56PM PLT COUNT-169 <MEDICATIONS ON ADMISSION> Pre-natal vitamins <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *2 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q3H: PRN Pain ___ start now RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth four times a day Disp #*40 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 2 capsule(s) by mouth daily Disp #*60 Capsule Refills: *3 4. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *5 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p c/s for twins breech/breech <DISCHARGE CONDITION> Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Follow up in 6 weeks for a postpartum check
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On ___, Ms. ___ was admitted to L&D after undergoing a primary cesarean section for diamniotic dichorionic twin gestation with non vertex presentation both twin A and B. Please refer to the operative note for full details. Her post-partum course was complicated by a post-partum hemorrhage with a total EBL for c-section and hemorrhage of 1900cc. Intra-op, the patient received 30u pitocin and 1000mg cytotec for an EBL of 1200cc. While in the PACU, the patient had an additional 900cc EBL. An exam was performed and clot was evacuated from the uterus, and the patient was given an additional 0.2mg methergine with good hemostasis. Her pre-op Hct was 32.6; on PPD 1, her Hct nadired at 19.4 and the patient was symptomatic, so she was transfused 2u pRBCs with appropriate rise in Hct to 24.5. She was discharged home in good condition on PPD 4 with follow-up scheduled.
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10093120-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal distention <MAJOR SURGICAL OR INVASIVE PROCEDURE> paracentesis diagnostic laparoscopy, explorative laparotomy, total abdominal hysterectomy, bilateral salpingo-ophorectomy, omentectomy, appendectomy, left pelvic lymphadenectomy, pelvic peritonectomy, oversew of bowel serosa and cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a lovely ___ G0 transferred from ___ to ___ ED on ___ for partial small bowel obstruction, pelvic masses, and carcinomatosis on CT scan. She was admitted to the medicine service from the ED, where she has been managed. She initially presented to ___ with abdominal distention and nausea that developed over the past week. She reports decreased appetite and nausea with dry heaving, no vomiting because she feels her stomach has been empty from minimal PO intake. She also reported abdominal pain throughout her abdomen. At ___, she had CT A/P that was read as follows: 1. 8 x 12 cm cystic and solid pelvic soft tissue mass likely representing ovarian malignancy. Malignant ascites and peritoneal enhancement suggesting peritoneal carcinomatosis. 2. Partial SBO likely secondary to small bowel into by pelvic tumor. She was then transferred to ___ for further evaluation and management. In the ED here, she was initially mildly tachycardic but afebrile. Her HR normalized with hydration. Her vitals have remained normal in the floor. Her SBO has been managed conservatively NPO/IVFs. She has not required an NG tube. She states today that her nausea has completely improved and she has not had vomiting or dry heaving since being in the hospital. She has continued to pass gas throughout the past week, including today, and feels like she is going to have a BM soon. Her last BM was on ___. She did undergo a paracentesis for 2L of clear, straw-colored fluid on ___, and states she felt much better after paracentesis but is already feeling fluid re-accumulate. Peritoneal fluid was sent for cytology which is pending. ___ was consulted by medicine to consider ___ biopsy of omental nodules, but felt that the nodules were too small to successfully and safely biopsy with ___ so this was deferred. On ROS, patient states she had a 15lb weight-loss over the past year but has been trying to lose weight. She denies CP, SOB, fever, chills, changes in bowel movements or urination, vaginal bleeding, or abnormal discharge. ROS: full review of systems was negative except as above <PAST MEDICAL HISTORY> Health Maintenance: - ___: BIRADS-2 benign ___ - Colonoscopy: none, FOBT negative this year - Pap smear: wnl ___ PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP ___ years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in ___ - not sexually active - denies history of abnormal Pap smears, last in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father: ___ Mom: osteoporosis <PHYSICAL EXAM> Physical Exam on Admission ___: T 98.0 HR 108 BP 130/82 RR 18 O2Sat 98% RA Gen: A&O, NAD CV: RRR Resp: CTAB Abd: somewhat hypoactive BS, softly distended, nontender, no rebound or guarding Ext: calves nontender bilaterally SSE: Normal vaginal mucosa with pink tinge, no lesions, Cervix unable to be visualized due to patient discomfort even with small size speculum BME: Small smooth cervix, exam limited due to ascites, large pelvic mass palpated, nontender Rectovaginal exam: no nodularity, again large pelvic mass palpated Physical Exam on Day of Discharge: ___ 0731 Temp: 98.5 PO BP: 127/79 HR: 88 RR: 18 O2 sat: 95% O2 delivery: Ra ___ 0506 Temp: 98.1 PO BP: 145/75 HR: 94 RR: 18 O2 sat: 98% O2 delivery: RA ___ Total Intake: 60ml PO Amt: 60ml ___ Total Intake: 300ml PO Amt: 300ml ___ Total Output: 1100ml Urine Amt: 1100ml ___ Total Output: 3370ml Urine Amt: 3350ml Emesis: 20ml General: NAD, comfortable appearing. Neuro: AxO x 3, affect appropriate. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Cardiovascular: RRR, no rubs/murmurs/gallops. Pulmonary: normal rate and work of breathing, Lungs CTAB Abdomen: + bowel sounds. Soft, nontender to palpation, minimally distended. No rebound/guarding. Vertical midline incision closed with staples and c/d/I without surrounding erythema, induration, or exudate. GU: No blood on pad. MSK: Lower extremities with 2+ edema to knee bilaterally; no erythema or TTP, compression stocking on <PERTINENT RESULTS> ___ 02: 00AM BLOOD WBC-8.8 RBC-4.92 Hgb-12.9 Hct-39.9 MCV-81* MCH-26.2 MCHC-32.3 RDW-12.8 RDWSD-37.3 Plt ___ ___ 06: 10AM BLOOD WBC-7.4 RBC-4.36 Hgb-11.6 Hct-36.4 MCV-84 MCH-26.6 MCHC-31.9* RDW-12.8 RDWSD-38.8 Plt ___ ___ 02: 00AM BLOOD Neuts-62.2 ___ Monos-13.0 Eos-0.8* Baso-0.7 Im ___ AbsNeut-5.47 AbsLymp-1.98 AbsMono-1.14* AbsEos-0.07 AbsBaso-0.06 ___ 06: 10AM BLOOD ___ ___ 02: 00AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-139 K-4.3 Cl-96 HCO3-23 AnGap-20* ___ 02: 00AM BLOOD ALT-<5 AST-9 AlkPhos-66 TotBili-0.4 ___ 06: 10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 ___ 02: 00AM BLOOD Albumin-3.1* ___ 02: 00AM BLOOD CEA-0.6 ___* - CT chest (___): anterior supradiaphragmatic lymph nodes are 0.9cm, concerning for possible metastatic involvement, for further follow-up. - CT A/P: 12cm cystic and solid pelvic soft tissue mass likely representing ovarian malignancy, malignant ascites, and peritoneal carcinomatosis <MEDICATIONS ON ADMISSION> Loratadine 10 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 4000mg in 24 hrs RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as needed Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 3. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*19 Syringe Refills: *0 4. Ondansetron ODT 4 mg PO Q8H: PRN nausea may be constipating, call MD if needing to use frequently RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*10 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate do not drive or drink alcohol, may cause sedation RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 6. Loratadine 10 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> partial small bowel obstruction pelvic mass and carcinomatosis left tuboovarian abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology oncology service for a partial small bowel obstruction and were found to have a pelvic mass. You then underwent the procedure listed below. You have recovered well after your procedure, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist you in administering these injections. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea.
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Ms. ___ is a ___ year old woman without significant past medical history presenting with partial small bowel obstruction, pelvic masses, carcinomatosis, who was initially admitted to medicine for further workup and was transferred to gynecologic oncology service on hospital day #2 given concern for ovarian malignancy. In regards to her partial small bowel obstruction, patient had a CT abdomen/pelvis which demonstrated a dilated small bowel with transition point in pelvis. Per radiology, the small bowel was likely entrapped and dilated by tumor. Patient did not endorse any nausea and continued to pass flatus. Acute care surgery was consulted and patient was made NPO with IV fluids, anti-emetics, and narcotics as needed. Patient tolerated sips on hospital day #2, Ensure clear/toast/crackers on hospital day #3, and a regular diet on hospital day #4. In regards to the concern for ovarian malignancy, she had a CT which demonstrated a 12cm cystic and solid pelvic soft tissue mass, ascites, and peritoneal carcinomatosis. A CT chest revealed 0.9cm supradiaphragmatic lymph nodes, which could possibly represent metastases. ___ was Tumor markers revealed elevated CA-125 of 522 and CEA level of 0.6. She had a paracentesis performed in the emergency room for 2 liters of ascites, and cytology was sent for analysis. Interventional radiology was consulted, however her omental lesions were too small to biopsy. On hospital day #6, patient underwent a TAH/BSO, appendectomy, omenectomy. Afterwards she was admitted to ___ for mild hypotension post-op requiring neo. She was treated with unasyn for purulent fluid from one ovary as well as imaging concerning for pneumonia, and her blood pressure improved. She had an NGT placed intra-operatively which was removed without issue on post-operative day 3. Her post-operative course was complicated by an elevated INR, for which she received vitamin K with resolution. Her pain was initially managed with an epidural and was then transitioned to oral medications. Her diet was advanced slowly due to post-operative ileus. Her foley catheter was removed on post-operative day 3 and she voided spontaneously. By post-operative day 10 she was voiding, tolerating a regular diet, ambulating independently with good pain control. She was then discharged home with ___ services to continue lovenox for prophylactic anticoagulation.
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| 515
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10093120-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> seasonal / frangrance / lidocaine <ATTENDING> ___. <CHIEF COMPLAINT> nausea and vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old gravida 0 with history of stage IIIB platinum refractory low grade serous and endometrioid ovarian carcinoma and stage II grade I endometrioid endometrial adenocarcinoma status post diagnostic laparoscopy converted to exploratory laparotomy, modified radical abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, and tumor debulking (___), status post 6 cycles of adjuvant ___ (complicated by neuropathy) and malignant pleural effusion with right pleurex (___), 5 cycles of doxil/bevacizumab, and currently undergoing gemcitabine/bevacizumab (C7D1 ___ who presents as transfer from ___ emergency department with nausea and vomiting. She reports being in her usual state of health until yesterday morning. She reports waking up in morning and having one episode of non-bloody non-bilious emesis. She then ate some toast and had an additional episode of non-bloody non-bilious emesis. She then presented to clinic for chemotherapy. Given the two episodes of emesis, Dr. ___ deferring chemotherapy at the time and getting imaging to rule out small bowel obstruction. At ___ emergency department, she underwent an abdominal xray on ___ which was concerning for dilated loops of small bowel. She then underwent a CT abdomen and pelvis with intravenous contrast which was notable for "Moderate to high-grade partial small bowel obstruction with transition in right lower pelvis possibly due to tethering from an apparent enhancing soft tissue mass, likely metastatic, measuring 2.2 cm in the right lower pelvis. Moderate perihepatic ascites, slightly increased. Trace free fluid in the pelvis, slightly less on prior exam. New pneumonia or aspiration right lung base. Moderate size right pleural effusion is slightly larger. A small left effusion is much smaller." She was then transferred to ___. Here she is doing well. She denies any further emesis after her second episode yesterday at 1100. Denies abdominal pain. Last bowel movement was ___. She has periods of alternating diarrhea and constipation. She will usually have daily bowel movements for the first few days after chemo. She has been passing flatus per usual and last passed flatus at 0800 this morning in the emergency department. She also reports feeling hungry. She notes that she had a right chest pleurex placed by interventional radiology on ___ and her shortness of breath has improved. She reports she is supposed to have the catheter drained every 2 days at home by ___ and is due to have it drained today. She denies any coughs, chest pain, sputum production, shortness of breath, or fevers. Does not remember any recent episodes of aspiration. <PAST MEDICAL HISTORY> Health Maintenance: - ___: BIRADS-2 benign ___ - Colonoscopy: none, FOBT negative this year - Pap smear: wnl ___ PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP ___ years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in ___ - not sexually active - denies history of abnormal Pap smears, last in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father: ___ Mom: osteoporosis <PHYSICAL EXAM> On day of discharge: General: no apparent distress, comfortable in bed CV: regular rate and rhythm Lungs: Right sided pleural friction rub on lower lung field, left side clear, no crackles, clear to auscultation bilaterally, pleurex catheter in place Abdomen: soft, non-distended, non-tender, normoactive bowel sounds, tympanic in upper abdomen Skin: port and pleurex dressing clean, dry, and intact Extremities: no edema, non-tender, pboots in place <PERTINENT RESULTS> ___ 11: 45PM URINE HOURS-RANDOM ___ 11: 45PM URINE UHOLD-HOLD ___ 11: 45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-80* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 11: 45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11: 45PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 ___ 11: 27PM LACTATE-1.1 ___ 11: 16PM GLUCOSE-85 UREA N-13 CREAT-0.5 SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-23 ANION GAP-13 ___ 11: 16PM estGFR-Using this ___ 11: 16PM ALT(SGPT)-<5 AST(SGOT)-14 ALK PHOS-83 TOT BILI-0.2 ___ 11: 16PM LIPASE-19 ___ 11: 16PM ALBUMIN-3.3* CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.2 ___ 11: 16PM WBC-6.1 RBC-3.89* HGB-11.0* HCT-35.6 MCV-92 MCH-28.3 MCHC-30.9* RDW-14.4 RDWSD-47.1* ___ 11: 16PM NEUTS-76.1* LYMPHS-15.5* MONOS-7.4 EOS-0.2* BASOS-0.3 IM ___ AbsNeut-4.60 AbsLymp-0.94* AbsMono-0.45 AbsEos-0.01* AbsBaso-0.02 ___ 11: 16PM PLT COUNT-293 ___ 11: 16PM ___ PTT-45.2* ___ ___ 10: 26AM UREA N-13 CREAT-0.5 SODIUM-136 POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-23 ANION GAP-17 ___ 10: 26AM estGFR-Using this ___ 10: 26AM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-91 TOT BILI-0.3 ___ 10: 26AM CALCIUM-10.1 PHOSPHATE-3.3 MAGNESIUM-2.1 ___ 10: 26AM CA125-186* ___ 10: 26AM WBC-8.6 RBC-4.61 HGB-13.1 HCT-41.4 MCV-90 MCH-28.4 MCHC-31.6* RDW-14.4 RDWSD-45.5 ___ 10: 26AM NEUTS-74.5* LYMPHS-12.8* MONOS-9.5 EOS-1.9 BASOS-0.8 IM ___ AbsNeut-6.43* AbsLymp-1.10* AbsMono-0.82* AbsEos-0.16 AbsBaso-0.07 ___ 10: 26AM PLT COUNT-388 <MEDICATIONS ON ADMISSION> 1. Acetaminophen Extra Strength 500 mg tablet1-2 tablet(s) by mouth every eight (8) hours as needed for pain [Not Taking as Prescribed] 2. Calcium with Vitamin D 600 mg (1,500 mg)-400 unit tablet(dose uncertain) 3. Claritin 10 mg tablet1 tablet(s) by mouth once a day as needed for allergy symptoms 4. docusate sodium 100 mg capsule1 capsule(s) by mouth once to twice daily as needed for to prevent constipation hold for loose stools 5. famotidine 20 mg tablet1 tablet(s) by mouth twice a day 6. lorazepam 0.5 mg tablet1 tablet(s) by mouth every eight (8) hours as needed for nausea/anxiety/insomnia do not drink or drive if taking 7. polyethylene glycol 3350 17 gram/dose oral powder1 powder(s) by mouth daily as needed for constipation <DISCHARGE MEDICATIONS> 1. Acetaminophen 500 mg PO Q6H: PRN Pain - Mild Do not exceed 4000 mg per day. RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> partial small bowel obstruction <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology oncology service for a small bowel obstruction. You were conservatively managed. You were made n.p.o. Your nausea was treated with antiemetics. Labs were done which showed no signs of systemic infection. You were afebrile with stable vital signs and monitored closely for resolution of symptoms. When signs of return of bowel function were present your diet was advanced without incident and you are discharged home on a low residual diet. Your home medications were continued. You have recovered well and the team now feels it is safe for you to be discharged home. Please follow these instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen, and use the narcotic as needed for breakthrough pain. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * Please continue on your low residual diet until xxxxxx Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gyn/onc service with a small bowel obstruction. CT abdomen/pelvis from ___ demonstrated moderate to high-grade partial small bowel obstruction with transition likely in the right lower pelvis possibly due to tethering from an apparent enhancing soft tissue mass, likely metastatic, measuring 2.2 cm in the right lower pelvis. She was managed conservatively, made NPO and started on maintenance IV fluids. Her abdominal exam showed no peritoneal signs during her stay and she remained afebrile with a normal white blood cell count. On hospital day 2, she passed gas and her diet was advanced to clears. On hospital day 3 she was advanced to a regular diet. On hospital day #5, she was tolerating a regular diet, she continued to pass flatus and bowel movements and had a normal abdominal exam. Prior to her admission, IP guided right pleurex catheter was placed on ___ for known malignant pleural effusion. Her pleurex was drained on each ___, and ___ of her hospital stay. Her CT abdomen/pelvis demonstrated airspace opacification at right lung base and could not rule out pneumonia vs aspiration, atelectasis. Given that she was afebrile, no leukocytosis, or signs or symptoms of infection, treatment was deferred. She remained afebrile with appropriate oxygen saturation on room air and with a benign respiratory exam. Because she remained stable and was tolerating a regular diet without nausea and vomiting, she was discharged home with follow-up on hospital day 5.
