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10133828-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / ciprofloxacin / latex / talc <ATTENDING> ___ <CHIEF COMPLAINT> INCOMPLETE UTEROVAGINAL PROLAPSE, STRESS URINARY INCONTINENCE <MAJOR SURGICAL OR INVASIVE PROCEDURE> BILATERAL TRANSVAGINAL SACROSPINOUS LIGAMENTS HYSTEROPEXY USING I-STOP SYNTHETIC BAND, SUBURETHRAL SLING, CYSTOSCOPY AND PERINEORRHAPHY <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ nulliparous who presented in the office for consultation requested by Dr. ___ vaginal prolapse. The patient reports a history of noticeable prolapse since ___. She has been managed with a pessary successfully. Approximately ___ years ago she started experiencing recurrent UTI episodes that have been challenging to manage. She experiences dysuria, change in odor and increase in frequency as symptoms of UTIs. She has had to resort to daily prophylaxis with nitrofurantoin prescribed by Dr. ___. She also reports episodes of urge incontinence for which she was started on 5 mg of oxybutynin. She is voiding ___ times a day 2 times per night. She changes ___ pads per day. She reports her urinary flow as "normal". She only has 1 cup of coffee daily and denies any other consumption of bladder irritants. She is comfortable managing her pessary and reports protruding prolapse when she takes it out. She has seen Dr. ___ who recommended a different pessary. She does admit to history of vaginoplasty. Mrs. ___ denies any constipation. She is sexually active and does not experience any dyspareunia. She is otherwise without any other clinically significant complaints. <PAST MEDICAL HISTORY> The patient had past history significant for bladder exstrophy who is status post multiple abdominal surgeries, vaginoplasty and hernia repair. PAST SURGICAL HISTORY Multiple lower abdominal surgery regarding her bladder exstrophy. Knee surgeries x3 Vaginoplasty ___ Jaw surgery Hernia Cholecystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Ovarian or Colon cancer. + Maternal grandmother and paternal cousin with a history of breast cancer <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, appropriately tender, no rebound/guarding; prominent lower abdominal scarring; incision clean, dry, intact Ext: no tenderness to palpation <PERTINENT RESULTS> ___ 07: 15AM BLOOD WBC-11.9* RBC-4.40 Hgb-12.2 Hct-38.5 MCV-88 MCH-27.7 MCHC-31.7* RDW-12.7 RDWSD-40.6 Plt ___ ___ 07: 15AM BLOOD Plt ___ <MEDICATIONS ON ADMISSION> Nitrofurantoin 100 mg daily Premarin cream Oxybutynin Vitamin D Claritin Omeprazole <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not take more than 4000 mg (8 tablets) per day. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 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: *1 3. 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 #*40 Tablet Refills: *0 4. 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 #*20 Tablet Refills: *0 5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 6. Omeprazole 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal prolapse stress incontinence <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 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. * 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. 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 Bilateral transvaginal sacrospinous ligament hysteropexy using I-Stop synthetic band; Suburethral sling; Cystoscopy; Perineorrhaphy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV morphine/ATC 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/acetaminophen. 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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10143519-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> FEVER AND CHILLS ON DISCHARGE DAY FROM LAPRASCOPIC RESECTION FOR ECTOPIC PREGNANCY <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ year old POD2 from laparoscopic right salpingectomy for heterotopic pregnancy presents with fevers at home to 100.4, 100.6, and with a maximum temp to 101.2. She was discharged today and was doing fine at home until developing chills this afternoon. No shortness of breath. No chest pain. Has minimal abdominal pain. No nausea, vomiting, or diarrhea. No new rashes. No vaginal bleeding or discharge. Denies back pain. No dysuria. Of note, her ___ hospital course was complicated by urinary retention, requiring