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10094132-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> menometorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, left salpingo-oophorectomy Cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G3P3 here for pre op. Pt previously had seen Dr ___ ___ fibroids and MMR with neg EMB since ___. Pt has monthly periods that last 7 days where the first 4 days are heavy with clots and then light by day 7. She was started on Provera and noted some improvement but still having heavy periods on and off. Some constipation but no gu symptoms. Surgery had been scheduled but pt cancelled due to child care issues and now returns desiring definitive mangament for her MMR and fibroids. Pt was advised by another physician to stop her iron due to reflux pain. Advised pt to take antacids instead of stop taking the iron as her latest H/H was ___ in ___. We discussed other options as well however pt declines UAE and really wants surgery. Dicussed that she is at risk of bleeding excessively and needing a blood transfusion emergently and voiced understanding. Also discussed that based on her US nad exam she may have extensive adhesions and may have a complications like an enterotomy or a bladder or ureteral injury requiring correction or return to OR. Pt voiced understanding. Pt was advised for IV iron therapy prior to surgery but has not had that done. <PAST MEDICAL HISTORY> OB/GYN OB History: G-3,P-3 c/s x 3 GYN History: Menses: 14 iregular q 2 - 6 weeks, usually 3 days until this past year when it became heavy. Fibroids: yes since ___ Ovarian cysts: none STD: HPV Abnormal pap: ___ Last pap: ___ WNL Breast disease: none Birth Control: BTL at ___ Sexually active: yes Sexual abuse: no Domestic violence: no PMH: GERD, back pain, hypertension PSH: C/S x 3, BTL, abdominoplasty, breast reduction, back surgery ALL: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> FH: Mother - diabetes, Father - diabetes, ___. No hx of cancer, CVD <PHYSICAL EXAM> BP: 110/70. Weight: 189. Height: 63. BMI: 33.5. LMP: ___. GEN: WN/WD, NAD Lungs: Clear bilaterally Cardiac: RRR. No murmurs ABD: Soft, NT, ND, No HSM, No masses, long scar from tummy tuck w some dimpling noted, umbilical scar as well, concern for adhesion to anterior wall from poor mobility of tissue EXTL No CT, No edema PELVIC EGBUS No lesions, discoloration. NEFG VAG: No atrophy. no d/c, or lesion. CX: unable to be seen based on extremely retroverted uterus on exam UT: irregular contour, enlarged to 15 weeks but limited by body habitus and poor relaxation, difficult to mobilize due to weight R AD NT. No masses palpable but difficult to separte from uterus L AD NT. No masses palpable but difficult to separte from uterus <PERTINENT RESULTS> PACU labs: ___ 06: 15PM BLOOD WBC-12.4*# RBC-3.87* Hgb-8.6* Hct-26.6* MCV-69* MCH-22.1*# MCHC-32.2 RDW-19.6* Plt ___ ___ 06: 15PM BLOOD Glucose-130* UreaN-10 Creat-0.6 Na-138 K-4.3 Cl-108 HCO3-23 AnGap-11 ___ 06: 15PM BLOOD Albumin-2.7* Calcium-6.9* Phos-3.6 Mg-1.4* Follow-up labs: ___ 07: 00AM BLOOD WBC-9.2 RBC-3.97* Hgb-8.4* Hct-27.3* MCV-69* MCH-21.3* MCHC-30.9* RDW-19.9* Plt ___ ___ 08: 55PM BLOOD WBC-5.5 RBC-3.33* Hgb-7.3* Hct-23.3* MCV-70* MCH-22.0* MCHC-31.6 RDW-20.9* Plt ___ <MEDICATIONS ON ADMISSION> MEDROXYPROGESTERONE - medroxyprogesterone 10 mg tablet. 1 Tablet(s) by mouth once a day OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE ONE CAPSULE BY MOUTH EVERY DAY Medications - OTC FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. one Tablet(s) by mouth once a day - (OTC) <DISCHARGE MEDICATIONS> 1. Omeprazole 20 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *2 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *2 5. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> multifibroid uterus metomenorrhagia anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the gynecology service after undergoing the procedure listed below. After a couple of days of observation, we felt you were meeting all of your post-operative goals, and thus we felt you were safe to go home. You should follow the instructions listed below: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___ Ms. ___ was admitted to the gynecology service after undergoing a Total Abdominal hysterectomy, Left salpingo-oophorectomy and cystoscopy. Please see the operative report for full details. Of note, she was transfused 2 units of packed red blood cells intra-operatively for a large blood loss. Immediately post-op, her pain was controlled with a Dilaudid PCA. Given that her hematocrit was stable on post-operative day 1, she was given Toradol as well. On post-operative day 2, her urine output was adequate and her hematocrit stable so her foley was removed and she voided spontaneously. Her diet was advanced slowly given extensive lysis of adhesions during the operation. By post-operative day 3 she was tolerating a regular diet and transitioned to oral pain medication. On post-operative day 3, she was tachycardic to 110 so she was kept an additional night for observation. A CBC checked at the time showed a hematocrit of 23 from 27, likely from equilibration. She was started on iron. The tachycardia resolved by post-operative day 4. By post-operative day 4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10094282-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> none <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 9 weeks gestation with T1 DM, sent by Dr. ___ ___ OB admission for diabetic control. She was on Lantus and Humalog prior to pregnancy and on NPH and Humalog during pregnancy. Reports fingersticks have been average 250's. She feels well and is without complaints. <PAST MEDICAL HISTORY> PRENATAL COURSE (1)LMP ___ (2)No initial prenatal yet PAST OBSTETRIC HISTORY G1 PAST GYNECOLOGIC HISTORY - no abnl paps or STIs PAST MEDICAL HISTORY - T1DM PAST SURGICAL HISTORY - ureteral reimplantation at age ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: T 96.8, HR 96, BP 128/70, RR 26, O2 100%RA GENERAL: NAD HEART: RRR LUNGS: CTAB ABDOMEN: soft, NT EXTREMITIES: NT/NE PELVIC US: live IUP confirmed <PERTINENT RESULTS> ___ WBC-8.3 RBC-4.26 Hgb-13.0 Hct-37.0 MCV-87 Plt-314 ___ WBC-9.5 RBC-4.30 Hgb-13.2 Hct-36.5 MCV-85 Plt-314 ___ Neuts-61.8 ___ Monos-4.8 Eos-2.0 Baso-0.3 ___ WBC-12.6 RBC-4.66 Hgb-14.4 Hct-39.3 MCV-84 Plt-326 ___ BLOOD Glu-209 BUN-9 Cre-0.7 Na-133 K-4.0 Cl-98 HCO3-26 ___ ALT-13 AST-12 APhos-67 TBili-0.2 Ca-9.9 Pho-4.3 Mg-1.8 ___ BLOOD %HbA1c-10.0 ___ TSH-1.7 ___ BLOOD HBsAg-NEGATIVE, HIV Ab-NEGATIVE ___ URINE pH-7 Hrs-24 Volu-1500 Creat-86 TotProt-<6 ___ URINE 24Creat-1290 RUBEOLA ANTIBODY, IgG (Final ___ POSITIVE BY EIA RAPID PLASMA REAGIN TEST (Final ___ NONREACTIVE Rubella IgG/IgM Antibody (Final ___ POSITIVE by Latex Agglutination ___ EARLY OB ULTRASOUND IMPRESSION: Single live intrauterine gestation. Size equals dates. <MEDICATIONS ON ADMISSION> prenatal vitamins NPH 36 units qam and 20 units qhs Humalog per sliding scale with meals <DISCHARGE MEDICATIONS> 1. Insulin NPH Human Recomb Subcutaneous 2. Please follow the insulin doses and sliding scale as detailed on the attached sheet. 3. Humalog Subcutaneous 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Type 1 Diabetic admitted for glycemic control <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your ob doctor please call if you experience vaginal bleeding, leakage of fluid or any other concerns. Please continue current insulin regimen.
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___ G1 with poorly controlled T1DM admitted at 9wks for glycemic control. . Ms ___ had fingersticks ranging from 151-236 on arrival to the emergency room. She had no complaints and electrolytes were normal. Her hemoglobin A1C was 10.0%. She was admitted to the antepartum floor and ___ consulted and continued to follow her closely throughout this admission. Initially, it was unclear whether her recent elevated fingersticks were due to insulin omission or due to increased requirements. Nutrition was consulted. Her regimen was titrated to achieve optimal glycemic control. She was continued on NPH in the am as well as an NPH sliding scale at night. She had a humalog sliding scale with meals. Her regimen was increased and by hospital day #4 her fingersticks were improved. She was discharged home and will have close outpatient management with ___ and the Diabetes in Pregnancy clinic. She was instructed to call with fingersticks greater than 200 for two hours. . During this admission, Ms ___ had an early OB ultrasound which showed a live IUP, size equal to dates. Prenatal labs were done and were unremarkable. She was seen by social services due to her uncertain pyschiatric history. Please see OMR note for details.
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10094902-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine <ATTENDING> ___. <CHIEF COMPLAINT> Right-sided abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> IV antibiotics <HISTORY OF PRESENT ILLNESS> ___ yo G0 presents with worsesned RLQ pain. Patient reports for past week has had pelvic pain, first on left side, now mainly on right side. She reports she was evaluated in OSH ED one week prior for pain and was told she had a negative workup with a small ovarian cyst and discharged home. Reports since that time pain has persisted, becoming worse on right and last night became severe with episode of emesis so presented to ___ ED. In ED patient had pelvic ultrasound as well as CT scan performed with CT scan concerning for possible bilateral ___, worse on right side. Patient reports not currently sexually active, last active one month prior. Had colposcopy with biopsies performed on ___ for LSIL Pap with negative biopsies. Denies any other GYN procedures. She has a Mirena IUD which has been in place for ___ years. Reports fever at home yesterday to 100.5. No fever on presentation. Episode of emesis as above. No further vomiting. Denies abnormal discharge, constipation, diarrhea, dysuria, abnormal vaginal bleeding. <PAST MEDICAL HISTORY> GYN Hx: - LMP: does not get period with Mirena IUD - Denies history of STI, pelvic infection - Previously sexually active with one partner, not sexually activity for past month - Denies history of abnormal or painful periods PMHx: Denies PSHx: Breast implants, Wisdom teeth extraction <ALLERGIES> - Morphine-> itching, hives <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, moderate tenderness to palpation over right upper quadrant, voluntary guarding (due to anticipation per patient), no rebound Ext: no TTP <PERTINENT RESULTS> Admission labs: . ___ 01: 45AM BLOOD WBC-12.1* RBC-4.09 Hgb-12.0 Hct-35.7 MCV-87 MCH-29.3 MCHC-33.6 RDW-13.0 RDWSD-41.3 Plt ___ ___ 01: 45AM BLOOD Neuts-79.1* Lymphs-9.5* Monos-10.6 Eos-0.2* Baso-0.2 Im ___ AbsNeut-9.53* AbsLymp-1.14* AbsMono-1.28* AbsEos-0.03* AbsBaso-0.03 ___ 01: 45AM BLOOD Glucose-84 UreaN-9 Creat-0.7 Na-136 K-3.7 Cl-100 HCO3-24 AnGap-16 . Relevant labs: . ___ 06: 03AM BLOOD WBC-8.7 RBC-3.68* Hgb-10.9* Hct-32.8* MCV-89 MCH-29.6 MCHC-33.2 RDW-13.0 RDWSD-42.8 Plt ___ ___ 07: 35AM BLOOD WBC-7.9 RBC-3.88* Hgb-11.1* Hct-34.6 MCV-89 MCH-28.6 MCHC-32.1 RDW-13.0 RDWSD-42.4 Plt ___ ___ 01: 15PM BLOOD ALT-10 AST-15 LD(LDH)-113 AlkPhos-55 Amylase-24 TotBili-0.4 ___ 01: 15PM BLOOD Lipase-28 ___ 01: 15AM BLOOD Genta-0.4* . Imaging: . ___ CT ABD & PELVIS WITH CO 1. Bilateral tubular hypodensities in the pelvis may suggest dilated fallopian tubes which may indicate salpingitis. Clinical correlation advised. 2. Non visualized appendix however no evidence of acute appendicitis. . ___ PELVIS, NON-OBSTETRIC 1. Right ovarian cyst measuring 2.6 x 2.2 x 2.2 cm. 2. Smaller cystic structure posterior to the cyst on the right, which may represent dilated tube/mild hydrosalpinx vs para-ovarian cyst. No internal echoes or other complicating features. No evidence of torsion. . ___ ABDOMEN US (COMPLETE ST 1. Mild fullness of the right renal collecting system may reflect presence of underlying reflux as bilateral ureteric jets are well demonstrated and no definite cause for obstruction is noted. There is no nephrolithiasis. 2. 8 mm echogenic hepatic lesion in the left lobe is incompletely characterized but likely represents a hemangioma. 3. No evidence of cholelithiasis or cholecystitis. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain do not take more than 4000mg total per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID please take while taking narcotic pain medication RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 4. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain do not drive while taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 5. MetRONIDAZOLE (FLagyl) 500 mg PO BID please take until ___, please do not drink alcohol while taking this medication RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 6. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*20 Tablet Refills: *0 7. Doxycycline Hyclate 100 mg PO Q12H Please take until ___, take with food but not dairy RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Tubo-ovarian abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for IV antibiotics. Your infection and symptoms have improved and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. Please take the doxycycline with food but not dairy and not drink alcohol while taking metronidazole. Take both antibiotic medications until ___. * Please notify your partner of the need to seek treatment for Chlamydia. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service with right-sided abdominal pain and imaging concerning for tubo-ovarian abscess. . She was treated with IV gentamicin and clindamycin initially. Her IUD was removed due to concern for tubo-ovarian abscess. Her leukocytosis resolved and her right lower quadrant pain improved. However she continued to have right upper quadrant pain and IV ampicillin was added on ___ given no subjective improvement. Liver function tests were all within normal limits, and an abdominal ultrasound showed a <1cm stable hepatic hemangioma, no cholelithiasis, no nephrolithiasis or urethral stone, minor dilation of right collecting system possibly due to reflux. She was transitioned to oral antibiotics on ___. Her right upper quadrant pain was reported to be ___ initially, though she was able to ambulate and carry out normal daily activities such as showering, and her pain improved to ___. . Patient was found to have a positive Chlamydia test. She was offered Expedited Partner Treatment but declined. She had one partner in the last three months, and agrees to notify her partner. . By hospital day 6, she was on oral antibiotics, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home to complete a total of 14 days of oral antibiotics, in stable condition with outpatient follow-up scheduled.
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10097195-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Depression and suicidal ideation <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal delivery <HISTORY OF PRESENT ILLNESS> This is a ___ yo G3P2002 at ___ GA who presented to L&D from the ED where she voluntarily presented with depression and suicidal ideation. She described depression after the death of her father, for whom she was the primary caretaker during a ___ year illness. She reported thoughts of suicide by crashing her car. Psychiatry consult was done and recommended inpatient admission with initiation of zoloft 10mg during an admission to the antepartum service. Please see their note for full details. PNC: ___ ___ A+/Ab-/RI/RPRNR/HBsAg-/HIV-/GBS- nl FFS, nl ERA, nl GLT prednisone for asthma in pregnancy <PAST MEDICAL HISTORY> ObHx: SVD x2 GynHx: no hx abn Pap or STI. PSYCHIATRIC HISTORY: Denies psychiatric history, history of hospitalizations, suicide attempts prior to father's death. Now sees a grief therapist ___ on a weekly basis. Presented to ___ with depression in ___ and was d/c home with plans to find a psychopharmacologist. Now sees ___ NP and started lamictal 25mg 3 weeks ago. No history of antidepressant use. PAST MEDICAL HISTORY: - sinus polyps s/p sinus surgery x3. PSH: - sinus surgery as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> father had hx bipolar disorder <PHYSICAL EXAM> VSS Afeb Gen: comfortable appearing woman with friend and husband bedside, sitter bedside Psych: speech goal-directed, affect appropriate, pls see psych note for full exam CV: RRR lungs: CTAB abd: soft, gravid, NT, ~7# SVE: 1/long/-2 Extr: NT, NE FHT: 130, mod var, +A, no decels Toco: no cxtns <PERTINENT RESULTS> ___ 03: 48PM GLUCOSE-134* UREA N-12 CREAT-0.6 SODIUM-138 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15 ___ 03: 48PM estGFR-Using this ___ 03: 48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 03: 48PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 03: 48PM WBC-7.6 RBC-3.91* HGB-12.4 HCT-35.8* MCV-91 MCH-31.6 MCHC-34.5 RDW-13.4 ___ 03: 48PM NEUTS-78.2* LYMPHS-16.7* MONOS-3.6 EOS-1.1 BASOS-0.4 ___ 03: 48PM PLT COUNT-348 ___ 03: 48PM URINE COLOR-Brown APPEAR-Cloudy SP ___ ___ 03: 48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-SM ___ 03: 48PM URINE ___ BACTERIA-RARE YEAST-NONE EPI-6 <MEDICATIONS ON ADMISSION> 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Pulmicort Inhalation 4. Itraconazole - unsure of dosage <DISCHARGE MEDICATIONS> 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Pulmicort Inhalation 4. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for Pain. 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 6. Dibucaine 1 % Ointment Sig: One (1) Appl Topical PRN (as needed) as needed for Pain. 7. Itraconazole Oral <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal delivery depression with suicidal ideation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine postpartum instructions
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Pt was admitted to OB service at 38 ___ ___ GA with depression and suicidal ideation. She had a sitter for her safety. Given her gestational age, we made plans for induction of labor so patient could continue with treatment of her depression. She underwent an uneventful induction of labor which results in a normal vaginal delivery of a male infant on ___. There were no complications. Her postpartum course was unremarkable except for her ongoing depression. Psychiatry recommends inpatient admission for her depression and plans are being made for her transfer. She is medically stable for discharge from the OB unit.
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10100177-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> SOB, decreased FM at 40w0d <MAJOR SURGICAL OR INVASIVE PROCEDURE> Spontaneous vaginal delivery <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ yo G2P1 @ 40+0 with SOB since evening prior to admission, unable to lie flat. Feeling some vaginal pressure but no contractions or VB. Notes fetal movement has been decreased but still feeling. No coughs, colds, or sick contacts. Notes HA, blurry spots in her vision. No RUQ pain. <PAST MEDICAL HISTORY> OBhx: - SVD after IOL @ term for likely preeclampsia, +magnesium. neonatal demise (known anomalies- obstructive uropathy with severe oligo) GynHx: - abnl pap ___: ASCUS/+HPV, last pap ___ wnl PMH: - +PPD ___ s/p INH x 2 mo, last CXR ___ PSH: - Denies <SOCIAL HISTORY> ___ ___ History: Mother: deceased, complications from surgery Father: alive, healthy Siblings: 2 sisters, 1 brother: alive and healthy FOB: alive and healthy <PHYSICAL EXAM> Physical Examination on Admission VS: Afeb HR: 70-90's previously 100-120's 114/75 26 98%RA Gen: tachpneic mildly 24 Card: regular, no murmurs, no rubs Resp: Clear bilaterally Abd: Soft, NT, gravid, EFW 7# SVE: 1/long/high Ext: NT, NE <PERTINENT RESULTS> ___ 01: 46PM BLOOD WBC-11.9* RBC-3.72* Hgb-11.5* Hct-33.1* MCV-89 MCH-30.8 MCHC-34.6 RDW-14.2 Plt ___ ___ 09: 30AM BLOOD WBC-12.3* RBC-3.39* Hgb-10.7* Hct-30.6* MCV-90 MCH-31.6 MCHC-34.9 RDW-13.3 Plt ___ ___ 09: 30AM BLOOD Glucose-104* UreaN-7 Creat-0.6 Na-138 K-4.2 Cl-107 HCO3-24 AnGap-11 ___ 01: 46PM BLOOD ALT-10 AST-15 CK(CPK)-38 ___ 01: 46PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 01: 46PM BLOOD Calcium-9.2 Phos-2.6* Mg-2.0 UricAcd-4.3 Echo ___: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is a small pericardial effusion anterior to the right ventricle with no echocardiographic signs of tamponade. CTA ___: Normal biventricular cavity size with normal regional and low normal global left ventricular systolic function. Small ?loculated anterior pericardial effusion without evidence of hemodynamic compromise. -No evidence of pulmonary embolism. -Small pericardial effusion, which can be seen with pericarditis. Echocardiogram may be obtained for further evaluation. -Heterogeneous appearance of the right kidney, which is incompletely visualized. Ultrasound may be obtained for further evaluation <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *2 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *2 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy, delivered <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting or any other concerns
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Ms ___ is a ___ yo G2P1000 at 40w0d with history of pre-eclampsia on previous pregnancy admitted with shortness of breath. Patient was initially worked up for concern of PE, and had a CTA which showed no evidence of pulmonary embolism and a small pericardial effusion. An echocardiogram was then obtained for further evaluation of pericardial effusion which showed normal biventricular cavity size with normal regional and low normal global left ventricular systolic function. Small loculated anterior pericardial effusion without evidence of hemodynamic compromise ejection fraction of 50% to 55%. Patient was then induced as was term and had had poor compliance with follow up and concern for etiology of pericardial effusion. Patient had a spontaneous vaginal delivery male infant on ___. Post-partum, patient recovered well, met all milestones and was discharged home in stable condition on post-partum day 2. Patient instructed to follow up with PCP at end of ___, and with Dr. ___ postpartum visit in 6 weeks.
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10100177-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> RLQ pain, chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnostic laparoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G2P___ presents with 3 days of RLQ pain and chest pain. Both started at ~same time while sleeping. RLQ pain severe ___, constant, radiates to RUQ, no aggrevating/relieving factors. Has been taking motrin with little effect. Chest pain is moderate, central, dull/constant, and associated with mild SOB. Feels like PP pericardial effusion that she had in ___. One episode blood-tinged sputum. Poor PO intake x24 hours. ROS positive for mild dysuria, new white discharge, one episode emesis today, constipation x3 days. ROS negative for fevers at home. <PAST MEDICAL HISTORY> OBhx: G2P2001 1. prior SVD after IOL @ term for likely preeclampsia, +magnesium. neonatal demise at 1 day of age(known anomalies- obstructive uropathy with severe oligo) 2. IOL in ___ after presenting with CP/SOB, CTA neg for PE, echo wnl -> SVD and spontaneously resolved Gyn hx: - last intercourse ~2 weeks ago, not using contraception - denies h/o STDs/PID - h/o abnl Pap, most recent normal reportedly ___ PMH: +PPD ___ s/p INH x 2 mo, last CXR ___ PSH: Denies Meds: motrin prn All: none Soc: lives with child, denies tob/illicit drugs, occ EtOH, feels safe <SOCIAL HISTORY> ___ ___ History: Mother: deceased, complications from surgery Father: alive, healthy Siblings: 2 sisters, 1 brother: alive and healthy FOB: alive and healthy <PHYSICAL EXAM> on presentation: on presentation 13: 38 98.1 132 ___ 100% 13: 50 117 115/78 22 100% 17: 09 T 102.1 125 113/58 22 100% 18: 02 T 101.1 111 129/74 18 100% - appears uncomfortable, lying in fetal position, in pain - CV RRR, no reproducible MSK pain - lungs CTAB, not working heard to breath - abd soft throughout, +voluntary guarding and very TTP in RLQ, less so in LLQ, no rebound - BME: exquisite CMT, no blood on glove - SSE per ___ resident: white discharge ? prurulent <PERTINENT RESULTS> Lactate: 0.6 UCG: Negative UA trace protein, few bacteria D-Dimer: ___ 11 ------------< 92 3.1 23 0.7 ALT: 8 AP: 60 Tbili: 0.2 Alb: 4.1 AST: 11 Lip: 13 HCG: <5 16.4 > 31.2 < 392 ___ N: 81.9 L: 14.4 M: 3.0 E: 0.4 Bas: 0.3 EKG reviewed by Dr. ___ sinus ___ RUQ US (wetread): Small hemangioma. Polycystic kidney disease. No evidence of gallstones/cholecystitis. CXR normal GC and CT negative blood and urine cx sent Pelvic US (wetread), reviewed with radiologist: Asymmetrically enlarged right ovary (4x3 cm) with peripheralization of the follicles. No arterial waveforms were identified. Normal venous waveforms were present. This raises the concern for right ovarian torsion; clinical correlation is required. 2. No discrete fluid collection or abscess. 3. No pelvic free fluid. <MEDICATIONS ON ADMISSION> motrin prn <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain Do not exceed 4000mg acetaminophen in 24 hours RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Every 4 hours Disp #*30 Tablet Refills: *0 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth Twice a day Disp #*28 Capsule Refills: *0 3. MetRONIDAZOLE (FLagyl) 500 mg PO BID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth Twice a day Disp #*28 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice a day Disp #*60 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic infection polycystic kidneys <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms ___, You were admitted to the GYN service after presenting to the ___ with fevers and abdominal pain. You underwent a diagnostic laparoscopy to rule out ovarian torsion, which showed no torsion of the ovary. You were treated with IV antibiotics to treat a possible pelvic infection. It was also noted on CT scan that you have polycystic kidneys and will need to follow up with your primary care physician for further management of this condition. An appointment has been made for you. Please take antibiotics as prescribed and follow up at scheduled appointments. Please follow the instructions below: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted with 3 days of RLQ pain and chest pain. Her initial presentation was notable for fever to 102 and tachycardia, exquisite TTP in RLQ and imaging concerning for torsion and no e/o appendicitis. She was started on antibiotics and taken to the OR for a diagnostic laparoscopy where her anatomy was grossly normal and no torsion observed. She was admitted to the floor with a diagnosis of presumed PID in the absence of other etiology. She was initially treated with IV gent & clinda, improved clinically and remained afebrile so was transitioned to oral doxy & flagyl to complete 14d of treatment. Regarding her chest pain, she likened it to a prior episode of pain peripartum when a small pericardial effusion was noted. Her EKG was notable for sinus tachycardia, and CTA was negative for PE but suggested borderline cardiomegaly. A medicine consult was requested and recommended no further workup of these issues as her pain had completed resolved. Finally, when doing the CTA, an abdomen/pelvis run-through was performed and polycystic kidneys were noted. The patient had no knowledge of this condition. Creatinine was normal. For this, follow-up with HCA was arranged.
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10100478-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> cervical mass biopsy minilaparomy transverse colostomy repair of enterotomy bilateral ureteral stent placement <HISTORY OF PRESENT ILLNESS> ___ G2P2 transferred from ___ with likely cervical CA, pelvic mass, large bowel obstruction, and bilateral ureteral obstruction with ARF, anemia. The pt began having abdominal discomfort around ___, which worsened significantly last week. Last week she also had two episodes of nausea and vomiting, with no flatus or bowel movements for approximately a week. She currently has no nausea. She also has lost a significant amount of weight since ___, though she does not know how much. Some shortness of breath a few days ago, but resolved since she received her PRBC transfusion. At ___, a CT scan was performed which showed a pelvic mass with bilateral pelvic sidewall invasion, distal large bowel obstruction, bilateral ureteral obstruction with severe bilateral hydronephrosis. She was also found to have ARF/azotemia with Cr of 1.6, thought to be post-obstructive due to ureteral compression + dehyration. She also had profound anemia with Hct 16.7, was briefly admitted to the ICU given this finding, and was tranfused 3 u PRBC's, with no evidence of acute intraabdominal bleeding. A pap smear was done by Dr. ___ Gyn, with preliminary pathology report consistent with squamous cell carcinoma of the cervix. The patient was transferred to ___ for gyn oncology admission. ROS: No chest pain/shortness of breath; weight loss as above; GI findings as above; some vaginal bleeding today since exam; no ___ pain or swelling <PAST MEDICAL HISTORY> Gyn: No prior gyn care or pap smears OB: SVD x ___ Med: No known medical problems, no medical care for many years Surg: No prior surgeries All: "Bad reaction" and vaginitis with PCN <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Father died of lung cancer, mother had lymphoma, aunt ?MI Physical ___: 99.2 130/62 93 18 95RA Severely cachectic woman in NAD RRR, somewhat decreased BS at bases Abd firmly distended with palpable mass, no fluid wave, tender to palpation, no rebound or guarding Pelvic normal external genitalia, palpable mass adjacent to and deep to cervix likely extending to pelvic sidewall bilaterally, some irregular texture to cervix which is deviated posteriorly and to the left by the mass, no palpable vaginal mucosal lesion. Per Dr. ___ exam, no fungating mass seen. Rectal deferred per pt request given multiple rectal exams at ___, per Dr. ___, fullness palpated in the region of the cervix on rectal exam, extending to the sidewall bilaterally. CT ___: Ill-defined pelvic mass w/ bilateral pelvic sidewall invasion. Severe bilateral hydronephrosis, distal large bowel obstruction, retroperitoneal lymphadenopathy, probable peritoneal carcinomatosis. The cervix appears enlarged and lobulated. The left ureteral obstruction has been long-standing given the left renal atrophy. Although the large bowel is obstructed w/ signficant cecal dilatation, no small bowel dilatation is identified. There are bilateral nodular findings wihtin both adrenal glands which could be related to adrenal hypertrophy, however metastatic disease cannot be excluded. PA/Lat CXR: Normal chest, no acute process KUB: There is some gas in the rectum, mild to moderate distention of the small bowel loops. There is no evidence of free air. Distal colon obstruction. Labs ___: Troponin <0.05 x 3 ALT 11 AST 4 INR 1.18 -> 1.06 Na 137 K 4.2 Cl 103 HCO3 18 BUN 34 Cr 1.6 WBC 14.5 Hct 16.7 -> 33.7 after transfusion Plts 515 <PERTINENT RESULTS> *** URINE: ___ 10: 16PM URINE RBC-13* WBC-167* BACTERIA-FEW YEAST-NONE EPI-0 ___ 10: 16PM URINE BLOOD-SM NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG *** URINE CULTURE (Final ___: ESCHERICHIA COLI >100,000 ORGANISMS/ML.. CIPROFLOXACIN---------<=0.25 S *** BLOOD on admission: ___ 10: 50PM ___ PTT-29.9 ___ ___ 10: 50PM WBC-11.3* RBC-4.40 HGB-10.3* HCT-31.5* MCV-72* MCH-23.3* MCHC-32.6 RDW-23.1* ___ 10: 50PM CEA-125* CA125-104* ___ 10: 50PM calTIBC-367 FERRITIN-69 TRF-282 ___ 10: 50PM ALBUMIN-3.5 CALCIUM-8.4 PHOSPHATE-2.3* MAGNESIUM-1.9 IRON-14* *** BLOOD during hospital stay: ___ 06: 40AM BLOOD WBC-7.6 RBC-3.84* Hgb-9.1* Hct-27.9* MCV-73* MCH-23.6* MCHC-32.4 RDW-23.6* Plt ___ ___ 06: 00AM BLOOD WBC-6.5 RBC-3.34* Hgb-7.9* Hct-27.9* MCV-83# MCH-23.5* MCHC-28.2*# RDW-22.7* Plt ___ ___ 08: 34AM BLOOD WBC-6.9 RBC-3.52* Hgb-8.2* Hct-26.5* MCV-75*# MCH-23.3* MCHC-31.1# RDW-24.5* Plt ___ ___ 06: 42AM BLOOD WBC-8.2 RBC-3.49* Hgb-8.1* Hct-26.7* MCV-77* MCH-23.3* MCHC-30.4* RDW-22.7* Plt ___ ___ 05: 27AM BLOOD WBC-9.9 RBC-3.55* Hgb-8.4* Hct-25.9* MCV-73* MCH-23.6* MCHC-32.4 RDW-24.6* Plt ___ ___ 06: 10AM BLOOD WBC-9.4 RBC-3.40* Hgb-8.1* Hct-24.8* MCV-73* MCH-23.9* MCHC-32.8 RDW-25.2* Plt ___ ___ 07: 07AM BLOOD WBC-9.4 RBC-3.39* Hgb-8.0* Hct-25.1* MCV-74* MCH-23.5* MCHC-31.7 RDW-25.0* Plt ___ ___ 07: 02AM BLOOD WBC-14.9*# RBC-3.64* Hgb-8.5* Hct-27.9* MCV-77* MCH-23.3* MCHC-30.4* RDW-23.1* Plt ___ ___ 05: 32AM BLOOD WBC-10.3 RBC-3.25* Hgb-7.6* Hct-23.5* MCV-72* MCH-23.4* MCHC-32.4 RDW-24.8* Plt ___ ___ 12: 32PM BLOOD WBC-11.6* RBC-3.35* Hgb-7.8* Hct-24.9* MCV-75* MCH-23.2* MCHC-31.2 RDW-25.1* Plt ___ ___ 06: 15AM BLOOD WBC-11.4* RBC-3.23* Hgb-7.6* Hct-23.5* MCV-73* MCH-23.4* MCHC-32.3 RDW-24.9* Plt ___ ___ 10: 50PM BLOOD Glucose-105 UreaN-27* Creat-1.4* Na-140 K-4.2 Cl-109* HCO3-21* AnGap-14 ___ 06: 40AM BLOOD Glucose-100 UreaN-27* Creat-1.6* Na-139 K-5.2* Cl-108 HCO3-21* AnGap-15 ___ 10: 35AM BLOOD Glucose-107* UreaN-28* Creat-1.8* Na-138 K-5.2* Cl-106 HCO3-21* AnGap-16 ___ 06: 00AM BLOOD Glucose-691* UreaN-36* Creat-1.9* Na-133 K-5.0 Cl-104 HCO3-19* AnGap-15 ___ 08: 34AM BLOOD Glucose-108* UreaN-38* Creat-1.9* Na-134 K-4.3 Cl-107 HCO3-20* AnGap-11 ___ 06: 42AM BLOOD Glucose-118* UreaN-36* Creat-1.5* Na-136 K-3.9 Cl-106 HCO3-21* AnGap-13 ___ 05: 27AM BLOOD Glucose-104 UreaN-31* Creat-1.2* Na-135 K-3.5 Cl-103 HCO3-21* AnGap-15 ___ 06: 10AM BLOOD Glucose-101 UreaN-32* Creat-1.1 Na-137 K-3.6 Cl-105 HCO3-24 AnGap-12 ___ 07: 07AM BLOOD Glucose-105 UreaN-32* Creat-1.2* Na-136 K-3.9 Cl-104 HCO3-24 AnGap-12 ___ 07: 02AM BLOOD Glucose-283* UreaN-36* Creat-1.2* Na-138 K-5.1 Cl-106 HCO3-24 AnGap-13 ___ 05: 32AM BLOOD Glucose-131* UreaN-40* Creat-1.3* Na-140 K-4.1 Cl-103 HCO3-27 AnGap-14 ___ 06: 15AM BLOOD Glucose-96 UreaN-38* Creat-1.1 Na-139 K-4.5 Cl-106 HCO3-25 AnGap-13 *** RADIOLOGY: ABDOMEN (SUPINE & ERECT) ___ 11: 13 ___ IMPRESSION: Mottled gas pattern of the distended cecum, suspicious for ischemia or infection. COLON (GASTROGRAF) ___ 10: 32 AM IMPRESSION: Severe narrowing of the sigmoid colon by surrounding pelvic mass. CT PELVIS W/CONTRAST ___ 10: 32 AM CT OF THE ABDOMEN WITH IV CONTRAST: The visualized portion of the lung bases demonstrates small bilateral pleural effusion and dependent atelectatic changes at both lung bases. No pulmonary nodule is visualized. The visualized portion of the heart and great vessels appears normal. The right lobe of the liver is hypoenhancing compared to the left lobe. The gallbladder, spleen, right adrenal gland have a normal appearance. The left adrenal gland contains a relatively hypodense nodule within it. The left kidney is severely atrophic. Both kidneys demonstrate moderate degree of hydroureteronephrosis, the point of obstruction being in the lower pelvis. The pancreas has a mildly prominent duct, measuring ___ile duct is not enlarged. The stomach, duodenum, multiple loops of small bowel and large bowel appear dilated. The cecum is specifically remarkable, questionable pneumatosis is visualized within the cecum. Free fluid is noted around the liver. No free air is visualized within the abdomen. The largest node is noted in the left rtroperitoneum measuring 14 x19mm. The aorta demonstrates severe degree of calcification with no evidence of aneurysm or thrombosis. CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder contains a Foley catheter and a small amount of air. The rectum contains stool. The sigmoid colon is being encased by a large heterogeneous-appearing enhancing structure within the left side of the pelvis that is apparently arising at the expected location of the uterus. No normal uterine tissue is noted. This mass measures 42 x 52 mm. There is moderate- to- severe dilatation of the sigmoid colon proximal to the site of obstruction. Small amount of free fluid is noted within the pelvis. No pathologically enlarged pelvic or inguinal nodes are noted. BONE WINDOWS: No concerning lytic or sclerotic lesions are identified. IMPRESSION: 1. Large bowel obstruction due to large heterogeneous mass in the left pelvis. The mass appears to arising from the expected location of the cervix, differential diagnosis includes an ovarian primary. The appearance is atypical for a colon primary. Maximum distention is noted within the cecum with questionable pneumatosis within the cecal wall raising the possibility of ischemia. 2. Bilateral hydroureteronephrosis with the point of obstruction being the pelvic mass. The left kidney is severely atrophic. 3. Small bilateral pleural effusions. 4. Ascites is visualized within the peritoneal cavity. 5. The liver demonstrates geographic disparity in enhancement with the part of the right lobe of the liver being relatively hypoenhancing compared to the rest of the liver. This appearance is most likely related to a perfusion abnormality. CHEST PORT. LINE PLACEMENT ___ 12: 20 ___ IMPRESSION: 1. Right-sided PICC with tip at the cavoatrial junction. 2. Extensive subcutaneous emphysema, please clinically correlate (postop) ABDOMEN (SUPINE & ERECT) ___ 1: 28 ___ SUPINE AND UPRIGHT VIEWS OF THE ABDOMEN: Bilateral ureteral stents are present in the expected positions. Multiple air-fluid levels with minimally distended loops of bowel likely represent ileus. The cecum appears slightly less distended than on prior imaging. Pleural effusions and atelectasis is present at both lung bases. *** PATHOLOGY: Cervix, biopsy: Invasive squamous cell carcinoma, moderately differentiated. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp: *40 Tablet(s)* Refills: *0* 2. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed for nausea. Disp: *30 Tablet, Rapid Dissolve(s)* Refills: *0* 3. PICC care PICC line care per NEHT protocol 4. Outpatient Lab Work Weekly chem 10. Please fax to the office of Dr. ___, ___. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> cervical mass large bowel obstruction bilateral ureteral obstruction <DISCHARGE CONDITION> Stable: afebrile, stable vitals, ambulant, pain controlled, voiding <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor if you have any fever >101, chills, nause/vomiting, inability to keep fluids/food down, abdominal pain that is not controlled with medications, or if you notice any redness, increased pain, or pus/foul smelling discharge from your ostomy site. Please call your doctor if you have vaginal bleeding that soaks greater than one pad per hour or if you have any other concerns. Please keep all of your scheduled appointments. Please
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Ms. ___ was admitted to the gynecologic oncology service for large bowel obstruction and bilateral ureteral obstruction secondary to a cervical mass. On HD#2, the patient underwent a bilateral ureteral stent placement by the urology team, an exam under anesthesia and cervical biopsy of pelvic mass by the gynecology oncology team and a transverse loop colostomy and oversew of small-bowel enterotomy by the general surgery team. The procedures were uncomplicated. The details of the surgery are available in seperate operative notes elsewhere. The patient did well postoperatively. She received a PICC line on POD#1 and was started on TPN. Her diet was slowly advanced and the patient was tolerating regular diet by POD#5. She however started to feel nauseated after the bridge removal from the colostomy on POD#6, and did not take any fluids/food on POD#7, but resumed a clear liquid diet on POD#8. She was tolerating a full liquid diet with small amount of regular diet on POD#9. Her TPN was titrated daily according to her electrolytes status and was weaned from a 24 cycle to a 12 hour cycle without problems. She remained on TPN for the hospital stay, and was discharged home with continuation of paraental nutrition. She was ambulant without assistance and voiding spontaneously. Her pain was well controlled initially on dilaudid PCA and remained well controlled after being transitioned to oral medications. The patient was seen by the ostomy nurse multiple times and educated on ostomy care while in house. The ___ hospital course was also notable for the following: * UTI: She was noted to have a urinary tract infection on admission and was started on ciprofloxacin IV x 3days. She completed the antibiotic course without complications, and remained afebrile throughout her hospital stay. * Acute renal failure/azotemia: The patient on arrival was noted to have an elevated creatinine at 1.4mg/dL secondary to post-obstructive acute renal failure and dehydration. Aggressive IV hydration was started and urology was consulted for bilateral stent placements. Post procedure, her creatinine was followed daily. The creatinine rose to a peak of 1.9 on POD# 2, but subsequently normalized. She remained on maintenance IVF and no further intervention was thus required. * Anemia: The patient was noted to have a hct of 31.5% on admission, status post 3units of PRBC at the outside hospital. Postoperatively, her hct was followed and noted to stabilize around 25%, with equilibration of fluids. The patient was discharged home on POD#9 in stable condition: afebrile, stable vitals, tolerating oral intake, ambulant, voiding spontaneously. She was discharged with services to assist with ostomy care as well as the TPN. She is to follow up with gyn oncology service, as well as with the general surgery team for follow up, including discussion about the end point of TPN, and with hematology oncology team to discuss further treatment planning.
| 3,677
| 651
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10100478-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> nausea/vomiting, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Percutaneous endoscopic gastrostomy tube placement <HISTORY OF PRESENT ILLNESS> ___ P2 with Stage IIIB squamous cell cervical CA, ___ s/p mini-lap transverse colostomy, repair of enterotomy for large bowel obstruction, and b/l ureteral stent placement. The pt presented to ___ early yesterday with abdominal pain and distention. An NGT was placed at ___, which has essentially relieved all of the patient's pain. Denies any nausea/vomiting. She has had some ostomy output of gas and stool. She denies any fever/chills. <PAST MEDICAL HISTORY> PGynHx: IIIB Cervical CA as above POBHx: SVD x 2 PMH: 1. Post-obstructive ARF - ureteral stents in place 2. Anemia PSH: ___ Laparoscopic -> Mini-lap transverse loop colostomy, oversewn small-bowel enterotomy, bilateral ureteral stent placement, biopsy of cervical mass <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Father died of lung cancer, mother had lymphoma, aunt ?MI Physical ___: AF VSS severely cachetic, NG tube in place rrr no m/r/g lungs clear to auscultation bilaterally abdomen: softly distended; stoma pink and well perfused, ostomomy with brown non bloodly output ext thin, no edema <PERTINENT RESULTS> RADIOLOGY Final Report CT PELVIS W/CONTRAST ___ 3: ___BDOMEN: There is mild dependent atelectasis at the lung bases bilaterally. The liver enhances homogeneously. Previously noted perfusion abnormality is no longer seen. Mild intrahepatic biliary ductal dilatation is unchanged. Trace ascites around the liver and throughout the abdomen is slightly decreased. The gallbladder is distended, but there is no wall thickening or pericholecystic fluid. Mild extra-hepatic common bile duct and pancreatic duct prominence is unchanged. The pancreas is otherwise normal. The spleen and adrenal glands are normal. A nasogastric tube is in place within the stomach. There are multiple dilated loops of small bowel, measuring up to 4 cm in diameter, with multiple air- fluid levels, consistent with small-bowel obstruction. Contrast has only progressed through to mid-jejunum, somewhat limiting evaluation of distal small bowel. The transition point is difficult to determine precisely, but likely lies in the right lower abdomen, adjacent to the large pelvic mass. In the region of the terminal ileum, the small bowel loops are relatively decreased in caliber, and the colon is nearly completely decompressed. There has been interval transverse colostomy, and air and stool are seen throughout the colon to the level of the 'ostomy. There is no sign of pneumatosis or other vascular compromise. There is no fluid collection or other evidence of abscess formation. Bilateral nephroureteral stents have been placed. On the right, hydronephrosis has improved, is now mild. Right kidney enhances and excretes contrast normally. On the left, however, moderate hydronephrosis is unchanged, and the left kidney does not normally enhance, and excretes no contrast. There is no free intraperitoneal air. No intra-abdominal lymphadenopathy is seen. CT PELVIS: Large heterogeneously enhancing mass in the midline pelvis, encasing remaining loops of large bowel, and both ureters is grossly unchanged in size and appearance. Interval transverse colostomy has been performed, as described above. Bilateral nephroureteral stents extend into the urinary bladder, which is partially decompressed, with a Foley catheter balloon in place. Small amount of free pelvic fluid is decreased from previous exam. OSSEOUS STRUCTURES: No suspicious osteolytic or sclerotic lesions are seen. IMPRESSION: 1. High-grade distal small bowel obstruction. The exact transition point is difficult to identify, as contrast has only progressed to mid jejunum; however, it is likely located in the right lower quadrant, in the region of the large heterogeneous pelvic mass, just prior to insertion into the colon, which is nearly completely decompressed. 2. Unchanged appearance of large heterogeneous pelvic mass, which continues to encase both ureters, as well as the remaining pelvic loops of large bowel. 3. Delayed enhancement of the left kidney, and unchanged moderate left hydronephrosis, despite nephroureteral stent placement. This raises concern for stent malfunction due to extrinsic compression from the mass. The right kidney enhances and excretes contrast, and right hydronephrosis is slightly decreased. 4. Unchanged mild intrahepatic biliary ductal dilatation, and mild gallbladder distention <MEDICATIONS ON ADMISSION> TPN 12h cycle <DISCHARGE MEDICATIONS> 1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed): Flush PICC, heparin dependent, flush with 10ml NS followed by heparin as above, daily and PRN per lumen. Order was filled by pharmacy with a dosage form of Syringe and a strength of 10 UNIT/ML . Disp: *100 ML(s)* Refills: *2* 2. PICC Care ___ line care per NEHT protocol 3. Outpatient Lab Work Weekly chem 10. Please fax to the office of Dr. ___, ___. 4. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 5. Bedside commode at home 6. Morphine 10 mg/5 mL Solution Sig: ___ mL PO Q2H (every 2 hours) as needed for pain. Disp: *qs mL* Refills: *0* 7. Artificial Saliva 0.15-0.15 % Solution Sig: ___ MLs Mucous membrane q 4 hr prn. Disp: *100 ML(s)* Refills: *2* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Advanced cervical cancer <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor if you have any fever >101, chills, nause/vomiting, inability to keep fluids/food down, abdominal pain that is not controlled with medications, or if you notice any redness, increased pain, or pus/foul smelling discharge from your ostomy site. Please call your doctor if you have vaginal bleeding that soaks greater than one pad per hour or if you have any other concerns.