re-catheterization. <PAST MEDICAL HISTORY> POBHx: G4P2 -___ Ectopic pregnancy - unable to locate the pregnancy and had abnl HCG level - s/p MTX tx -___ SVD at term uncomplicated -___ SVD at term uncomplicated -___ current pregnancy (fail to get pregnant after 7 mths, this was her first cycle of Clomid and timed intercourse); complicated by heterotopic pregnancy s/p right salpingectomy PGynHx: denies hx of STDs or hx of abnl paps PMH: denies PSH: ___ -> laparoscopic right salpingectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> on admission: Exam: T: 98.8, HR 104 (up to 115), BP 116/71, RR 20, O2sat 98% on RA Gen: ill-appearing, but NAD CV: Tachycardic to 100s, no M/R/G Lungs: CTAB Abd: softly distended, no R/G. Incision: c/d/i, no erythema Back: +CVAT on right Vaginal exam: deferred <PERTINENT RESULTS> ___ 07: 40AM WBC-8.2 RBC-2.72* HGB-8.3* HCT-24.6* MCV-91 MCH-30.5 MCHC-33.7 RDW-12.6 ___ 07: 40AM WBC-8.2 RBC-2.72* HGB-8.3* HCT-24.6* MCV-91 MCH-30.5 MCHC-33.7 RDW-12.6 ___ 07: 40AM NEUTS-85.9* LYMPHS-9.8* MONOS-3.6 EOS-0.6 BASOS-0 ___ 07: 40AM PLT COUNT-194 ___ 09: 52PM WBC-11.8* RBC-2.77* HGB-8.3* HCT-24.5* MCV-88 MCH-29.9 MCHC-33.9 RDW-12.7 ___ 09: 52PM NEUTS-83.4* LYMPHS-11.4* MONOS-4.3 EOS-0.8 BASOS-0.2 ___ 09: 52PM PLT COUNT-174 ___ 09: 52PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09: 52PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM ___ 09: 52PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-5 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Levothyroxine Sodium 50 mcg PO 1X/WEEK (SA) 4. Prenatal Vitamins 1 TAB PO DAILY 5. Cephalexin 500 mg PO Q12H RX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Urinary tract infection Possible pyelonephritis <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 fevers and concern for urinary tract infection vs. a kidney infection called pyelonephritis. You were treated with IV antibiotics and remained without a fever while you were here, so we felt it was safe for you to go home and take antibiotics by mouth. Please follow these instructions: *) Take antibiotic as prescribed *) If you have any fevers (>100.4), or if you have back pain, pain with urination, or difficulty urinating call your doctor
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IV Abx, ceftriaxone for ___febrile repeated CBC wnl, Hct stable urine showed >100,000 Staph Aureus coag + sensitivities pending on discharge
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| 42
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10143896-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> left breast pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> breast I&D <HISTORY OF PRESENT ILLNESS> ___ yo ___ presents to the ED with worsening left breast pain in the setting of being treated for mastitis. Had been taking dicloxacillin from ___ until ___. However, upon follow-up at ___ reports it was not improving so her antibiotics were switched. She had not filled the prescription yet and did not know what antibiotic it was. She denies fever or chills but has significant left breast pain. She did not take anything for the pain. She stopped breast feeding on ___ due to pain. <PAST MEDICAL HISTORY> POB/GYNH: - G3P2102, SVDx3- two full term, one 32 week IUFD - Hx of chlamydia in past - H/o LSIL pap in past PMH: Denies Psurgh: Denies Meds: tylenol, motrin All: NKDA SH: ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On admission Temp: 99 HR: 60 BP: 126/73 Resp: 18O2 Sat: 99 Gen: NAD CV: RRR Pulm: CTAB Breast: diffuse edema and erythema of left breast between 10 and 3 o'clock. Extremely tender and warm on palpation. No discrete area of abscess. Abd: soft, nontender Ext: nontender Labs: 12.2>10.1/34.8<339 N: 77.6 L: 14.9 M: 5.0 E: 2.1 Bas: 0.5 140 104 4 ----------- < 85 3.9 25 0.5 On day of discharge Left breast, erythema and induration have greatly improved. Dressing is clean/dry/intact. Bed of wound is clean with pink granulation tissue <PERTINENT RESULTS> ___: 00AM BLOOD WBC-9.0 RBC-3.76* Hgb-9.0* Hct-30.3* MCV-81* MCH-23.9* MCHC-29.6* RDW-14.7 Plt ___ ___ 07: 15AM BLOOD WBC-10.2 RBC-4.00* Hgb-9.5* Hct-32.6* MCV-81* MCH-23.6* MCHC-29.0* RDW-14.8 Plt ___ ___ 09: 50PM BLOOD WBC-12.2* RBC-4.30 Hgb-10.1* Hct-34.8* MCV-81* MCH-23.6* MCHC-29.2* RDW-14.6 Plt ___ ___ 07: 00AM BLOOD Neuts-75.2* Lymphs-16.5* Monos-5.5 Eos-2.6 Baso-0.2 ___ 07: 15AM BLOOD Neuts-75.6* Lymphs-15.4* Monos-5.3 Eos-2.7 Baso-1.0 ___ 09: 50PM BLOOD Neuts-77.6* Lymphs-14.9* Monos-5.0 Eos-2.1 Baso-0.5 <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure taking care of you while you were at ___. You were admitted with a breast abscess and recieved IV medication to treat your abscess. You also recieved drainage by radiology and surgical treatment by the breast surgery team. You were found to have an infection with staph (MSSA). You were felt to be safe to be discharged and should follow up with your outpatient docotor and continue taking antibiotics and dressing changes as prescribed.