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Ms. ___ was transferred from an OSH and readmitted to the ___ for small bowel obstruction on POD #15. She appeared comfortable on arrival to the ___, apparently so after NGT placement at the OSH. She required no pain medication. She underwent a CT scan that confirmed SBO without evidence of ischemia as well as raised concern for L stent malfunction due to extrinsic compression from the mass. For further details of the imaging study, please see the pertinent results section. * Small bowel obstruction The patient remained with NGT in place, and did well after the NGT was clamped. She remained without nausea/emesis nor abdominal pain. Discussion regarding decompression with percutaneous endoscopic gastrostomy was had, and the patient opted for this procedure. This procedure was performed on HD#3/POD#17. Details of the procedure are available elsewhere. Meanwhile, the patient remained on TPN. The patient was tolerating full liquids at the time of discharge. * Anemia Ms. ___ was found to be anemic, with a hematocrit of 21. She was then transfused two units of PRBC. Her posttransfusion hematocrit was appropriate and remained stable throughout her hospital stay. Guaiac of the stool was negative. * Acute renal failure: Her creatinine was elevated on arrival at 1.6. Bilateral ureteral stents that were placed on ___ during her previous admission were evaluated by the CT scan. The left one was noted to be malfunctioning. Urology was consulted, and recommended stent replacement, which the patient declined. Further recommendation for percutaneous nephrostomy tube was discussed, and was also declined per patient. Her creatinine meanwhil had declined to 1.1. No further actions were taken during this hospital stay. * Advanced cervical cancer The patient was visited by the hematology-oncology team as well as the palliative care team. It was discussed that considering palliative chemotherapy is difficult in her situation, given her ___ nutritional and functional status. Cisplatin is active in advanced cervical cancer, however this is complicated by possible renal toxicity. Given that the goals of care are palliative, it was noted that exceptional caution should be taken to not add to her symptoms or toxicity for marginal benefit if any. * Code Status change from full code to DNR/DNI was made on HD#1 after a family meeting. The patient was discharged home on HD7 with services with plans to transition to palliative care.
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10100712-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine <ATTENDING> ___ <CHIEF COMPLAINT> Elevated BP's <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 at 35+5 who was sent to OB triage for elevated BPs. Denies HA, visual changes, RUQ pain. PNC: ___: ___ by ___ Labs: A+/Ab-/RI/RPRNR/HbsAg-/GBS unk Screening: Nl ERA, nl AFP, FFS notable for LV focus Issues: 1) AMA: Screening as above 2) Hx oligo in first pregnancy 3) Hx of LSIL. Last pap ___ neg with +HR/LR HPV. Will rpt PP. 4) Hx asthma, asx now, not required albuterol inhaler 5) Hx of C/S for NRFHR. Pt would like repeat C/S. <PAST MEDICAL HISTORY> POBHx: ___ Primary LTCS for NRFHT after IOL for oligo, 6#11oz PGynHx: History of LSIL Pap. Denies STIs. PMH: Denies PSH: LTCS x ___ Meds: PNV, albuterol, All: Codeine (itching) SH: ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Physical exam: VS: 137/84, 130/87, 128/83, 138/88, 118/70 Gen: Well NAD Abd: Soft, NT, gravid SVE: Deferred Ext: NT, no edema <PERTINENT RESULTS> ___ 05: 37PM WBC-10.6 RBC-3.95* HGB-13.1 HCT-36.5 MCV-92 MCH-33.0* MCHC-35.7* RDW-12.8 ___ 05: 37PM PLT COUNT-265 ___ 05: 37PM ALT(SGPT)-12 AST(SGOT)-22 ___ 05: 37PM URIC ACID-4.5 ___ 05: 37PM CREAT-0.7 24 hour urine collection completed at home after discharge <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> PNV <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> gestational hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Continue to collect your urine until 730pm. You will need to bring the urine in to OB triage (10 ___ on ___. Rest as much as possible Call for: - Headaches, visual changes, upper abdominal pain - Decreased fetal movement - contractions, loss of fluid, vaginal bleeding
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Ms. ___ was admitted to the ___ service to monitor her BP's and initiate a 24h urine. Overnight her BP's were <140/90 and she remained asymptomatic. Fetal testing was reassuring. She was discharged home with instructions to complete the 24h urine collection at home and bring in for analysis
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10104133-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Novocain <ATTENDING> ___ ___ Complaint: Rupture of the fetal membranes at term <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> The patient is a ___ year old G2 P1 with a history of DVT on heparin who presented at term with ruptured membranes in labor. <PAST MEDICAL HISTORY> Anxiety s/p LEEP Endometriosis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Aunt died of pulmonary embolus. <PHYSICAL EXAM> AVSS cervix ___ <PERTINENT RESULTS> ___ 03: 22AM WBC-8.7 RBC-4.13* HGB-12.4 HCT-34.5* MCV-84 MCH-29.9 MCHC-35.8* RDW-13.2 ___ 03: 22AM PLT COUNT-203 ___ 03: 22AM ___ PTT-42.7* ___ ___ 03: 22AM ___ <MEDICATIONS ON ADMISSION> heparin sulfate <DISCHARGE MEDICATIONS> 1. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous once a day. Disp: *40 * Refills: *2* 2. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p vaginal delivery <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> No heavy lifting Use lovenox as directed
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The patient went into labor and had an uncomplicated vaginal delivery. She had an uncomplicated postpartum course and was restarted on lovenox. She is to be discharged on her ___ postpartum day.
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10106315-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> breech presentation <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary c-section <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old at term who presents for scheduled c-section for breech presentation. <PAST MEDICAL HISTORY> G1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> on discharge: afebrile, VSS NAD, comfortable RRR, CTAB abd soft, NT, ND, incision intact minimal peripheral edema minimal vag bleeding/lochia <PERTINENT RESULTS> ___ 03: 33PM BLOOD WBC-10.4 RBC-4.38 Hgb-12.8 Hct-36.9 MCV-84 MCH-29.2 MCHC-34.7 RDW-15.1 Plt ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for Pain. Disp: *30 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p primary c section for breech <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see nursing instructions
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Ms. ___ is a ___ year old G1 now P1 who was admitted with ? labor on ___ at term, however, ultrasound on L&D showed breech presentation so she underwent primary caesarean section. Please see op note for full details. Her post-op course was complicated by temp of 101.3 on postpartum day 1, with fundal TTP, and she was started on gentamicin and clindamycin. She defervesced and antibiotics were discontinued after 24 hours. However, on postpartum day 3, she again spiked to 100.9, so she was treated with an additional 24 hours of IV antibiotics. She defervesced almost immediately. She was discharged to home in good condition on postpartum day 5.
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10113381-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Celebrex / Naproxen / Salsalate <ATTENDING> ___. <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, tumor debulking, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, ileocecectomy w/ primary re-anastamosis <HISTORY OF PRESENT ILLNESS> This is an ___ year old female with 81 HTN/HLD and recently discovered ovarian mass, likely cancer, who presented for planned ex-lap and debulking. The mass was identified after presentation to PCP with vague abd cramping, CT scan showed multiseptated soft tissue mass arising from the pelvis measuring 16 x 10 x 9 cm and a second measuring 4.6 x 4.9 x 3.6 cm in the ant pelvis, no evidence of ascites and no evidence of metastasis, no LAD. There was no bowel obstruction but there was some compression of rectosigmoid. CA-125 was 343. Debulking today was more extensive than expected and included bilateral salphingooophorectomy, total abd hysterectomy, omentectomy, and ileocecectomy with primary re-anastamosis. The mass was incompletely resected, roughly 80% removed. Pain control was achieved with epidural and dilaudid PCA. She tolerated the procedure well, total blood loss estimated 500cc and she was given 3000cc LR, 2units PRBC's post op, and 25gm 5% albumin x1. In the PACU her pressures were consistently in the high 90's to low 100's. Her urine output was noted to be low at ___. She was mentating well and otherwise had no complaints. Pain service was contacted and reduced her epidural bupivicaine dose to 5mg/hr. Review of systems: (+) Per HPI (-) Denies fever, chills. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, abdominal pain. Denies arthralgias or myalgias. Denies rashes or skin changes. <PAST MEDICAL HISTORY> hypertension hyperlipidemia GERD borderline anemia Gastritis related to ASA, NSAIDs subclinical hypothyroidism DJD obesity Past Surgical History: Confirmed with HCP s/p b/l total knee s/p T&A cataract surg ___ s/p breast biopsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother died from CAD with history of hypertension and first MI in her ___, also pacemaker. Father died of pneumonia with a history of hypertension. One brother died from stomach CA and emphysema and another brother, who was ___ impaired, died of a MI Also family history of macular degeneration. <PHYSICAL EXAM> On Admission: Vitals- T96.0 98/51 HR 64 RR 18 O2 99% 2LNC General: Alert, oriented, no acute distress HEENT: dry MM, NGT in place draining bilious fluid Neck: supple, JVP not elevated Lungs: Clear to auscultation anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Midline incision dressed, c/d/i, nontender, soft, absent bowel sounds. GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema <PERTINENT RESULTS> On Admission: ___ 01: 05PM BLOOD WBC-4.0# RBC-4.18* Hgb-11.4* Hct-34.7* MCV-83 MCH-27.3 MCHC-32.9 RDW-13.9 Plt ___ ___ 04: 30PM BLOOD ___ PTT-25.0 ___ ___ 12: 00PM BLOOD UreaN-32* Creat-1.2* ___ 01: 05PM BLOOD Calcium-7.3* Phos-4.5 Mg-1.4* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. Pravastatin 20 mg PO HS 5. Ranitidine 150 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Zolpidem Tartrate 5 mg PO HS: PRN insomnia 8. Docusate Sodium 100 mg PO BID <DISCHARGE MEDICATIONS> 1. Atenolol 25 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. Acetaminophen 1000 mg PO Q6H: PRN pain RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 5. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills: *2 6. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*40 Tablet Refills: *0 7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills: *0 8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral daily 9. I-Caps (antiox#10-om3-dha-epa-lut-zeax) ___ mg oral daily 10. Ranitidine 150 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Zolpidem Tartrate 5 mg PO HS: PRN insomnia 13. Cephalexin 500 mg PO Q6H Duration: 5 Days RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp #*20 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . . Abdominal instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 8 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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___ with HTN/HLD who presented status-post sub-optimally debulked ex-lap, BSO, TAH, omentectomy, ileocecectomy with primary re-anastomosis for likely ovarian cancer with post-operative hypotension. She was admitted post-op to the ICU. ICU Course: # Hypotension Post-operative blood pressure was in the ___ she typically runs in the 110-120s/60s. This was felt to be secondary to significant intra-operative fluid shifts as well as bupivicaine epidural for pain control. She had no evidence of significant blood loss or infection. She was bolused with albumin for MAP < 65 and continued on maintenance crystalloid. The bupivicaine epidural was dose-reduced and discontinued when her pain was adequately controlled. Her blood pressures improved. She never required pressors. # Abdominal Mass Status post BSO, TAH, omentectomy, ileocecectomy with primary re-anastomosis. She received prophylactic cefazolin and flagyl two doses each. Pain was controlled with a bupivicaine epidural and dilaudid pca, which were managed by the acute pain service. She was continued on bowel rest. # GERD: Held ranitidine until taking PO. # Insomnia Held zolpidem while hospitalized. # Code Status The patient was DNR/DNI, but in the perioperative period she was Full Code, which confirmed with ___ who is patient's neice and secondary HCP. Primary HCP is ___ ___, patient's sister in law and ___ mother, and with whom the patient lives. Per ___ prefers to be secondary. ----------------- Floor course The patient was called out of the ICU on ___. On POD #4, her foley was d/c'ed in the setting of adequate urine output, however it was replaced after she failed a voiding trial. She had some nausea overnight, and an EKG was ordered which showed new t-wave inversions in leads V1-3, however the pt's nausea subsided and she was otherwise asymptomatic. Cardiology was consulted and recommended trending troponins and repeating EKG. POD #5, her AM troponin came back at 0.15 with a normal CK-MB of 4. The pt remained asymptomatic w/ no CP/SOB, no n/v, and she continued to sat well on RA and was not tachycardic. In consultation with cardiology, a heparin drip was started as well as ASA and a statin for the treatment of NSTEMI. An echocardiogram was ordered. She was started on a heparin drip, ASA, and a statin. Bilateral basilar crackles were noted on lung exam, prompting a CXR which revealed bilateral pleural effusions. She was given IV lasix and remained stable saturating fine on room air. POD #6, her troponin peaked at 0.23 early in the AM. She was kept NPO secondary to nausea. She had an echocardiogram which showed a LVEF >55%, mild aortic regurgitation, and a dilated ascending aorta. POD #7, her heparin drip was discontinued after 48 hrs per cardiology's recommendations. SC lovenox was re-started for post-operative DVT prophylaxis. Her bp was controlled with her home medications (HCTZ, atenolol, and lisinopril). Some wound cellulitis was noted on exam, and cefazolin 1g IV q12 was started. She had several episodes of loose stools, prompting us to send for C. diff toxin, which came back negative. She was given loperamide for her diarrhea. LFTs wnl, lipase 208, amylase 100 POD #8, nutrition was consulted given her lack of adequate po intake, and she was started on PPN. Her incisional erythema did not increase. POD #9, she was transitioned to clears. Her wound was opened as there was serous drainage from the upper portion of the incision. A hematoma was evacuated and fascia was found to be intact. The wound was dressed with dry 2" kerlex BID. POD #10, she was transitioned to full liquids/toast and crackers, and med's were changed to po. POD #11, she was transitioned to a regular diet. PPN was discontinued. Diarrhea had subsided. Arrangements were made for placement of a wound vac. On POD #12, the day of discharge, she was tolerating a regular diet, voiding spontaneously, ambulating, and passing gas. She was discharged home with a plan for placement of wound vac.
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10113381-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Celebrex / Naproxen / Salsalate <ATTENDING> ___. <CHIEF COMPLAINT> Nausea/vomiting. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Bedside I/D of inferior portion of wound with drainage of 25 cc seroma. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year-old G0 ___ s/p TAH/BSO, omentectomy, ileocecetomy with reanastomosis who presented for nausea, vomiting, abdominal pain, and SOB ___. She reported having one episode of emesis ___, and then again on ___, she continued to feel nauseous and had not had much to eat. She denied any chest pain or diaphoresis upon presenting. Given that these symptoms were similar to what she felt when she was diagnosed with NSTEMI, she called and presented for evaluation. Overall, she was feeling better upon being admitted to the ED. She had a mild headache which improved shortly after presenting to the ED, and she denied any dysphagia, focal numbness orweakness, or difficulty emptying her bladder. At the time she continued to have incisional pain and had pain in the area of her inferior incision since it was I&D'ed in the office by Dr. ___ on ___, and she continued taking keflex as prescribed. She reported passing flatus and had a BM ___. She denied any fevers or dizziness but had subjective chills ___. <PAST MEDICAL HISTORY> hypertension hyperlipidemia GERD borderline anemia Gastritis related to ASA, NSAIDs subclinical hypothyroidism DJD obesity Past Surgical History: Confirmed with HCP s/p b/l total knee s/p T&A cataract surg ___ s/p breast biopsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother died from CAD with history of hypertension and first MI in her ___, also pacemaker. Father died of pneumonia with a history of hypertension. One brother died from stomach CA and emphysema and another brother, who was ___ impaired, died of a MI Also family history of macular degeneration. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm pulm: clear to auscultation bilaterally abd: soft, nontender, nondistended. Superior aspect of abdominal wound without erythema or induration, with woundvac in place. Inferior aspect of wound with serous drainage, packed with plain gauze with bandage in place without erythema or purulent drainage. Middle portion of incision healing well without erythema or induration. ___: nontender, nonedematous <PERTINENT RESULTS> ___ Blood cultures drawn, results pending at time of discharge. ___ CT Abdomen showed (prelim read, final pending at discharge): 1. Rim enhancing fluid collection with surrounding fat stranding in the midline anterior abdominal wall at the level bladder, about 10 cm inferior to the umbilicus. Findings consistent with an abscess versus possible postsurgical changes. 2. Trace ascites and intra-abdominal fat stranding, while findings may be postsurgical cannot rule out an infectious process in the right clinical setting. No drainable collection is seen intra-abdominally. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. Ranitidine 150 mg PO DAILY 5. Zolpidem Tartrate 5 mg PO HS: PRN Insomnia 6. Vitamin D 1000 UNIT PO DAILY 7. Atorvastatin 80 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Atenolol 25 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. Ranitidine 150 mg PO DAILY 5. Zolpidem Tartrate 5 mg PO HS: PRN Insomnia 6. Aspirin 81 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth three times a day Disp #*60 Capsule Refills: *2 9. Senna 8.6 mg PO BID: PRN constipation RX *sennosides [senna] 8.6 mg 1 to 2 softgel by mouth twice a day Disp #*40 Capsule Refills: *2 10. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain RX *oxycodone 5 mg 0.5 to 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills: *0 11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 8 Days RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*16 Tablet Refills: *0 12. Atorvastatin 80 mg PO DAILY 13. I-Caps (antiox#10-om3-dha-epa-lut-zeax) ___ mg oral 1 capsule daily 14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral daily <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Subcutaneous abscess on lower incision. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: * No heavy lifting of objects >10lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Abdominal instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 8 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: *Wound vac of superior portion of wound to be changed every 3 days by at home nursing staff until wound is completely healed. Most recently changed ___. *Packing of inferior portion of wound to be done once a day by at home nursing staff until wound is completely healed. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecology oncology service on ___ with nausea and vomiting, also found to have a subcutaneous abscess on her lower abdominal incision. She was previously discharged from the gynecology oncology service on ___ after sub-optimally debulked ex-lap, BSO, TAH, omentectomy, ileocecectomy with primary re-anastomosis for likely ovarian cancer. Please see previous discharge summary for full details. Her hospital course is detailed as follows. Due to the patient's history of NSTEMI with only presenting symptom of nausea, an ECG was obtained and cardiac enzymes were negative x3. Blood cultures were drawn prior to initiation of IV ciprofloxacin and flagyl due to a wound culture on ___ at the time of incision and drainage of a lower incision abscess that was positive for E.coli. CT scan of the abdomen at the time of admission showed continued fluid collection, which was further drained on ___ with drainage of a 25cc seroma with some purulent discharge. Intravenous antibiotics were continued for 48 hours and then transitioned to oral antibiotics to be continued upon discharge for a total of 10 days. The superior portion of her abdominal incision continues to improve with the woundvac in place. The patient's nausea improved shortly after her admission and by hospital day 2 she was tolerating oral intake with only a complaint of constipation. She was then discharged home in stable condition with a rigorous bowel regimen, oral antibiotics for a total of 10 days of treatment and outpatient follow-up scheduled.
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10113778-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Weight loss and fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy Cystoscopy <HISTORY OF PRESENT ILLNESS> ___ G1P0-0-1-0 perimenopausal Caucasian female with uterine fibroids, extensive endometriosis, and multiple medical problems (HTN, arrhythmia, occasional chest pain requiring nitroglycerin, pineal brain cyst with hydrocephalus S/P drainage x2, GI ulcers, cervical dysplasia S/P cryotherapy). She recently had an unintended 17 lb weight loss with no clear explanation. She is concerned there may be an undiagnosed cancer. . She was initially seen in ___ for GYN consultation regarding her symptomatic fibroid uterus. That evaluation included an endometrial biopsy (___) that revealed disordered proliferative endometrium. Pelvic ultrasound (___) revealed a uterus measuring 10.7 x 7.6 x 7.4 cm with multiple fibroids (6.6 cm anterior fundal, as well as submucosal fibroid of undetermined size). There was endometrial stripe of 3 mm and normal ovaries bilaterally. The patient initially requested surgical management with a robotically assisted total laparoscopic hysterectomy, but then changed her decision to maintain conservative management. The patient ultimately opted not to proceed with surgery because her bleeding actually began to improve. . On today's visit, she reports improved menstrual bleeding with sporadic much lighter flow than her past menstrual pattern. Her greatest concern is actually not her bleeding pattern but a recent unexplained 17 pound weight loss that occurred over three weeks span in ___. She is drinks three Ensures a day to increase her weight, but has been unsuccessful. She currently weighs 90.5 pounds and she is ___ feet 1 inch. . She has a history notable for ulcers. She underwent a GI evaluation with Dr. ___ gastroenterologist on ___. She had an endoscopy and colonoscopy, both of which were negative per patient report. A CT scan of the abdomen and pelvis performed (___) revealed no GI findings to explain the weight loss. There was a normal gallbladder, pancreas, spleen, right adrenal gland, slight prominence of the left adrenal gland, unchanged from prior examination. Normal kidneys. No mesenteric lymphadenopathy or retroperitoneal lymphadenopathy. In the pelvis there was a large partially necrotic 7.2 x 5.5 x 6.5 cm fibroid as well as a 2.5 cm submucosal fibroid. There was a 2 x 1.6 cm simple left adnexal cyst. No pelvic lymphadenopathy. Impression: Fibroid uterus with 6.5 x 5.5 cm anterior partiallynecrotic fibroid. A 2.5 cm submucosal fibroid. Simple 2 cm left adnexal cyst that requires no further workup. <PAST MEDICAL HISTORY> OB History: G1, P0-0-1-0 - one miscarriage in ___ at 4 months gestation, requiring a D&C for retained placenta. GYN History: Menarche age ___. irregular light bleeding c/w perimenopausla transition. The patient is not currently sexually active but does report a history of dyspareunia in the past. The patient reports a long history of cervical dysplasia requiring cryotherapy. Last Pap smear in ___, negative SIL. The patient is not currently sexually active, but prefers opposite sex. Other than the cervical dysplasia, denies any other STDs. Medical Problems: 1. Uterine fibroids. 2. Extensive endometriosis. 3. h/o abnormal Pap smears. s/p cryotherapy. Last Pap ___ negative SIL, HPV testing negative. 4. Hypertension. 5. Arrhythmia, occasional chest pain requiring nitroglycerin, followed by cardiologist at ___ every six months. 6. Pineal brain cyst resulting in hydrocephalus that required drainage (x2), in ___ and ___. Currently monitored by MRI every six months, noted to be stable. 7. GI ulcers. 8. Hemorrhoids. 9. Headaches Surgical History: 1. ___, D&C for SAB at four months for retained products. 2. Prior to ___, laparoscopy x2, at which time she was diagnosed with severe endometriosis. Uterus was sutured to create an anteverted uterine tilt. This caused severe pain and second laparoscopy was performed to release the uterus. 3. Cryotherapy for cervical dysplasia. 4. Drainage of hydrocephalus/pineal brain cyst (x2) ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Reports a grandmother deceased from ovarian cancer at age ___, no other GYN cancers in the family such as breast, uterine, cervical, vaginal, or colon cancer. The patient reports three uncles (smokers) with lung cancer and mother with hypertension. <PHYSICAL EXAM> Pleasant, very thin Caucasian female in no acute distress. BP 136/80, pulse 80, weight 90.5 pounds, height 5 feet 1 inch, O2 sat 100% on room air. HEENT: normocephalic/atraumatic, anicteric sclera Neck: supple, full range of motion, no thyromegaly or nodules Lymphatic: no palpable neck lymphadenopathy Back: no CVA tenderness Lungs: clear to auscultation b/l, good inspiratory effort CV: regular rate and rhythm, no murmurs/rubs/gallops Abd: +bowel sounds, soft, non-tender, non-distended, no R/G. well-healed lower pelvic scars that the patient states was from prior laparoscopy. These scars are much larger than typical laparoscopy incisions and much more medial. Extremities: no clubbing/cyanosis/edema On pelvic exam, there is grossly normal external female genitalia. On bimanual exam, there is a nontender, mobile, anteverted fibroid uterus sizing roughly 12 weeks in size with no palpable adnexal masses. No tenderness on deep palpation. No CMT. Overall, benign exam. On speculum exam, there is a normal-appearing cervix with no unusual bleeding, lesions, or discharge. Normal-appearing vaginal vault. The cervix is somewhat patulous (pt s/p prior cryotherapy). Normal-appearing vaginal vault. <MEDICATIONS ON ADMISSION> Atenolol 50 mg BID Fiorinal 50 mg-325 mg-40 mg QID: prn for headache Esomeprazole magnesium 40 mg BID Lactulose (Enulose) ___ ml daily-BID prn for constipation Docusate sodium 100 mg BID prn for constipation Nifedipine 120 mg daily Aspirin 325 mg daily Ensure plus TID <DISCHARGE MEDICATIONS> 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Fiorinal 50-325-40 mg Capsule Sig: One (1) Capsule PO four times a day as needed for headache. 3. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 5. lactulose 10 gram/15 mL Solution Sig: ___ mL PO once to twice a day as needed for constipation. 6. nifedipine 60 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. 7. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain for 5 days. 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 10. Ensure Plus Liquid Sig: One (1) can PO three times a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroids Endometriosis Weight loss <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was our pleasure to take care of you while you were at the ___. You were admitted for the laparoscopic procedure to remove your uterus, tubes, and ovaries because of your recent 17-pound weight loss and known fibroids. You stayed in the hospital following the operation and recovered well. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity and no heavy lifting of objects >10lbs for 6 weeks. * Nothing in the vagina for 3 months or until Dr ___. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted for scheduled total laparoscopic hysterectomy; see operative report for details of surgery. She was admitted overnight for observation because she was unable to void in the recovery room. She eventually voided spontaneously overnight without requiring a foley catheter. She otherwise had an uncomplicated recovery, her pain was well-controlled on oral medications, she tolerated a regular diet, and ambulated without difficulty. She was discharged home on post-operative day #1 in stable condition with voiding precautions given her slightly delayed post-operative voiding function.
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10124699-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / shellfish derived / doxycycline <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Laparoscopic Hysterectomy with Bilateral Salpingectomy and Cystoscopy <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <MEDICATIONS ON ADMISSION> citalopram 40 mg QID diclofenac sodium 1% topical gel for foot pain fluticasone 50 mcg/activation nasal spray ibuprofen 400mg PRN cholecalciferol (VitD) 5000 units per week simethicone 180mg QID <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ , You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing Laparoscopic Hysterectomy with Bilateral Salpingectomy and Cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid/toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oxycodone/acetaminophen/ibuprofen (pain meds). By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10124966-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Nsaids <ATTENDING> ___ <CHIEF COMPLAINT> "I have what feel like staples coming through my vagina" <MAJOR SURGICAL OR INVASIVE PROCEDURE> Mesh excision anterior and posterior colporrhaphy placement of Elevate biologic mesh cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 8 Para ___ who presents for a consultation requested by Dr. ___ mesh erosion. She is in fact complaining of discharge, pelvic pain and dyspareunia. Her symptoms have been present for approximately ___ years. She believes that they are now worse. She reports 0 incontinence events. She voids ___ times per day and ___ times per night. She uses 0 pads per day. She denies any urgency, she denies any dysuria and reports bladder emptying with interrupted flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ also admits to some vaginal pressure but denies any palpable prolapse. She also denies any constipation. She is sexually active and does experience dyspareunia. She denies any vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> - Lung Collapse - Lower back pain <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is significant for a history of Breast cancer in her maternal aunt and is otherwise unremarkable for Ovarian or Colon Cancer. <PHYSICAL EXAM> Physical Examination was performed by Dr. ___ ___: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Normal sounds, no murmurs Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Ext: No edema or varicosities. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skin & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: no lesions, no discharge Uterus: small; non-tender Adnexa: no masses non tender. POP-Q Exam: Aa: 0 Ba: 0 TVL: 9.5 D: -6 C: -3 ___: 4 PB: 3 Ap: -1.5 Bp: -1.5 ___ Exam: Cystocele: 3 Uterus/Cervix: 2 Vault: 2 Ant enterocele: Post enterocele: Rectocele: 2 Grade VAGINAL EXAM - There was mild vaginal atrophy: 2cm exposed synthetic arm of perigee (left proximal) Exposed segment of Perigee Left proximal synthetic arm transected and sent to pathology Area still with significant tenderness Empty Supine Stress Test was: negative Her (PVR) post void residual was 220 ml assessed by straight catheterization 45 minutes post void (Drinking Large iced coffee) <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> Cyclobenzaprine by mouth as needed for back spasms <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *50 Tablet(s)* Refills: *0* 2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal DAILY (Daily). Disp: *30 patch* Refills: *1* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while using narcotics to help prevent constipation. Disp: *60 Capsule(s)* Refills: *2* 4. Macrobid ___ mg Capsule Sig: One (1) Capsule PO once a day. Disp: *7 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Mesh Erosion Pelvic organ prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms ___, you were admitted for post-operative care following a mesh excision, anterior and posterior repair, placement of Elevate biologic mesh and a cystoscopy. * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * You may eat a regular diet.
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Ms ___ was admitted into the gynecology service for routine post-operative care following her mesh excision, anterior and posterior colporrhaphy, placement of Elevate biologic mesh and cystoscopy for eroding mesh and prolapse. She did well. Her voiding trial is as follows We instilled 1. 300cc, voided 200, PVR 400. 2. 300cc, voided 200, bladder scanned 400, PVR 600. She failed her voiding trial. She was discharged on post-op day one with adequate pain control, tolerating a regular diet and pain medications by mouth and ambulating without assist. She was given adequate instructions from nursing staff on how to manage an indwelling catheter. She was also discharged with prescription Macrobid for Urinary Tract Infection prophylaxis. She will follow up at the office with Dr. ___ removal of the indwelling catheter.
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| 197
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10124966-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Nsaids <ATTENDING> ___ <CHIEF COMPLAINT> uterine prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ 1. Robotic-assisted laparoscopic supracervical hysterectomy with bilateral salpingo-oophorectomy. 2. Sacrocervicopexy with synthetic graft. 3. Cystoscopy. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old woman with a history of COPD and hypertension, and urinary incontinence, who presented to the hospital for a planned procedure for management of ongoing stress incontinence and is admitted to the ___ for post procedure monitoring in setting of subcutaneous emphysema. On ___ she underwent a robotic assisted lap hysteroscopy, bilateral salpingo-oophorectomy, sacrocervicopexy and cystoscopy for symptomatic uterine prolapse. The procedure was without complication, with EBL of 25cc. However, the patient was noted to become increasingly swollen, with significant crepitus up her neck and into her face. In the PACU she remained intubated given subcutaneous emphysema in her neck for airway protection. An x-ray was done, and per prelim read was without pneumothorax or pneumomediastinum. She was transferred to ___ for monitoring until cutaneous emphysema resolves and she can be safely intubated. On arrival to ___ patient is intubated and sedated, not responding to commands. Vitals on transfer T 100.2, P 87, BP 159/88. On 100% FiO2. REVIEW OF SYSTEMS: unable to obtain given sedation <PAST MEDICAL HISTORY> - Urinary incontinence, uterine prolapse, s/p bladder suspension in ___ - COPD - hypertension - low back pain - osteopenia <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM: VITALS: T 100.2, P 87 RR 14 (on vent) O2 100% on 100%FiO2 GENERAL: intubated and sedated, not following commands HEENT: Sclera anicteric, MMM, oropharynx clear NECK: JVP not elevated, no LAD. +crepitus b/l CHEST: Crepitus over anterior chest LUNGS: Diffuse expiratory wheezing on anterior exam CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Surgical dressings in place, c/d/i. Soft, +bs EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No rashes NEURO: unable to assess ACCESS: PIV <PERTINENT RESULTS> ADMISSION LABS: ___ 07: 00AM BLOOD WBC-8.7 RBC-5.31* Hgb-14.9 Hct-47.1* MCV-89 MCH-28.1 MCHC-31.6* RDW-14.2 RDWSD-44.7 Plt ___ ___ 04: 55AM BLOOD Neuts-66.5 ___ Monos-9.3 Eos-0.8* Baso-0.3 Im ___ AbsNeut-7.25* AbsLymp-2.48 AbsMono-1.01* AbsEos-0.09 AbsBaso-0.03 ___ 07: 00AM BLOOD Plt ___ ___ 04: 55AM BLOOD Glucose-96 UreaN-15 Creat-0.8 Na-144 K-3.8 Cl-103 HCO3-31 AnGap-10 ___ 04: 55AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.1 IMAGING: ___ ABD XRAY The linea radiopacity adjacent to the left anterior inferior iliac spine may represent the missing surgical needle. NOTIFICATION: The findings were discussed with ___, M.D. by Dr ___, M.D. on the telephone on ___ at 11: 08 am, 2 minutes after discovery of the findings. ___ CXR The tip of the endotracheal tube is 6.4 cm above the carina appropriately sited. There is an extensive amount of subcutaneous emphysema throughout the chest extending into the lower neck bilaterally. This is new from the previous study and consistent with known recent surgery. Lungs are grossly clear; however, they are partially obscured by the subcutaneous emphysema. ___ CXR The tip of the endotracheal tube is 4.5 cm above the carina, appropriately sited. Heart size is within normal limits. There is extensive subcutaneous emphysema throughout the chest and lower neck. Allowing for this, no definite consolidation or pneumothoraces are seen. <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gabapentin 200 mg PO QHS 2. Nicotine Patch 21 mg TD DAILY 3. beclomethasone dipropionate 80 mcg/actuation inhalation BID 4. albuterol sulfate 90 mcg/actuation inhalation QID: PRN 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Vitamin D ___ UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen [Acetaminophen Pain Relief] 500 mg ___ tablet(s) by mouth every 6 hours as needed Disp #*50 Tablet Refills: *2 2. Diazepam 5 mg PO Q6H: PRN pain RX *diazepam 5 mg ___ or 1 tablet by mouth every 6 hours as needed Disp #*20 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice per day Disp #*30 Tablet Refills: *2 4. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % apply 1 patch daily, in the morning Disp #*5 Patch Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours as needed Disp #*35 Capsule Refills: *0 6. Gabapentin 600 mg PO TID 7. albuterol sulfate 90 mcg/actuation inhalation QID: PRN 8. beclomethasone dipropionate 80 mcg/actuation inhalation BID 9. Hydrochlorothiazide 12.5 mg PO DAILY 10. Nicotine Patch 21 mg TD DAILY 11. Vitamin D ___ UNIT PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic uterine prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___: You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * difficulty urinating, or if you do not urinate in 8 hours
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On ___, Ms. ___ underwent a robotic assisted laparoscopic supracervical hysterectomy, bilateral salpingo-ophorectomy, sacrocervicopexy and cystoscopy for symptomatic uterine prolapse. The procedure was surgically uncomplicated, however patient developed subcutaneous emphysema to the level of jaw in setting of insufflation. Given marked subcutaneous emphysema and baseline COPD, the patient was unable to be extubated and was admitted to the FICU for post-procedural monitoring. In the FICU, she had a chest XRAY which demonstrated no pneumothorax or pneumomediastinum. While intubated, patient had no difficulty in oxygenating. Her FiO2 was initially set high in attempt to help reduce emphysema, however was later lowered given no indication it will decrease time to reabsorption. She was sedated with propofol and pain control was managed immediately post-operative with fentanyl. On post-operative day 1, patient was extubated successfully and transferred from FICU to the floor. Her pain was managed with Dilaudid PCA and IV Tylenol. Patient's diet was advanced without difficulty and patient was transitioned to oral oxycodone, tylenol, gabapentin, valium and lidocaine patch. Patient was making adequate urine output, had her foley removed, passed her trial of void, and continued to void spontaneously. She was continued on nicotine patch given smoking history, home medications QVAR and albuterol for COPD/emphysema, and hydrochlorothiazide for hypertension. On post-operative day 2, patient's pain was well-controlled with oral medications, she was tolerating a regular diet without nausea or emesis, was voiding spontaneously, and ambulating without dizziness. Patient was discharged home in stable condition with close outpatient follow-up scheduled.
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10125734-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> left lower quadrant pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> see admission H&P <PAST MEDICAL HISTORY> see admission H&P <SOCIAL HISTORY> ___ <FAMILY HISTORY> see admission H&P <PHYSICAL EXAM> On day of discharge: VS: T 98.3, HR 83, BP 105/62, RR 18, O2 99% RA Gen: well-appearing, no acute distress, comfortable in bed and ambulating Resp: nl resp effort Abd: soft, thin, non-distended, minimal left lower quadrant tenderness -- improved from prior, no rebound or guarding Pelvic: deferred <PERTINENT RESULTS> ___ 12: 55AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12: 55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 11: 27PM ___ PTT-28.9 ___ ___ 10: 49PM GLUCOSE-86 UREA N-9 CREAT-0.7 SODIUM-137 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17 ___ 10: 49PM ALT(SGPT)-30 AST(SGOT)-23 LD(LDH)-187 ALK PHOS-52 TOT BILI-0.5 ___ 10: 49PM ALBUMIN-4.2 ___ 10: 49PM HCG-<5 ___ 10: 49PM WBC-8.4 RBC-3.59* HGB-10.9* HCT-33.4* MCV-93 MCH-30.4 MCHC-32.6 RDW-11.9 RDWSD-40.2 ___ 10: 49PM NEUTS-68.1 ___ MONOS-7.6 EOS-0.1* BASOS-0.4 IM ___ AbsNeut-5.75 AbsLymp-1.97 AbsMono-0.64 AbsEos-0.01* AbsBaso-0.03 ___ 10: 49PM PLT COUNT-210 Pelvic Ultrasound ___: Report pending. Per verbal discussion with radiologist, persistent dilated tubular structure in left adnexa. Fluid appears mostly simple with small amount of debris. Ddx includes hydrosalpinx vs hematosalpinx vs pyosalpinx. Normal ovaries. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days Take with food to avoid GI upset. 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild 4. MetroNIDAZOLE 500 mg PO BID Duration: 14 Days <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Left lower quadrant pain Left adnexal fluid filled structure, likely hydrosalpinx, possible hematosalpinx or pyosalpinx Possible intermittent torsion of tube <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after presenting with left lower quadrant pain, found to have a likely dilated fallopian tube. You underwent a pelvic ultrasound, renal ultrasound and CT scan of your abdomen/pelvis. Your ovaries appeared normal on the scans. There was concern for an infection within the fallopian tube, or possible tubo-ovarian abscess, so antibiotics were started. You received 1 dose of IV doxycycline, 1 dose of IV Gentamicin (24-hour dosing), and 3 doses of IV Clindamycin. Your symptoms significantly improved over the course of a day and you required no additional pain medications or anti-nausea medications. A repeat U/S on ___ showed a persistently dilated fallopian tube which contains simple fluid with a small amount of debris. This may represent a hydrosalpinx (simple fluid alone), hematosalpinx (blood-filled tube), or a pyosalpinx (pus in the fluid). Given that you never had a fever, your blood counts remained normal, your exam was reassuring without evidence of significant infection, and your symptoms improved so quickly, we have a low suspicion for a serious infection in the tube. However, we recommend treating you for a presumed infection, with continuation of oral antibiotics (Doxycycline and Metronidazole) for 14 days. We also recommend you follow-up with your primary gynecologist in the next ___ weeks, or sooner if you develop concerning symptoms or signs. Overall, you have recovered well and the team believes you are safe to be discharged home. Please call our office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed and complete the whole course of antibiotics, even if you feel better. Your antibiotics have been faxed to the ___ at ___, ___, ___. * Avoid intercourse or strenuous exercise until you follow-up with your gynecologist. You may walk up and down stairs and be active throughout the day. * Take ibuprofen and Tylenol as needed for discomfort. * You may eat a regular diet. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication If you have questions or concerns, or would like to speak the doctors that were involved in your care here, or your doctor would like to, please call our clinic at ___. To reach medical records to get the records from this hospitalization at ___ sent to your doctor at home, call ___. Since you were also in the ER at ___, you may also call ___ to get those records. This is where you had a pelvic ultrasound, renal ultrasound, and CT scan on ___. It was a pleasure taking care of you! -Your Ob/Gyn team ___, and others)
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The patient initially presented to urgent care on ___ morning with acute onset of left lower quadrant pain, associated nausea and vomiting, and one episode of diarrhea. she was transferred to ___, where she underwent a pelvic ultrasound, renal ultrasound and CT scan. Her CT scan noted a 10cm x 4cm (in maximum dimension) tubular fluid-filled structure in the left adnexa, consistent with the fallopian, tube, wrapping posteriorly around the uterus. Her WBC was 11. She had no fever and normal vital signs. She received 1 dose of IV doxycycline. She received 2 doses of IV morphine with improvement in her pain, and 1 dose of IV Zofran, with resolution in her nausea and vomiting. She was transferred to ___ for concern for a tubo-ovarian abscess. Upon arrival to the ___ ER, she noted overall improvement in her pain. She required one additional dose of IV morphine, and subsequently only had left lower quadrant achy pain. She had no further nausea, emesis, diarrhea, and was feeling hungry. Her WBC was 8. Her vital signs continued to be normal. On exam, she had mild left lower quadrant tenderness, with no distension or rebound or guarding. On bimanual exam, she had minimal left adnexal tenderness with no fullness or mass appreciated. Her cervical LEEP site appeared to be healing well, without evidence of infection, and she had no cervical motion tenderness or uterine tenderness. Overall, her clinical picture was inconsistent with a tubo-ovarian abscess. However, given the CT findings and mild tenderness on exam, the decision was made to treat for possible pyosalpinx and admit for IV antibiotics. She was given 1 dose of IV gentamicin (24 hour dosing) and 3 doses of IV Clindamycin. She was observed inpatient for almost 24 hours. Her pain essentially resolved and she was comfortable in bed and ambulating throughout the day. She tolerated a regular diet. She required no pain medicines or anti-emetics. She had no abnormal discharge or bleeding. She underwent a repeat pelvic ultrasound on ___, which showed a persistent dilated fallopian tube containing simple fluid with a small amount of debris. The final report was not yet available but per verbal discussion with the radiologist, this could represent a hydrosalpinx, hematosalpinx, or a pyosalpinx. Given that she never had a fever or significant leukocytosis, her pain improved quickly and her exam remained reassuring and improved overall, it was felt to be less likely that she had a true pyosalpinx or tubo-ovarian abscess. However, given the presence of debris in the fluid and possibility of an infection that improved with IV antibiotics, the decision was made to continue treatment with oral antibiotics (Doxycycline and Metronidazole) for 14 days. She was discharged home in stable condition. She was recommended to follow-up with her primary gynecologist in the next ___ weeks, or sooner if she developed concerning symptoms or signs, which were discussed with her.