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Ms. ___ was admitted for treatment of mastitis with underlying breast abscess. She underwent an ultrasound guided drainage and spontaneous drainage on ___ which largely decompressed the abcess. On the morning of ___ the collection had greatly increased and the breast surgery service was consulted. Ms. ___ underwent a bedside incision and drainage of the left breast abscess. She had twice daily wet to dry dressing changes and was discharged home on ___ with services for dressing changes at home. Ms. ___ remained afebrile and stable during her hospitalization. Wound cultures grew pan sensitive staph and she was discharged home with PO Dicloxacillin. Discharge Medications: 1. DiCLOXacillin 500 mg PO Q6H Follow up with your outpatient doctor within 10 days to determine if you need longer treatment. RX *dicloxacillin 500 mg 1 capsule(s) by mouth every 6 hours Disp #*56 Capsule Refills:*0 2. Ibuprofen 600 mg PO Q8H:PRN pain do not take more than prescribed. Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills:*1 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain Do not drive. Do not take more than 4000mg tylenol (acetaminophen) per day. RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth 30 minutes prior to dressing change Disp #*10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: breast abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10144035-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex <ATTENDING> ___. <CHIEF COMPLAINT> endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oopherectomy, pelvic lymph node dissection <HISTORY OF PRESENT ILLNESS> ___ woman with hx of several weeks of pelvic cramping, straining to urinate and vaginal spotting which prompted evaluation. Pelvic ultrasound ___ showed a normal sized uterus with a focal endometrial lesion measuring 1.5cm. She then underwent office hysteroscopy with biopsy on ___. Pathology showed grade 2 endometriod endometrial adenocarcinoma. Patient denies weight changes, SOB/CP, changes in bowel habits. Recent feeling of needing to strain with urination as above. She presented for planned robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oopherectomy, and staging. <PAST MEDICAL HISTORY> POb: - G8P6, SVD x 6, SAB x 2 PGyn: menarche at ___, regular, menopause at ___. Denies jx ofSTIs and abnl Pap tests PMH: HTN, diabetes PSH: prior cholecystectomy in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies hx of gyn and colon cancer, denies hx of clotting disorders. <PHYSICAL EXAM> On admission: NAD, well-appearing RRR CTAB Abd soft, ND, mildly and diffusely tender in lower quadrants Pelvic: nl-appearing external genitalia, atrophic vaginal mucosa, no cervical lesions Bimanual w/ nl-sized uterus, no adnexal masses or tenderness Ext without edema, NT On discharge: General: NARD, comfortable CV: RRR Lungs: CTAB Abd: Soft, appropriately diffusely tender without areas of focal tenderness, no rebound or guarding. Incision: laparoscopic incisions clean, dry, intact Extremities: nontender, no edema <PERTINENT RESULTS> ___ 11: 29AM BLOOD WBC-13.3*# RBC-4.18* Hgb-11.8* Hct-36.5 MCV-87 MCH-28.1 MCHC-32.2 RDW-12.3 Plt ___ ___ 08: 00AM BLOOD WBC-9.4 RBC-4.07* Hgb-11.6* Hct-35.6* MCV-87 MCH-28.5 MCHC-32.6 RDW-12.3 Plt ___ ___ 11: 29AM BLOOD Glucose-149* UreaN-8 Creat-0.6 Na-139 K-5.0 Cl-105 HCO3-25 AnGap-14 ___ 08: 00AM BLOOD Glucose-123* UreaN-7 Creat-0.6 Na-137 K-3.7 Cl-101 HCO3-28 AnGap-12 ___ 11: 29AM BLOOD Calcium-7.0* Phos-4.0 Mg-1.5* ___ 08: 00AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES UNDEFINED 2. Clotrimazole Cream 1 Appl TP UNDEFINED 3. Lisinopril 10 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES UNDEFINED 2. Clotrimazole Cream 1 Appl TP UNDEFINED 3. Lisinopril 10 mg PO DAILY 4. Ibuprofen 400 mg PO Q8H: PRN Pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills: *0 5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills: *0 6. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial 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: * 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 >10lbs for ___ 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 ___ 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