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10127480-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Nitrofurantoin / Amoxicillin / Penicillins / Codeine / latex <ATTENDING> ___. <CHIEF COMPLAINT> blood glucose management <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G6P5 who presented at 8w2d with ___ transferred from ___ s/p DKA treatment for further blood glucose management. Patient reports running out of syringe needles last week and unable to take medications for 4 days. Additionally this pregnancy has been complicated with recurrent nausea. She started feeling unwell ___ and presented to ___ where she was admitted to their ICU for DKA treatment on ___. While hospitalized her insulin regimen had been adjusted to Levemir 20 units BID and Novolog 10 units before breakfast, lunch, and dinner. She was subsequently transferred to ___ for further management of her blood glucose. Patient reports she was diagnosed with T1DM after her last pregnancy in ___. She has since been followed by ___ with multiple admissions for DKA. This is her first pregnancy since being diagnosed with diabetes. She reports most recently being on a sliding scale of Novolog and 23 units of Lantus in the morning and 19 units at night. She feels well today. Denies VB, LOF. She is having some lower abdominal cramping and reports +FM. <PAST MEDICAL HISTORY> OBHx: G6P5 - SVD x 5, FT, no complications GynHx: - h/o of abnormal Pap with nl f/u ___ - Denies fibroids, Gyn surgery, STIs PMH: - T1DM Diagnosed at age ___ with multiple hospitalizations for DKA. ___ HgA1C 12.6 - Depression: Surrounding brother's death ___, was on Celexa but no longer taking. Additionally, her boyfriend was shot and killed in ___ - Vitamin D deficency - Renal stones ___ - Denies asthma, HTN PSH: Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: fibromyalgia, polymyalgia rheumatic, ESRD Maternal grandmother: COPD ___ grandfather: DM Physical ___: admission Physical Exam Vitals: HR 98 BP 121/76 RR 18 O2 98% RA Gen: A&Ox3, comfortable CV: RRR PULM: no respiratory distress Abd: soft, gravid, nontender, no rebound/guarding Ext: no calf tenderness TAUS: CRL 1.82 cm, 8w2d, FHR 176 <PERTINENT RESULTS> ___ 07: 23PM BLOOD WBC-9.2# RBC-3.84* Hgb-12.3 Hct-36.7 MCV-96 MCH-32.0 MCHC-33.5 RDW-13.4 RDWSD-47.4* Plt ___ ___ 07: 23PM BLOOD Glucose-317* UreaN-15 Creat-0.6 Na-135 K-4.4 Cl-98 HCO3-25 AnGap-16 ___ 07: 23PM BLOOD Calcium-9.6 Phos-4.6* Mg-1.9 ___ 01: 00PM BLOOD HBsAg-Negative ___ 01: 00PM BLOOD HIV Ab-Negative ___ 07: 23PM BLOOD Acetmnp-NEG ___ 08: 11PM URINE Color-Straw Appear-Clear Sp ___ ___ 08: 11PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 02: 13PM URINE Hours-RANDOM Creat-64 TotProt-8 Prot/Cr-0.1 ___ 1: 00 pm SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. <MEDICATIONS ON ADMISSION> levemir novalog PNV <DISCHARGE MEDICATIONS> 1. One-A-Day Women VitaCraves (multivit with min-folic acid) 200 mcg oral BID 2. levemir 20 Units Breakfast levemir 5 Units Bedtime Insulin SC Sliding Scale using novalog Insulin <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> T1DM resolved diabetic ketoacidosis pregnancy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms ___, You were admitted to the hospital with T1DM and diabetic ketoacidosis which resolved. You were seen by ___ regarding your diabetes management plan. It is now safe for you to be discharged home. Please follow the instructions below: - please check fingersticks: fasting in the morning, 15 minutes before each meal, one hour after each meal. Please record these fingersticks and bring them to your follow-up visits with ___ - Please take your levemir 20 unit every morning and levemir 5 units every night. It is important that you do not miss doses. You may substitute Lantus for Levemir if you do not have Levemir available, however, please call the clinic if you are having difficulty filling your insulin prescription. Please call the clinic if you have any questions or concerns about your insulin - Please take your Novolog according to the sliding scale provided based on your pre-meal fingersticks. Please take the Novolog 15 minutes before your meal.
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Ms ___ is a ___ yo G6P5 who presented at 8w2d with poorly controlled T1DM (HbA1C 12.8 on ___ transferred from ___ ___, where she had been admitted to the ICU for DKA. On arrival to ___, fingerstick glucose 330. Well-appearing. Normal vital signs. US with CRL c/w dates, FHR 176 bpm. Labs(CBC, Chem-7) aside from glucose normal - K 4.4, HC03 25, anion gap 11.6 (16 recorded in OMR, 11.6 when K removed). No e/o continued DKA. She was given 4 units of humalog SQ in GYN triage prior to starting her on an insulin drip per ___ recommendations. She was transitioned off her insulin drip to Levemir BID and Novalog SSI with meals. She declined her ___ Levemir on HD2 and subsequently had elevated BP to 300's overnight which was controlled with spot dose of Novalog. She was counseled thoroughly by ___ and the primary team regarding her recommended insulin regiment and the fetal and maternal risks of uncontrolled blood glucose and the importance of taking insulin as instructed. She was discharged home in stable condition on HD3 with follow up scheduled with ___ and ___.
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10129882-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex / hayfever / gluten <ATTENDING> ___. <CHIEF COMPLAINT> Fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salpingectomy, right oophorectomy, left ureterolysis <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 06: 40AM BLOOD WBC-11.0* RBC-3.70* Hgb-11.8 Hct-36.7 MCV-99* MCH-31.9 MCHC-32.2 RDW-13.9 RDWSD-51.1* Plt ___ ___ 07: 57AM BLOOD WBC-8.2 RBC-4.02 Hgb-13.0 Hct-38.2 MCV-95 MCH-32.3* MCHC-34.0 RDW-13.5 RDWSD-47.1* Plt ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe do not drive or drink alcohol while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 5. Lisinopril 10 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Your staples will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a total abdominal hysterectomy, right salpingo-oophorectomy, left salpingectomy for a symptomatic fibroid uterus. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with PO ibuprofen and acetaminophen. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty. She was continued on lisinopril for her history of HTN. She also received lovenox 40mg QD for her history of DVT. She received nystatin cream for vulvar yeast. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10130191-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ancef <ATTENDING> ___. <CHIEF COMPLAINT> Fever and vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G1P0 status post D&C for 7 week MAB on ___ at ___. She initially was feeling well, but then yesterday developed fevers to 100.4, chills, and generalized malaise. Denies nausea and vomiting. Denies urinary symptoms. Small amount of spotting, no clots. No abnormal discharge. Reports significant abdominal pain in ___ abdomen. <PAST MEDICAL HISTORY> Depression: on Venlafaxine 75mg QD <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Vital signs: ___ 0314 Temp: 98.1 PO BP: 96/58 HR: 83 RR: 16 O2 sat: 97% O2 delivery: RA Ins/Outs: ___ Total Intake: 3568.8 PO Amt: 1260ml IV Amt Infused: 2308.8 ___ Total Output: 700ml Urine Amt: 700ml General: NAD, comfortable Lungs: normal work of breathing Abdomen: soft, non-distended, appropriately tender to palpation over suprapubic/fundal region without rebound or guarding GU: pad ___ filled with dark dried blood Extremities: no edema, non-tender <PERTINENT RESULTS> ___ 08: 05AM ___ COMMENTS-GREEN TOP ___ 08: 05AM LACTATE-1.6 ___ 08: 00AM GLUCOSE-101* UREA N-5* CREAT-0.6 SODIUM-134* POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-19* ANION GAP-16 ___ 08: 00AM estGFR-Using this ___ 08: 00AM URINE HOURS-RANDOM ___ 08: 00AM URINE UHOLD-HOLD ___ 08: 00AM WBC-14.3* RBC-4.01 HGB-12.0 HCT-35.3 MCV-88 MCH-29.9 MCHC-34.0 RDW-11.7 RDWSD-37.5 ___ 08: 00AM NEUTS-88.2* LYMPHS-5.9* MONOS-4.4* EOS-0.7* BASOS-0.2 NUC RBCS-0.1* IM ___ AbsNeut-12.59* AbsLymp-0.84* AbsMono-0.63 AbsEos-0.10 AbsBaso-0.03 ___ 08: 00AM PLT COUNT-274 ___ 08: 00AM ___ PTT-28.2 ___ ___ 08: 00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08: 00AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 08: 00AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-2 <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the gynecology service after your procedure on ___. You have recovered well and the team believes you are ready to be discharged home. Please call your OB/GYN's office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___
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Ms. ___ was admitted from the ED with back pain, abdominal pain, spotting and fever concerning for endometritis. She was started on IV Clindamycin and Gentamicin and continued for 24 hours. A pelvic ultrasound was performed and was notable for a 13mm endometrial stripe. She had intermittent bleeding during her stay where she filled approximately ___ of pad without passage of clots. Pt was asymptomatic and bleeding resolved spontaneously. On admission day two, she remained afebrile, tolerating PO, and noted ___ pain. Blood cultures pending. Given reassuring physical exam and stable vitals, she was discharged to home with close outpatient follow up. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild RX *acetaminophen 500 mg 1 tablet(s) by mouth Every ___ hours Disp #*30 Tablet Refills:*0 2. Venlafaxine XR 75 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Endometritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10130449-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Opioids - Morphine Analogues <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> transvaginal ultrasound <HISTORY OF PRESENT ILLNESS> ___ s/p uncomplicated rLTCS, bilateral partial salpingectomy, ventral hernia repair ___, POD11, presenting with heavy vaginal bleeding x 2 days. Patient previously had been minimally spotting requiring <1 pad/day. However, on the day prior to admission she had increased bleeding, requiring 4 pads and last night developed ___ lower crampy abdominal pain. She reported overnight she felt sweaty and had chills but did not feel as if she had a fever. She reports alternating between Tylenol and Motrin every 6 hours. In triage, she reported that she fully saturated 3 large pads in 2 hours, a fourth pad over the next 3 hours, and a fifth pad the following hour after that. She was seen urgently in ___ clinic, and was found to have a large amount of pooling of blood within vaginal vault. She had a 5cm clot removed from os with continued flow, which required 12 scopettes to clear. She also had significant fundal tenderness. In triage, patient reported that she had ___ lower abdominal pain, not well controlled with Tylenol and Ibuprofen. She also reports a mild HA. Patient also reports that last week on ___, she began having minimal leakage of thin yellow-brownish nonodorous fluid from the ___ her ventral hernia incision. She reports this drainage stopped yesterday. Patient otherwise denied tenderness around c-section and ventral hernia incisions, fevers/chills, CP, SOB, palpitations, malodorous abnormal discharge, dizziness/weakness. <PAST MEDICAL HISTORY> PMH: denies PSH: LTCS x3, partial salpingectomy, ventral hernia repair OBHx: ___ -G1: pLTCS for breech presentation, term -G2: rLTCS, term -G3: SAB @ 10 weeks -G4: rLTCS, bilateral partial salpingectomy, ventral hernia repair ___, c/b PPH on POD1 (200cc clot + 300cc manually evacuated from LUS, s/p IM/PO methergine x24hrs) GYNHx: anterior fibroid measuring 18 mm x 25 mm x 21 mm <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> T 98.2, 121 / 78,HR 66, RR 18, 96% RA General: NAD, A&Ox3 Breasts: non-tender, no erythema Lungs: No respiratory distress Abd: soft, nontender, fundus firm below umbilicus. Site of ventral hernia repair intact with small amount of induration beneath the skin. Incision: clean, dry, intact with no erythema Pad with scant dark brown blood <PERTINENT RESULTS> ___ 06: 04PM CREAT-0.4 ___ 06: 04PM estGFR-Using this ___ 05: 06PM ___ PTT-27.8 ___ ___ 05: 06PM ___ ___ 05: 05PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 05: 05PM URINE BLOOD-LG* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG* ___ 05: 05PM URINE RBC-17* WBC-117* BACTERIA-FEW* YEAST-NONE EPI-1 ___ 05: 05PM URINE MUCOUS-RARE* ___ 05: 00PM WBC-11.3* RBC-3.70* HGB-11.3 HCT-33.6* MCV-91 MCH-30.5 MCHC-33.6 RDW-13.7 RDWSD-44.9 Transvaginal US ___: FINDINGS: The uterus is anteverted and measures 12.9 x 7.0 x 9.6 cm compatible with postpartum status. The endometrium contains heterogeneous fluid likely representing hemorrhage and several echogenic foci which may represent residual postoperative locule of gas. There is no evidence of vascularized retained products of conception. The ovaries are normal. There is no free fluid. IMPRESSION: No evidence of vascularized retained products of conception. <MEDICATIONS ON ADMISSION> Tylenol, Motrin <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Mild Pain do not take more than 4000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> post-partum endometritis post-partum vaginal bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the OBGYN service for abdominal pain and heavy vaginal bleeding concerning for retained products of conception. However, you transvaginal ultrasound was negative and reassuring. Your bleeding and pain both improved with intravenous antibiotics. The team feels you are now well and safe to go home. Please follow the instructions below: Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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On ___, MS. ___ was readmitted to the postpartum service for heavy vaginal bleeding and abdominal pain concerning for endometritis vs. retained POCs. She was treated with IV gentamicin and clindamycin for 24 hours. Her WB was 11.3 with 0 bands, UA was contaminated. She underwent a transvaginal ultrasound which showed no evidence of retained POCs. Her hematocrit was trended as follows: 28.2 ___ 22.6 (___) -> 33.6 (___). An active type & cross was maintained but she did not require a blood transfusion. Her vaginal bleeding decreased. On hospital day 2, her bleeding had decreased, her vitals were stable, and she was discharged from the hospital with close follow-up.