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On ___, Ms. ___ was admitted to the gynecology oncology service after undergoing a robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oopherectomy and pelvic lymph node dissection for grade 2 endometrioid endometrial adenocarcinoma. 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 oral percocet and motrin for pain control. She was maintained on an insulin sliding scale for her diabetes while hospitalized. She was restarted on lisinopril for hypertension on postoperative day 1. She received lovenox for venous thromboembolism prevention throughout the course of her hospitalization. By post-operative day one, 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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10144855-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> ultrasound guided cervical dilation, hysteroscopy, dilation and curretage, abdominal myomectomy, left paraovarian cystectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ ___, G0, P0, premenopausal, ___ female with fibroid uterus, migraines, urinary incontinence on ___ medical therapy and insomnia referred for GYN consultation regarding worsening menorrhagia and anemia in the setting of her known fibroids. She had a pelvic ultrasound (___), that revealed the uterus measuring 8.6 cm with multiple fibroids, the largest exophytic posterior 3.6 cm, left intramural 2.6 cm. There was an endometrial stripe of 15 mm with an 8 mm endometrial focal echogenic lesion. In addition, there was a 2.9 cm left ovarian cyst and a normal right ovary. Labs ___, revealed a hematocrit of 29.5 cm with iron of 16, and ferritin of 2.3. An office endometrial biopsy was attempted, but failed secondary to the severe cervical stenosis of the internal os. An attempt was made for cervical dilation in the office, but was unsuccessful due to patient discomfort during the procedure. After comprehensive counseling, the decision was made to proceed to the OR for an ultrasound-guided cervical dilation, hysteroscopy, D and C, and possible polypectomy pending the intraoperative findings. Inaddition, the patient opted to proceed with surgical treatment of her multi fibroid uterus given her severe menorrhagia resulting in anemia. Since numerous fibroids were noted and the patient was nulliparous, desiring future fertility, the decision was made to proceed with an abdominal myomectomy since several of the intramural fibroids would not be visible laparoscopically. In the interval from office evaluation to the OR date, the patient was treated with Lupron to improve her hematocrit to minimize the risk of blood transfusion. Her hematocrit did normalize to 42 with the Lupron therapy. <PAST MEDICAL HISTORY> OBSTETRIC HISTORY: G0 P0 GYNECOLOGIC HISTORY: - Menarche age ___, LMP ___. Menses at 23 day intervals with 6 days of cyclic menorrhagia resulting in severe anemia, see HPI. She reports notable dysmenorrhea. - Last PAP (___): Reportedly negative, results NA for my review. h/o ascus Pap (___), neg HPV testing at that time. - Pt is not currently sexually active, bisexual (male partners in the past, currently only female partners) - Contraception: None needed currently - STD History: Denies MEDICAL PROBLEMS: 1. Uterine fibroids, severe menorrhagia 2. Severe iron deficiency anemia 3. Migraine headaches 4. Urinary incontinence 5. Insomnia SURGICAL HISTORY: 1. ___, hysteroscopic "polypectomy" D&C by Dr. ___. Pathology revealed submucosal fibroid --> HSC MMY D&C 2. ___, breast reduction surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family h/o gynecologic cancers. <PHYSICAL EXAM> On discharge: Gen: NAD CV: RRR Lungs: CTAB Abd: soft, ND, inc c/d/i GU: voiding spontaneously, minimal spotting on pad Ext: WWP, calves nontender <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*55 Tablet Refills: *1 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not exceed 4000 mg acetaminophen in 24 hours. Do not drive while taking. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every six (6) hours Disp #*65 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID Take with narcotics to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroids <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) for 2 weeks * No heavy lifting of objects >10 lbs 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. 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 u/s guided cervical dilation, hysteroscopy, D+C, abd myomectomy x8, left paraovarian cystectomy; please 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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10144859-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Repair of vaginal cuff dehiscence <HISTORY OF PRESENT ILLNESS> ___ G5P5 with h/o HIV s/p TLH, BS in ___ for fibroids presented with sudden onset pain o/n at 2am. She reported she awoke at 2am with sudden onset severe abdominal pain. Had episode of emesis at the time of pain. Had some light spotting with urination when using the bathroom, not certain if it is from vagina or urine. Last BM 2 days ago, +constipation. +chills. Denied dysuria, fevers, heavy vaginal bleeding, abnormal vaginal discharge. <PAST MEDICAL HISTORY> PObHx: G5P5 - SVD x5 PGynHx: - Last Pap: ___ - Denies h/o abnormal Paps - H/o chlamydia, denies other STIs PMHx: - HIV PSHx: - H/o biopsy of buttock mass - TLH, BS - Excisional biopsy of breast <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> General: NAD, in some discomfort CV: RRR Lungs: CTAB Abdomen: soft, non-distended, tender in epigastric region GU: pad with no spotting Extremities: no edema, no TTP, pneumoboots at bedside <PERTINENT RESULTS> ___ 11: 35AM BLOOD WBC-5.0 RBC-3.76* Hgb-11.0* Hct-33.3* MCV-89 MCH-29.3 MCHC-33.0 RDW-14.7 RDWSD-47.8* Plt ___ ___ 11: 35AM BLOOD Neuts-72.1* ___ Monos-5.4 Eos-1.4 Baso-0.4 Im ___ AbsNeut-3.59 AbsLymp-1.01* AbsMono-0.27 AbsEos-0.07 AbsBaso-0.02 ___ 11: 35AM BLOOD Plt ___ ___ 11: 35AM BLOOD Glucose-87 UreaN-8 Creat-0.8 Na-140 K-3.6 Cl-104 HCO3-28 AnGap-8 ___ 08: 15AM BLOOD ALT-21 AST-48* AlkPhos-123* TotBili-0.6 ___ 11: 35AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.0 ___ 07: 09PM BLOOD Lactate-2.8* CT ___ IMPRESSION: 1. Large amount of free intraperitoneal air with a dominant pocket of free air seen in the deep pelvis. While the source is not definitively identified, it is most likely pelvic in origin. 2. Calcifications noted along the gallbladder fundal wall could reflect early porcelain gallbladder. Outpatient followup with general surgery could be considered. <MEDICATIONS ON ADMISSION> darunavir 800 mg daily; ritonavir 100 mg daily; truvada 1 tab daily <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 q6h prn Disp #*60 Tablet Refills: *0 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Take the entire course of antibiotics RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth twice a day Disp #*24 Tablet 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 q6h prn Disp #*60 Tablet Refills: *0 4. Ondansetron ODT 4 mg PO ONCE Duration: 1 Dose Do not take more than 8 mg in 8 hours RX *ondansetron 4 mg ___ tablet(s) by mouth q8h prn Disp #*10 Tablet Refills: *0 5. Darunavir 800 mg PO DAILY 6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 7. RiTONAvir 100 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal cuff dehiscence <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: ** Nothing in the vagina (no tampons, no douching, no sex) for 3 (THREE) months. ** Take the full course of antibiotics prescribed (Augmentin) for 12 days * 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. 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 GYN after repair of her vaginal cuff dehiscence. Please see operative report for more details. Her pain was controlled with oral Tylenol, ibuprofen, oxycodone and IV dilaudid for breakthrough. For antibiotic coverage, she received Zosyn (___) and was transitioned to PO Augmentin on ___ for a planned 14-day course total. Pelvic fluid Gram stain with showed no PMNs or organisms. Her lactate was 2.8 at admission and remained that level on recheck. She was continued on her home HIV medications. On postoperative day 2, she was voiding, ambulating, tolerating a regular diet, was afebrile, and her pain was controlled on oral pain medications. She was discharged home with oral augmentin and follow-up.
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| 175
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10148887-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex powder / Honey / Latex / bee venom (honey bee) / latex condom <ATTENDING> ___. <CHIEF COMPLAINT> Dysmenorrhea, Menometrorrhagia,and dyspareunia due to uterine fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy cystoscopy <HISTORY OF PRESENT ILLNESS> ___ is a ___ yo P3 F w/ symptomatic uterine fibroids causing dysmenorrhea, menometrorrhagia and dyspareunia. She has been on Lupron for the past four months and is now amenorrheic. Last Hct was 35.0 on ___. She has noticed mood swings and mild hot flashes on Lupron therapy. She was previously receiving Depo Provera injections, prescribed by her primary GYN, which failed to improve her bleeding and pain symptoms. EMB and Pap from ___ were negative. Pelvic u/s from ___: The uterus is anteverted, measuring 15.0 x 6.7 x 1.6 cm. Numerous fibroids are demonstrated, the largest located in the right aspect measuring 6.6 x 6.7 x 7.9 cm. At least two smaller discrete fibroids are seen at the left aspect. Diffuse heterogenenity of the myometrium likely denotes multiple indistinct fibroids. There is distortion of the endometrium with a trace amount of free intracavitary fluid. The ovaries are normal. <PAST MEDICAL HISTORY> PGYNH: Menarche age ___ LMP: ___ No h/o abnormal Pap tests Last Pap: ___ --> neg/neg HPV per pt Remote h/o HSV H/o recurrent BV Sexually active: Yes Sexual preference: opposite Current contraception: s/p tubal ligation POBH: TAB x 1, SAB x 1 c-section x 1 (vertical midline skin incision) VBAC x 2 PMH: 1) Fe deficiency anemia 2) ADHD PSH: 1) c-section - ___ (vertical midline skin incision 2) diagnostic LSC (?bowel adhesions) 3) LTL - ___ 4) LSC cholecystectomy - ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal great aunt - ovarian cancer Father, mother - precancerous colon polyps, DM, HTN, hyperlipidemia Father - cirrhosis Physical ___: On Preop with Dr. ___ Signs sheet entries for ___: BP: 125/83. Heart Rate: 102. Weight: 211. Height: 67. BMI: 33.0. O2 Saturation%: 100. Gen: well-appearing F in NAD CV: RRR Lungs: CTA B Abd: soft NT ND well-healed vertical midline incision Pelvic: 14 cm multifibroid uterus, mildly tender w/ palpation of R mid-body fibroid; no adnexal masses appreciated Discharge exam: Vitals: temp: 983 BP: 92/52 Pulse: 54 RR: 16 O2 Sat 99% RA General: Well appaearing in no acute distress Lungs: clear to auscultation bilaterally Cardiac: Regular rate and rhythm no murmurs appreciated Abdomen: + Bowel sounds, soft, appropriately tender, non distended Incision/ Dressing: Appropriately tender over incisions, RLQ incision dressing stained with sanguinous drainage, no evidence of hematoma. All other dressings clean dry and intact. GU: Minimal staining on vaginal pad Ext: warm and well perfused, no evidence of dvt <PERTINENT RESULTS> none during this admission <MEDICATIONS ON ADMISSION> denies <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: *50 Tablet(s)* Refills: *1* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on percocet to prevent 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> 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 3 months * 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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On ___, Ms ___ was admitted after undergoing a total laparoscopic hysterectomy and cystoscopy for symptomatic fibroids. Please refer to operative report for details of the procedure. On the evening of her operation, she complained of nausea not relieved by zofran. She was started on reglan and her pain medication changed from dilaudid to toradol with improvement in her nausea. On post operative day 1, her urine output was adequate, so her foley was removed and she voided spontaneously. By the morning of post-operative day one, she was tolerating a regular diet, ambulating independently, voiding spontaneously, and pain was controlled with percocet and motrin. She was then discharged home in good condition.