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10131337-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> dipirona <ATTENDING> ___. <CHIEF COMPLAINT> Adnexal mass and elevated CA-125 <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy Total abdominal hysterectomy Bilateral salpingo-oophorectomy Rectosigmoid resection and anastamosis Omentectomy Plasma jet ablation <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___, G2 P2, who began noticing left lower quadrant pain approximately two months ago. This was initially accompanied with constipation and nausea and vomiting. She had an initial workup done in ___ which showed "liquid" in the abdomen. She also had an elevated CA-125 and was told by the doctors in ___ that there was a concern for cancer. Her daughter lives in this country, and therefore, she came for the rest of her medical care here in the ___. She met with Dr. ___ at ___ on ___ who noted marked cervical motion tenderness and left adnexal fullness. Pelvic ultrasound showed a small normal uterus with a 3 mm endometrial stripe. The left ovary measured 5.1 x 3.2 x 2.5 cm and was heterogenous in echotexture, possibly representing the presence of an ill-defined ovarian mass. The right ovary appeared normal. There was a small amount of free fluid in the pelvis. She was then sent for an MRI. This was completed on ___. The MRI of the pelvis again showed a normal uterus with an atrophic right ovary. The left ovary was enlarged measuring 4.7 x 2.7 x 3 cm. There was a soft tissue mass in the left ovary with heterogenous enhancement, highly concerning for ovarian carcinoma. There was a small amount of ascites present. In the anterior peritoneum, there was felt to be nodular enhancement of soft tissue consistent with peritoneal carcinomatosis and omental disease. There was no significant adenopathy. Again appreciated was a small amount of free fluid in the pelvis as well. There were several pelvic lymph nodes with one on the left measuring 1.5 x 0.76 cm. This was concerning for metastatic lymphadenopathy. There were several inguinal lymph nodes also present. A CA-125 was sent and was notably elevated at 361. The patient continues to complain of severe abdominal pain. This pain is constant in the left lower quadrant. Her abdomen has felt distended and bloated. Oxycodone is effective and does minimize the pain. The pain has a burning sensation to it. She is using senna for constipation. The nausea and vomiting has resolved and she is tolerating a normal diet. She does complain of some shortness of breath, but only when the pain is present. <PAST MEDICAL HISTORY> PMH: Hep A as child, kidney stones, mitral valve prolapse. PSH: Cholecystectomy in ___, foot surgery in ___ and two transverse cesarean deliveries, breast reduction, abdominoplasty OB: G2P2. C-sectionx2 GYN: Her last period was six months ago. Has hot flashes consistent with perimenopause. Her menses were normal previously. A Pap smear done two weeks ago was normal and negative for high-risk HPV. She is sexually active, though has not had intercourse due to the pain. She used the IUD for contraception for ___ years and recently had it removed. She denies any hormone replacement therapy. She denies any significant gynecologic infections or issues in the past. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She had a maternal aunt with breast cancer, but denies any ovary, uterine or colon cancers. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress, resting comfortably CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 06: 45AM BLOOD WBC-5.5 RBC-3.90 Hgb-11.3 Hct-34.0 MCV-87 MCH-29.0 MCHC-33.2 RDW-13.1 RDWSD-40.8 Plt ___ ___ 06: 05AM BLOOD WBC-4.3 RBC-4.35 Hgb-12.7 Hct-38.0 MCV-87 MCH-29.2 MCHC-33.4 RDW-12.7 RDWSD-40.6 Plt ___ ___ 06: 03AM BLOOD WBC-4.2 RBC-3.80* Hgb-11.0* Hct-33.4* MCV-88 MCH-28.9 MCHC-32.9 RDW-13.0 RDWSD-41.9 Plt ___ ___ 06: 20AM BLOOD WBC-5.5 RBC-3.39* Hgb-10.0* Hct-29.6* MCV-87 MCH-29.5 MCHC-33.8 RDW-13.1 RDWSD-41.3 Plt ___ ___ 06: 45AM BLOOD WBC-7.2 RBC-3.59* Hgb-10.7* Hct-32.6* MCV-91 MCH-29.8 MCHC-32.8 RDW-13.1 RDWSD-42.9 Plt ___ ___ 06: 30AM BLOOD WBC-9.3# RBC-3.92# Hgb-11.5# Hct-34.5# MCV-88 MCH-29.3 MCHC-33.3 RDW-12.8 RDWSD-41.2 Plt ___ ___ 06: 45PM BLOOD WBC-5.6 RBC-3.08* Hgb-8.8* Hct-27.4* MCV-89 MCH-28.6 MCHC-32.1 RDW-12.7 RDWSD-41.0 Plt ___ ___ 06: 45AM BLOOD Plt ___ ___ 06: 05AM BLOOD Plt ___ ___ 06: 03AM BLOOD Plt ___ ___ 06: 20AM BLOOD Plt ___ ___ 06: 45AM BLOOD Plt ___ ___ 06: 30AM BLOOD Plt ___ ___ 06: 45PM BLOOD Plt ___ ___ 06: 45AM BLOOD Glucose-69* UreaN-9 Creat-0.5 Na-134 K-4.3 Cl-99 HCO3-20* AnGap-19 ___ 06: 05AM BLOOD Glucose-80 UreaN-7 Creat-0.5 Na-137 K-4.4 Cl-100 HCO3-23 AnGap-18 ___ 06: 03AM BLOOD Glucose-74 UreaN-4* Creat-0.4 Na-136 K-4.2 Cl-102 HCO3-23 AnGap-15 ___ 06: 20AM BLOOD Glucose-86 UreaN-4* Creat-0.5 Na-138 K-3.8 Cl-105 HCO3-27 AnGap-10 ___ 06: 45AM BLOOD Glucose-52* UreaN-10 Creat-0.6 Na-136 K-4.3 Cl-105 HCO3-19* AnGap-16 ___ 06: 30AM BLOOD Glucose-80 UreaN-12 Creat-0.6 Na-139 K-4.4 Cl-106 HCO3-24 AnGap-13 ___ 06: 45PM BLOOD Glucose-113* UreaN-14 Creat-0.8 Na-140 K-4.1 Cl-107 HCO3-22 AnGap-15 ___ 06: 45AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.7 ___ 06: 05AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.9 ___ 06: 03AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0 ___ 06: 20AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.6 ___ 06: 45AM BLOOD Calcium-8.6 Phos-2.0*# Mg-1.9 ___ 06: 30AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.2 ___ 06: 45PM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9 ___ 02: 36PM BLOOD ___ pO2-83* pCO2-39 pH-7.40 calTCO2-25 Base XS-0 ___ 02: 36PM BLOOD Glucose-80 Na-140 K-3.9 Final pathology pending <MEDICATIONS ON ADMISSION> Oxycodone Valium Ibuprofen Senna <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4,000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN pain Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *0 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain Do not drive or drink alcohol while taking medication RX *hydromorphone 2 mg ___ tablet(s) by mouth q4h prn Disp #*60 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID Take while taking pain medication RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *0 5. Lorazepam 0.5-1 mg PO Q4H: PRN anxiety RX *lorazepam 0.5 mg 1 tablet by mouth Once at night as needed Disp #*15 Tablet Refills: *0 6. Milk of Magnesia 30 mL PO Q6H: PRN constipation RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL ___ mL by mouth Once at night as needed Refills: *1 7. Ondansetron 4 mg PO Q8H: PRN Nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth Every 8 hours as needed Disp #*15 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ovarian cancer Final pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing eploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, rectosigmoid resection and anastamosis, and plasma jet ablation. Please see the operative report for full details. Immediately postoperatively, her pain was controlled with an Epidural. Her diet was slowly advanced and she was transitioned to PO oxycodone, acetaminophen, and ibuprofen. On post-operative day #3, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 8, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. Her staples and JP drain were removed on day of discharge. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10131339-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> urinary retention, pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> paracentesis, biopsy of pelvic mass <HISTORY OF PRESENT ILLNESS> ___ yo ___ who presents to ED with recent UTI and now urinary retention and abdominal distention. She reports having discomfort with initial void ___. She was concerned she had a urinary tract infection and therefore took antibiotics she had from ___. Her symptoms improved after two days, she therefore discontinued antibiotics. Later that week she developed continuously increasing lower abdominal pressure and distention. On ___ she presented to urgent care and was diagnosed with a UTI and started on macrobid. Her symptoms continued to worsen, therefore went to the ED on ___ where a UA was suggestive of a UTI, no evidence of pyelonephritis. She was given one dose of IV ceftriaxone and discharged home on a PO course of cefpodoxime. Her symptoms, however, were unimproved and she continued to experience increasing lower pelvic pressure and difficulty emptying her bladder. She presented to urgent care on ___ and could not void with a PVR ~900 mL. A foley catheter was placed and she was instructed to present to the ED for further evaluation. She denies recent fever, chills, night sweats. She has noticed an unintentional weight loss of ~2 kg with decrease in appetite in the last month. Additionally, she has noticed multiple small lymph nodes along her right supra-clavicular region. She is a post-doctorate student from ___ working at ___ and was last in ___ in ___. <PAST MEDICAL HISTORY> Gyn: - LMP: ___, once a month, 5 days, regular flow - Not sexually active - Not on contraception - Last Pap done in ___, denies hx of abnormal Pap, can not recall when last one was done - Denies hx of STIs - Denies history of ovarian cysts, endometriosis, fibroids OB: G1P0010 - SAB PMH: Denies PSH: Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian and colon cancer. <PHYSICAL EXAM> On admission: Gen: NAD, comfortable, well-appearing CV: RRR Resp: CTAB Lymph node: multiple small non-tender, enlarged lymph nodes along right lateral neck Abd: +BW, soft, non-tender, lower pelvic mass extending to umbilicus, 6-7 cm in width, non-tender Pelvic: SPE: normal external genitalia, normal vaginal mucosa, normal cervix, small blood in vault, origin not clear, no masses or friability of vaginal or cervical tissue SVE: short vaginal length measuring ~4 cm in depth, no cervical masses palpated, no CMT, small nodularity palpated along right lateral vaginal wall, pelvic mass non-mobile, no uterine tenderness <PERTINENT RESULTS> ___ 06: 40PM CEA-44.5* CA125-451* ___ 02: 20PM GLUCOSE-82 UREA N-8 CREAT-0.4 SODIUM-139 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 ___ 02: 20PM ALT(SGPT)-6 AST(SGOT)-36 ALK PHOS-67 TOT BILI-0.2 ___ 02: 20PM ALBUMIN-2.9* ___ 02: 20PM WBC-6.6 RBC-3.19* HGB-8.3* HCT-26.1* MCV-82 MCH-26.0 MCHC-31.8* RDW-12.6 RDWSD-37.7 ___ 02: 20PM NEUTS-78.6* LYMPHS-13.6* MONOS-6.5 EOS-0.5* BASOS-0.2 IM ___ AbsNeut-5.21 AbsLymp-0.90* AbsMono-0.43 AbsEos-0.03* AbsBaso-0.01 ___ 02: 20PM PLT COUNT-475* ___ 11: 45AM URINE UCG-NEGATIVE ___ 11: 45AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11: 45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-0.2 PH-6.5 LEUK-NEG ___ 11: 45AM URINE ___ BACTERIA-MANY YEAST-NONE ___ 11: 45AM URINE MUCOUS-MANY <MEDICATIONS ON ADMISSION> cefpodoxime 100 mg tablet 1 tablet(s) by mouth BID x 7 days started ___ <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4,000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> urinary retention, pelvic mass, stomach mass <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service from the Emergency Department for your pelvic mass and UTI. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the Gynecologic Oncology service from the Emergency Department for urinary retention and pelvic mass. She had a foley catheter placed as was continued on cefpodoxime for a UTI that was originally diagnosed when she first presented to the Emergency Department on ___. She had a CT scan abdomen/ pelvis which showed: 1. Large partially solid, predominantly cystic pelvic/adnexal masses extend into the abdomen and into the presacral region, measuring 16.4 cm and 10.3 cm, respectively. There is mass effect upon the superior aspect of the urinary bladder, which contains a Foley catheter. Differential considerations are primary gastric neoplasm with drop metastases (Krukenberg tumor) or a primary ovarian neoplasm. 2. 1.2 x 1.0 cm exophytic, partially cystic lesion extending from the lesser curvature of the stomach, with irregular thickening and hypodense nodularity along the proximal stomach. 3. Extensive retroperitoneal lymphadenopathy with central hypodensity, concerning for necrotic lymph nodes. 4. Large volume intra-abdominal intrapelvic nonhemorrhagic free fluid. It is difficult to exclude early omental involvement. She was placed NPO overnight and given IV hydration in preparation for her ___ biopsy and paracentesis. On hospital day #1 she underwent paracentesis, during which 1.4 L of sero-sanguinous fluid was drained and fluid cytology was sent for analysis. She also underwent ___ biopsy of her retro-peritoneal mass. She had a CT scan of her chest which on preliminarily review showed "Random scattered nodules diffusely measure up to 5 mm within the right lower lobe is associated with bilateral hilar adenopathy for which intrathoracic disease involvement is suspected. Peribronchiolar thickening within the left lower lobe superiorly with clustered nodules may reflect the earliest manifestation of lymphangitic spread or otherwise infectious in etiology." Her urine output was adequate so her foley was removed and she voided spontaneously. She was noted to have tachycardia in the 110-120s, and had an EKG which showed sinus tachycardia and HR of 114. She was asymptomatic throughout her admission, and specifically denied chest pain, shortness of breath, nausea or vomiting. By hospital day #1, she was tolerating a regular diet, voiding, ambulating and pain was controlled with oral medications. She was discharged home in stable condition with follow-up as scheduled.
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10132489-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Cellulitis <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> HPI: ___ G3P1 at 33+0 with 3 weeks of left ankle redness and swelling that has been gradually worsening. Seen by PCP on ___, dx with cellulitis, given 1g of IM Ceftriaxone and Rx for Keflex. Told to F/U today. Pt didn't pick up Keflex until this AM and only had one dose prior to F/U appointment. Cellulitis worsening. Sent to ED for ___ for r/o DVT but transferred to OB Triage for further evaluation. Pt denies inciting event. No bite, cut or scratch. Denies fever or drainage. Denies CTX, VB or LOF. +AFM. <PAST MEDICAL HISTORY> PNC: -___: ___ by ___ -Labs: O+/Ab-/HBsAg-/RPRNR/RI/HIV/GBSunk -Screening: LR ___! -FFS: WNL, anterior placenta -GLT: passed -EFW: ___ 81%ile -Issues: *AMA *h/o C/S, desires TOLAC, consent signed *desires permanent sterilization PPBTL consent signed *primary language ___. Declines interpreter. OBHx: -___ pLTCS fetal intolerance of labor remote from delivery 41+3, ___ -TAB -current GynHx: fibroids (current posterior left 2x2cm), h/o chlamydia PMH: h/o ASD s/p closure in ___, sickle cell trait PSH: pLTCS, D&C Meds: PNV NKDA SHx: denies ___ ___ Exam: Admission Exam: ___ 15: 59Temp.: 98.0°F ___ 17: 24BP: 107/63 (72) ___ ___: 92 -Gen: NAD, well appearing -Abd: gravid, soft, NT -NST: 125, mod var, +accels, occasional shallow variables -Toco: initially irritable, then flat after IVF/rest -TAUS: VTX, BPP ___, MVP 6 Discharge Exam: Gen: appears comfortable. VS: 98.1, 111/76, 85, 18, 99% Abd: soft, gravid, NT Ext: L lower extremity, erythema/tenderness at outlined area medially; regressed from outlined area laterally. no calf tenderness <PERTINENT RESULTS> ___ 04: 00PM BLOOD WBC-6.9 RBC-3.67* Hgb-11.4 Hct-32.7* MCV-89 MCH-31.1 MCHC-34.9 RDW-13.5 RDWSD-43.9 Plt ___ ___ 04: 00PM BLOOD Neuts-67.0 ___ Monos-7.2 Eos-0.6* Baso-0.6 Im ___ AbsNeut-4.65 AbsLymp-1.53 AbsMono-0.50 AbsEos-0.04 AbsBaso-0.04 ___ 04: 00PM BLOOD Glucose-67* UreaN-6 Creat-0.4 Na-138 K-4.8 Cl-106 HCO3-22 AnGap-10 <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum floor for treatment of your left lower extremity cellulitis (infection). You received 2 doses IV antibiotics and your infection improved significantly. It is very important that you continue taking the antibiotics as prescribed. You had no obstetric concerns while you were here and fetal testing was reassuring.
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Ms. ___ is a ___ yo G3p1 admitted to the Antepartum service for management of her left ankle cellulitis. Of note, she had received 1 dose of IM ceftriaxone on ___ ___s a dose of PO Keflex x1 (___) in the outpatient setting. She was started on IV ceftriaxone 1g Q8H (___) and admitted. On ___, her cellulitis was improving, and she had remained afebrile throughout the course of her admission. She was discharged home with a course of PO antibiotics. Discharge Medications: 1. Cephalexin 500 mg PO Q6H 2. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: pregnancy at 33w1d lower extremity cellulitis Discharge Condition: stable Followup Instructions: ___
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10132512-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / carbamazepine / hydrochlorothiazide / Pneumovax 23 <ATTENDING> ___ ___ Complaint: incidental finding of bilateral adnexal complex cystic masses <MAJOR SURGICAL OR INVASIVE PROCEDURE> EXPLORATORY LAPAROTOMY, BILATERAL SALPINGO-OOPHORECTOMY, CYSTOSCOPY <PHYSICAL EXAM> Physical Exam on Discharge: General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, vertical midline incision clean/dry/intact GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> Lab Results on Admission: ___ 07: 33AM BLOOD K-3.7 Lab Results on Discharge: ___ 06: 07AM BLOOD WBC-4.9 RBC-2.78* Hgb-8.3* Hct-26.0* MCV-94 MCH-29.9 MCHC-31.9* RDW-13.2 RDWSD-45.4 Plt ___ ___ 06: 07AM BLOOD Glucose-105* UreaN-51* Creat-2.1* Na-140 K-4.3 Cl-102 HCO3-23 AnGap-15 ___ 06: 07AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.0 <MEDICATIONS ON ADMISSION> 1. Amlodipine. 2. Calcitriol. 3. Carvedilol. 4. Voltaren. 5. Estrace vaginal cream. 6. Fluticasone. 7. Furosemide. 8. Gabapentin. 8. Lisinopril. 9. Oxycodone/acetaminophen. <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Please do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID Do not take if having loose stools RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 3. Ferrous Sulfate 325 mg PO DAILY can cause constipation, take with stool softener RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth every day Disp #*30 Tablet Refills: *6 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Please do not drink or drive while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*60 Tablet Refills: *0 5. amLODIPine 10 mg PO DAILY 6. Capsaicin 0.025% 1 Appl TP TID 7. Carvedilol 6.25 mg PO BID 8. Furosemide 20 mg PO BID 9. Gabapentin 100 mg PO QHS 10. Omeprazole 20 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> BILATERAL SEROUS CYSTADENOMAS <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. While you were here, we noticed that you had an abnormal heart rhythm. We ordered labs to make sure your heart was not damaged and these came back normal. We also consulted Cardiology. They recommended doing imaging of your heart called an echocardiogram. This showed no changes from your prior imaging. Cardiology reviewed your work up and said the rhythm seen was premature beats and no further work up or treatment was needed. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparotomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with Tap Block, IV tramadol and Acetaminophen. Her diet was advanced without difficulty and she was transitioned to oral Oxycodone and Acetaminophen. On post-operative day #2, her urine output was adequate so her Foley catheter was removed and she voided with self-straight catherization, which is her baseline. On POD #2 the patient was found to be anemic to 8.1mg/dL and 25.5 mg/dL, hemoglobin and hematocrit respectively. She was started on oral Ferrous Sulfate and encouraged to continue the medication until her follow-up appointment at which time her anemia will be reassessed. The patient remained asymptomatic throughout this time. She was not tachycardic or hypotensive. On POD#3, patient had a pattern recorded on telemetry concerning for possible A. fib. EKG was done and showed sinus bradycardia. Troponins were negative. Cardiology was consulted and recommended TSH and echo. TSH came back within normal limits. Echocardiogram showed no changes from her prior. Cardiology reviewed her telemetry and said rhythm was sinus tachycardia with premature beats and not A. fib. Scheduled a follow up appointment with PCP. By post-operative day #5, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10132512-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / carbamazepine / hydrochlorothiazide / Pneumovax 23 <ATTENDING> ___ ___ Complaint: abdominal pain, erythema/warmth surrounding incision <MAJOR SURGICAL OR INVASIVE PROCEDURE> incision & drainage of wound <HISTORY OF PRESENT ILLNESS> ___ yo with stage IV chronic kidney disease s/p ex-lap, BSO, cystoscopy on ___ for bilateral serous cystadenoma complicated by incisional cellulitis and UTI, now with worsening symptoms. Was seen in the ED on ___ for worsening abdominal pain and redness. Abdominal/pelvic CT showed: Irregularly shaped fluid collection in the anterior abdominal wall to the right of midline. While this may represent a seroma the surrounding fat stranding and skin thickening raises the possibility of infection. The collection would be amenable to ultrasound-guided aspiration or catheter drainage if warranted. In the ED she was also found to have hyperkalemia (6.1 -> 4.4) and ___ (3.1 -> 2.9, baseline), both of which resolved with IV fluids. One exam she was found to have signs concerning for incisional cellulitis, did not open on probing. She was received 1 dose of anceph and then started on a 7 day course of doxycycline. She was subsequently discharged with plan for outpatient follow-up. Her urine culture also grew e. coli (pan sensitive with exception to ampicillin and Bactrim) and was prescribed cefpodoxime for 7 days, which she started today. However, she reports worsening abdominal pain today despite taking 3 doses of Percocet. She also feels as if her incisional redness is worse. She reports feeling well today with no other complaints other than being surprised by her diagnosis. She is cold but states that this is at baseline. She denies any early satiety, unintentional weight changes, nausea/vomiting, SOB/CP, increased abdominal girth, abdominal or pelvic pain, postmenopausal/abnormal bleeding, vaginal discharge, or change in her bowel or bladder habits. <PAST MEDICAL HISTORY> OB/GYN History: - G0 - LMP prior to hysterectomy - Remote history of CT PAST MEDICAL HISTORY: - stage IV chronic kidney disease, fluid restricts - HTN - osteoarthritis, osteoporosis - gastritis - bladder dysfunction requiring intermittent self catheterization PAST SURGICAL HISTORY: - left knee surgery - total abdominal hysterectomy for fibroid uterus (___) - ex-lap, bilateral salpingo-opphorectomy, ___ <PHYSICAL EXAM> Physical Exam on Admission: General: NAD, A&O x3 CV: RRR Resp: CTAB Abd: vertical midline incision with surrounding blanching erythema extending 5cm outward bilaterally. 4x4cm hardened mass palpated above umbilicus. Incision and mass tender to palpation. 2cm area of non expressible pus on lower aspect of incision. Pelvic: Ext: no swelling, edema, calf tenderness. Physical Exam on Discharge: General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, dressing clean/dry/intact GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> Labs on Admission: ___ 06: 30AM BLOOD WBC-6.0 RBC-2.70* Hgb-8.1* Hct-25.8* MCV-96 MCH-30.0 MCHC-31.4* RDW-12.7 RDWSD-44.4 Plt ___ ___ 06: 30AM BLOOD Plt ___ ___ 06: 30AM BLOOD Calcium-9.6 Phos-5.7* Mg-2.3 Imaging: Abdominal US: Transverse and sagittal images were obtained of the superficial tissues of the anterior abdominal wall at previous surgical incision site demonstrates an anechoic collection measuring approximately 5.3 x 6.6 x 1.2 cm without adjacent increased vascularity. Labs on Discharge: ___ 06: 25AM BLOOD WBC-6.9 RBC-2.82* Hgb-8.2* Hct-25.5* MCV-90 MCH-29.1 MCHC-32.2 RDW-12.9 RDWSD-42.5 Plt ___ ___ 06: 25AM BLOOD Plt ___ ___ 06: 25AM BLOOD Glucose-100 UreaN-74* Creat-2.6* Na-140 K-4.2 Cl-98 HCO3-20* AnGap-22* ___ 06: 25AM BLOOD Calcium-10.1 Phos-4.8* Mg-2.0 <MEDICATIONS ON ADMISSION> 1. Amlodipine. 2. Calcitriol. 3. Carvedilol. 4. Voltaren. 5. Estrace vaginal cream. 6. Fluticasone. 7. Furosemide. 8. Gabapentin. 8. Lisinopril. 9. Oxycodone/acetaminophen. <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID Do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 6 hours Disp #*44 Capsule Refills: *0 3. Docusate Sodium 100 mg PO BID do not take if having loose stools RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 4. Levofloxacin 750 mg PO Q48H RX *levofloxacin 750 mg 1 tablet(s) by mouth every 48 hours Disp #*6 Tablet Refills: *0 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H: PRN Pain - Moderate Please do not drink or drive while taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*15 Tablet Refills: *0 6. amLODIPine 10 mg PO DAILY 7. Carvedilol 6.25 mg PO BID 8. diclofenac sodium 0.01 % topical BID 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. Furosemide 20 mg PO BID 11. Gabapentin 200 mg PO QHS 12. Lisinopril 40 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> wound cellulitis Wound assessment: Location: Abdomen Type/Etiology/Stage: Surgical wound Size: 9 X 5 X 3 with tunneling at wound base, proximal tunnel 3 cm and distal tunnel 2.5 cm Wound bed: light pink 90%, 10 % stringy slough Wound edges: attached, Exudate: milky white thin foul smelling drainage at two tunneling sites, large amount Odor: malodorous Periwound tissue: intact Wound Pain: moderate <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service for infection of your incision site. You were started on intravenous antibiotics to treat this infection. We did an ultrasound of your abdomen and a collection of fluid was seen underneath your incision. We opened up your incision at the bedside and drained the fluid. The Wound Nurse was consulted and she recommended continued daily wound dressing changes. You will have ___ nursing to help you with the wound at home. They will assess your need for a wound-vacuum as discussed and place one as indicated. The Infectious Disease team was consulted and gave us antibiotic recommendations to treat the infection. We then transitioned you from intravenous to oral antibiotics. Please continue to take these antibiotics as prescribed. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service for worsening abdominal pain and cellulitis of incision. On HD#1, she was started on IV Cefzolin. An abdominal ultrasound was performed that demonstrated a subcutaneous anterior abdominal wall incisional site collection measuring up to 6.6 cm most consistent with seroma. On HD#2, bedside incision and drainage was performed. Wound was opened, irrigated with NS, and debrided. It was packed with wet to dry dressings changed twice a day. Infectious disease was consulted to give antibiotic recommendations given her Stage IV chronic kidney disease and penicillin allergy. Infectious disease recommended IV vancomycin, ceftriaxone, and PO flagyl. On HD#5, she was transition to PO levofloxacin and clindamycin for a total of 14-day course from source control on HD#2. A Wound Nursing consult was placed. They recommended daily dressing changes with anti-microbial dressing. She was discharged home with ___ services for daily dressing changes with plan for wound-vac placement when indicated. On hospital day #5, she developed mild diarrhea. C. diff was sent and this came back negative. By hospital day #6, she was tolerating a regular diet, self catheterizing per baseline, ambulating with walker per baseline independently, pain was controlled with oral medications, and she was transitioned to oral antibioics. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10132628-DS-24
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodine-Iodine Containing / Darvon / Penicillins / Tetracycline / Erythromycin Base <ATTENDING> ___. <CHIEF COMPLAINT> Left sided vulvar cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> LEFT INGUINAL SENTINEL LYMPH NODE DISSECTION, LEFT PARTIAL RADICAL VULVECTOMY <HISTORY OF PRESENT ILLNESS> Dear ___, NP: Thank you very much for your referral ___ to our gynecologic oncology practice at ___. As you know she is a lovely ___ gravida 4 para 1 with a new diagnosis of a left-sided vulvar cancer. She reports she has noted an abnormal growth on the left side of her vagina for the last 6 months. She initially presented to Dr. ___ in ___ after an analysis of her urine cytology revealed atypical squamous cells with koilocytosis consistent with HPV related changes. On exam she was noted to have a left labia minora 0.5 cm lesion with irregular borders and firm to palpation. A Pap smear of the vagina with co-testing was performed which was negative for intraepithelial lesion or malignancy and high risk HPV negative. Patient then met with ___ conserve a of gynecology for a colposcopy and vulvar biopsy. At that time a 1.5 cm irregular raised lesion at the base of the left labia was noted. A vaginal biopsy at 9 at the apex and at the base of the left labia were obtained. Pathology from these biopsies on ___ 18 demonstrated in the left labia invasive squamous cell carcinoma keratinizing type arising in a background of squamous intraepithelial lesion and the 9: 00 biopsy was benign. Of note, patient has a distant history of a hysterectomy around ___ or ___ reportedly for cervical cancer. She denies any additional treatment with radiation or chemotherapy. She has had no issues with dysplasia since then. Complete 14 point review of systems is notable for chronic issues with nausea vomiting and heartburn, urinary frequency significant arthralgias or myalgias related to her arthritis, alopecia, weakness and insomnia. The remainder of a 14 point review of systems is negative <PAST MEDICAL HISTORY> MEDICAL HISTORY: 1. Rheumatoid arthritis 2. Osteoarthritis 3. History of cervical cancer 4. Chronic pain and opioid use 5. Osteoporosis 6. Factor V Leiden 7. Smoking PREVENTIVE HEALTH - [x] Vaccinations: Td ___, PPSV ___, PCV ___ [x] Pap done ___ due (diagnostic), normal, HR HPV NEG [X] Colonoscopy due ___ (last ___ [x] Mammography due ___ (last ___, BIRADS 0, non-diagnostic) [x] Last PCP ___ ___ PAST SURGICAL HISTORY: 1. Right total hip replacement at ___ ___ 2. Right toe amputation at ___ ___ 3. Hysterectomy at ___ in ___ 4. Gastrectomy due to bleeding ulcers 5. Bilateral carpal tunnel surgery (x 4 times) at BI 6. Repair of shoulder tears bilaterally at BI PAST OB HISTORY: G4P2021 - SABx2 - Stillborn - SVD ___ PAST GYNECOLOGIC HISTORY: History of cervical cancer as described above. Menarche at age ___, periods stopped at time of hysterectomy in ___. She is not certain whether or not she had her ovaries removed. She never had hot flashes. Periods were previously monthly with normal bleeding. She is not currently sexually active. Last Pap was in ___ with findings as above. She has had breast aspirations for benign disease previously. She denies any sexually transmitted infections or pelvic infections. ALLERGIES: IVP dye, Darvon, penicillin, erythromycin, tetracycline --> abx cause swelling, "stop breathing" <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: Denies history of breast cancer or colon cancers. She has a sister who she is not sure what the origin of her cancer was but had either ovarian, uterine or cervical cancer. She had a hysterectomy but it does not think she had additional treatment. Mother with heart disease, hypertension and kidney disease. Sister with diabetes. <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM --======== CONSTITUTIONAL: Well appearing, NAD NEURO: A&Ox3, normal gait PSYCH: Normal affect HEENT: NCAT, EOMI, Sclera anicteric, Neck supple, no masses LYMPH NODES: No supraclavicular, cervical or inguinal adenopathy. PULM: CTAB, no wheeze, crackles CV: RRR, normal S1 and S2, no murmurs GI: Soft, ND, NT. Surgical scars seen well healed. No hepatosplenomegaly, no masses palpable GU: No CVA tenderness, NEFG with lichen like changes bilaterally in interlabial folds anteriorly. Raised 1.5 x 2cm lesion at left posterior labia approximately 1-2cm from the anal verge, firm, irregular borders. Otherwise normal urethral meatus. Normal vaginal vault no blood or discharge, apex without lesions. Bimanual: Smooth vaginal walls, apex without lesions. No pelvic masses or tenderness. Rectovaginal: Normal tone, smooth RV septum, no nodularity. No encroachment, i.e. 1-2cm of normal tissues between the lesion close and the anus and anal sphincter MSK: Extremities WWP. ___ without edema, nontender. --======== PHYSICAL EXAM ON DISCHARGE: --======== On day of discharge: Afebrile, vitals stable General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, inguinal incision with surrounding bruising but otherwise clean/dry/intact without induration, vaginal incision intact, left inner thigh with blanching erythema radiating towards mons pubis without induration/fluctuance/drainage GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> --======== RELEVANT LABS: --======== CBC WITH DIFFERENTIAL ___ 06: 13AM BLOOD WBC-15.4* RBC-3.67* Hgb-10.9* Hct-35.1 MCV-96 MCH-29.7 MCHC-31.1* RDW-14.8 RDWSD-52.3* Plt ___ ___ 12: 30AM BLOOD WBC-16.3* RBC-3.41* Hgb-10.1* Hct-32.2* MCV-94 MCH-29.6 MCHC-31.4* RDW-15.0 RDWSD-52.1* Plt ___ ___ 06: 25AM BLOOD WBC-16.0* RBC-3.37* Hgb-10.1* Hct-32.0* MCV-95 MCH-30.0 MCHC-31.6* RDW-15.0 RDWSD-52.7* Plt ___ ___ 06: 05AM BLOOD WBC-12.7* RBC-3.29* Hgb-9.9* Hct-31.6* MCV-96 MCH-30.1 MCHC-31.3* RDW-15.1 RDWSD-53.0* Plt ___ ___ 06: 13AM BLOOD Neuts-77.7* Lymphs-14.1* Monos-6.5 Eos-0.8* Baso-0.3 Im ___ AbsNeut-11.93* AbsLymp-2.17 AbsMono-1.00* AbsEos-0.13 AbsBaso-0.04 ___ 12: 30AM BLOOD Neuts-81.1* Lymphs-9.3* Monos-8.0 Eos-0.9* Baso-0.2 Im ___ AbsNeut-13.20* AbsLymp-1.51 AbsMono-1.30* AbsEos-0.14 AbsBaso-0.04 ___ 06: 25AM BLOOD Neuts-80.2* Lymphs-9.8* Monos-8.3 Eos-0.9* Baso-0.2 Im ___ AbsNeut-12.85* AbsLymp-1.57 AbsMono-1.33* AbsEos-0.14 AbsBaso-0.03 ___ 06: 05AM BLOOD Neuts-78.8* Lymphs-9.7* Monos-8.1 Eos-2.4 Baso-0.4 Im ___ AbsNeut-10.03* AbsLymp-1.23 AbsMono-1.03* AbsEos-0.30 AbsBaso-0.05 BMP, ELECTROLYTES ___ 06: 13AM BLOOD Glucose-71 UreaN-21* Creat-0.9 Na-140 K-4.3 Cl-103 HCO3-26 AnGap-11 ___ 06: 25AM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-139 K-4.3 Cl-102 HCO3-27 AnGap-10 ___ 06: 05AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-142 K-4.6 Cl-106 HCO3-28 AnGap-8* ___ 06: 13AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.3 ___ 06: 25AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1 ___ 06: 05AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1 URINALYSIS ___ 07: 56PM URINE Color-Straw Appear-Clear Sp ___ ___ 07: 56PM URINE Blood-MOD* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 07: 56PM URINE RBC-14* WBC-18* Bacteri-NONE Yeast-NONE Epi-0 --======== RELEVANT MICROBIOLOGY: --======== ___ 7: 56 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. __________________________________ ___ 12: 30 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___________________________________ ___ 12: 45 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. --======== RELEVANT IMAGING: --======== N/A <MEDICATIONS ON ADMISSION> -Abetacept 125 mg sc weekly (held x 2 weeks pre-op) -folic acid 1mg daily -hydroxycloroquine 200 mg daily (patient reports she has not yet started this med) -methotrexate 25 mg sc weekly (held x 1 week pre-op) -MS ___ ER 15 mg TID + morphine ER 30mg TID -oxycodone ___ mg q6h PRN -ranitidine 150 mg BID -omeprazole 40 mg daily -simvastatin 20 mg qHS -Ferrous sulfate -Multivitamin, D3 -Nicotine patch, lozenges <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H Do not take more than 4000 mg per day. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID Hold for loose bowel movements. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Do not drive or drink alcohol while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 6. Sulfameth/Trimethoprim DS 2 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by mouth twice a day Disp #*13 Tablet Refills: *0 7. Hydroxychloroquine Sulfate 200 mg PO DAILY 8. Morphine SR (MS ___ 15 mg PO DAILY 9. Nicotine Patch 21 mg/day TD DAILY 10. Omeprazole 20 mg PO DAILY 11. Ranitidine 150 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> INVASIVE SQUAMOUS CELL CARCINOMA OF THE VULVA <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Post-operative instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Vulvar Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * please use ___ bottle to clean the vulva with warm water after each time you use the bathroom and pat dry afterwards * Please use ___ baths ___ times a day starting two days after surgery to help keep the area clean. please pat dry afterwards. * Use ice packs on the vulva for ___ days after surgery to help with the swelling. * Take Colace stool softener ___ times daily and senna once a day to help keep your stool soft and prevent constipation and straining. ___ hold for loose stool. You were prescribed antibiotics for a very early skin infection near your incision. Please complete the entire 7-day course. Please call if you notice increased pain, redness, drainage from the incision or you develop fevers or chills. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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DISCHARGE SUMMARY BRIEF HOSP COURSE -- Ms. ___ was admitted to the gynecologic oncology service after undergoing left partial radical vulvectomy and left inguinal sentinel lymph node dissection for vulvar cancer. Please see the operative report for full details. Her post-operative course is detailed by problem as follows: *) Post-operative Immediately postoperatively, her pain was suboptimally controlled with her home regimen of MS ___ with IV ___ Tylenol/oxycodone and breakthrough IV morphine. Given her chronic opioid use, the Chronic Pain Service was consulted for further recommendations regarding management of her post-operative pain, and she was transitioned to a Dilaudid PCA with IV Toradol + IV ativan PRN. Her diet was advanced without difficulty and she was transitioned to her home dosage of MS ___ with scheduled ___ and PO oxycodone/ibuprofen PRN. On post-operative day #2 (___), her urine output was adequate so her Foley catheter was removed; she was unable to void and had a Foley replaced for 600 cc of urine. After 24 hours of additional bladder rest, her Foley was removed with a trial of void after backfill with 300 cc on post-operative day #3 ___ she passed her trial of void after voiding 250 cc with a post-void residual of 150 cc. By post-operative day #3 (___), she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. *) Post-operative fever Ms. ___ developed a fever on post-operative day #1 (___) with a Tmax of 101.9 F. Patient reported malaise, chills, and irritative voiding symptoms. Her physical exam was overall reassuring, though notable for mild bibasilar crackles that resolved with deep inspiration and induration at the margins of her vulvar incision. Her labs were notable for a leukocytosis to 16.3 with left shift. A urinalysis showed no evidence of infection. Blood cultures and urine cultures collected at the time of her fever were negative. She remained afebrile for the remainder of her admission. *) Nonpurulent cellulitis On post-operative day #3 (___), a region of blanching erythema extending from the inner thigh to the mons pubis was noted on exam. No induration or fluctuance was noted. She was afebrile and otherwise asymptomatic. She was initiated on a course of Bactrim DS 2 tablets BID x 7 days for empiric treatment of cellulitis. *) Rheumatoid arthritis, osteoarthritis on chronic opioids: She was continued on her home regimen of MS ___ 45 mg TID. The Chronic Pain Service was consulted for optimization of her acute post-operative pain regimen as described above. Her methotrexate and Abetacept injections were held prior to surgery for 1 and 2 weeks respectively at the recommendation of her outpatient rheumatologist. Her Plaquenil was held, as she reported she had not yet initiated treatment with this new medication prior to surgery. *) Factor V ___, remote history of DVT She was treated with prophylactic dosing of Lovenox during her admission. It was determined that continued outpatient anticoagulation was not indicated.
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodine-Iodine Containing / Darvon / Penicillins / Tetracycline / Erythromycin Base / shellfish derived <ATTENDING> ___. <CHIEF COMPLAINT> stage IB squamous cell carcinoma of the vulva <MAJOR SURGICAL OR INVASIVE PROCEDURE> posterior partial simple vulvectomy <HISTORY OF PRESENT ILLNESS> ___ is a ___ s/p TAH (___) for h/o cervical cancer now s/p left partial radical vulvectomy, left inguinal SLND for vulvar cancer on ___ for stage IB squamous cell carcinoma of the vulva c/b vulvar wound dehiscence. An initial surveillance biopsy in ___ was negative for malignancy. More recently, in ___ she had a vulvar colposcopy with 2 vulvar biopsies. The 6: 00 biopsy revealed HSIL/dVIN in the 2: 00 biopsy showed lichen sclerosis. She presents today to discuss management of this. Of note, the last few weeks have been fairly eventful for her. Her husband who has multiple chronic illnesses including diabetes has been quite ill and last weekend the roof partially blew off their house. Her arthritis has also recently flared and is on a prednisone taper currently. Otherwise, she denies any vaginal bleeding, vulvar pain or irritation or palpable lesions. No urinary or bowel symptoms. ROS: Otherwise 10 point review of systems is negative except as above. Oncological History: - ___: Presented w/ complaint of abnormal growth on L side of vagina x 6 months + urine cytology w/ LSIL/atypical squamous cells with koilocytosis consistent with HPV related changes - Pap NILM, hrHPV neg - ___: colpo + vulvar biopsy, 1.5cm irregular raised lesion noted at base of L labia, pathology showing invasive squamous cell carcinoma keratinizing type, arising in a background of squamous intraepithelial lesion. - ___ PET scan showed no e/o metastatic disease, focal increased FDG avidity in the vulvar region without associated soft tissue mass, with an SUV max of 26 - ___ L inguinal sentinel LND, L partial radical vulvectomy -- Final pathology: L inguinal sentinel lymph node negative for malignancy; 15mm invasive squamous cell carcinoma w/ negative margins >8mm -- Diagnosis: stage IB squamous cell carcinoma of the vulva -- Tumor board recommendations: observation -- ___: developed dehiscence of the vulvar incision and left inguinal seroma s/p 14 day course of Bactrim given c/f cellulitis(last dose on ___. -- ___: Left vulva biopsy at 7 o'clock was benign -- ___: 6 o'clock, HSIL/dVIN, 2 o'clock lichen sclerosis <PAST MEDICAL HISTORY> MEDICAL HISTORY: 1. Rheumatoid arthritis 2. Osteoarthritis 3. History of cervical cancer 4. Chronic pain and opioid use 5. Osteoporosis 6. Factor V Leiden 7. Smoking PREVENTIVE HEALTH - Vaccinations: Td ___, PPSV ___, PCV ___ Colonoscopy due ___ (last ___ Mammography due ___ (last ___, BIRADS 0, non-diagnostic) PAST SURGICAL HISTORY: 1. Right total hip replacement at BI ___ 2. Right toe amputation at BI ___ 3. Hysterectomy at ___ in ___ 4. Gastrectomy due to bleeding ulcers 5. Bilateral carpal tunnel surgery (x 4 times) at ___ 6. Repair of shoulder tears bilaterally at ___ PAST OB HISTORY: ___ - SABx2 - Stillborn - SVD ___ PAST GYNECOLOGIC HISTORY: History of cervical cancer as described above. Menarche at age ___, periods stopped at time of hysterectomy in ___. She is not certain whether or not she had her ovaries removed. She never had hot flashes. Periods were previously monthly with normal bleeding. She is not currently sexually active. Dysplasia history as above. She has had breast aspirations for benign disease previously. She denies any sexually transmitted infections or pelvic infections. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies history of breast cancer or colon cancers. She has a sister who she is not sure what the origin of her cancer was but had either ovarian, uterine or cervical cancer. She had a hysterectomy but it does not think she had additional treatment. Mother with heart disease, hypertension and kidney disease. Sister with diabetes. <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM --======== Vital Signs sheet entries for ___: BP: 135/75. Heart Rate: 67. Weight: 135.7 (With Clothes; With Shoes). Height: 62. BMI: 24.8. Exam deferred today Exam from ___ below: Gen: NAD, well appearing female GI: Soft, ND, NT GU: No CVAT, completely healed vulvar dehiscence. AWE change bilaterally in fold of labia minora/majora adjacent to clitoral hood with loss of architecture c/w lichen sclerosis increased from prior. Increased white changes most prominent at ___ o'clock position, faint changes much improved from prior from ___ o'clock and ___ o'clock in a geopgraphic pattern of lesions with no associated vascular change. These are also all increased with application of acetic acid for vulvar colposcopy. Biopsy note below. MSK: Ext WWP, nontender, no edema --======== PHYSICAL EXAM ON DISCHARGE: --======== On day of discharge: Afebrile, vitals stable Gen: No acute distress CV: RRR Pulm: CTAB Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: non-tender, non-edematous <MEDICATIONS ON ADMISSION> MS ___, oxycodone, methotrexate, abatacept <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H Do not take more than 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO TID Hold for loose stool 3. Hydroxychloroquine Sulfate 200 mg PO DAILY 4. Methotrexate 0.7 mg SC 1X/WEEK (MO) <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> differentiated vulvar intraepithelial neoplasia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Vulvar Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * please use ___ bottle to clean the vulva with warm water after each time you use the bathroom and pat dry afterwards * Please use ___ baths ___ times a day starting two days after surgery to help keep the area clean. please pat dry afterwards. * Use ice packs on the vulva for ___ days after surgery to help with the swelling. * Take Colace stool softener ___ times daily and senna once a day to help keep your stool soft and prevent constipation and straining. ___ hold for loose stool. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service after undergoing posterior partial simple vulvectomy for dVIN/HSIL. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid. Her diet was advanced without difficulty and she was transitioned to PO MS ___. On post-operative day 1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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