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10149485-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right vulvar pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> incision and drainage <HISTORY OF PRESENT ILLNESS> ___ yo undergoing tx for inflammatory breast cancer transferred from ___ for further management of abscess. She reports she has noted intermittent fevers since last dose of Taxol 2 weeks ago, Tmax ___ yesterday morning. Since ___, she has noted a "bump" on the R mons, increasing in size, increasingly painful. Today it started spontaneously draining foul smelling fluid. She went to ___ today for evaluation, where evaluation was notable for fever of 100.3 at 1300, WBC 24 with left shift and 8 bands. At ___, she received: - 1L NS and 650mg Tylenol at 1424 - 1g vanc at 1634 - 3g unasyn at 1504 - ibuprofen 600mg and morphine 4mg at 1523 - Unclear if she was also given Clindamycin Given size of abscess on clinical exam, ob/gyn recommended transfer to ___ for further management. She was seen by surgical consult here, who recommended gyn consult. On evaluation in ED, she feels fatigued, denies current fevers/chills. Pain controlled by morphine. No n/v/d. No parasthesias. <PAST MEDICAL HISTORY> OB/GYN: G2P203 - SVD x 1 - C-section x 1 (twins) PMHx: inflammatory breast cancer on treatment with taxol, diagnosed in ___, ___ started in ___, med onc at ___, planning mastectomy after neoadjuvant chemo No h/o hidradenitis or skin disorders. No h/o MRSA infection. PSH: hysteroscopy for retained IUD, C-section <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, non tender, no rebound/guarding GU: ~3 inch area of induration consistent with vulvar cellulitis present on right mons, with packing in place, which is draining small amount of serosanguinous fluid Ext: no TTP <PERTINENT RESULTS> ___ 05: 15AM BLOOD WBC-8.4 RBC-2.80* Hgb-8.2* Hct-25.5* MCV-91 MCH-29.3 MCHC-32.2 RDW-15.6* RDWSD-50.3* Plt ___ ___ 02: 56AM BLOOD WBC-12.5* RBC-2.73* Hgb-8.1* Hct-24.8* MCV-91 MCH-29.7 MCHC-32.7 RDW-15.6* RDWSD-50.4* Plt ___ ___ 05: 00AM BLOOD WBC-15.0* RBC-2.72* Hgb-7.9* Hct-24.7* MCV-91 MCH-29.0 MCHC-32.0 RDW-15.6* RDWSD-50.3* Plt ___ ___ 06: 11AM BLOOD WBC-21.6* RBC-2.78* Hgb-8.2* Hct-25.8* MCV-93 MCH-29.5 MCHC-31.8* RDW-15.9* RDWSD-52.1* Plt ___ ___ 10: 25PM BLOOD WBC-19.5* RBC-2.71* Hgb-8.0* Hct-25.0* MCV-92 MCH-29.5 MCHC-32.0 RDW-15.7* RDWSD-51.5* Plt ___ ___ 05: 15AM BLOOD Neuts-80* Bands-1 Lymphs-10* Monos-6 Eos-2 Baso-0 ___ Metas-1* Myelos-0 NRBC-1* AbsNeut-6.80* AbsLymp-0.84* AbsMono-0.50 AbsEos-0.17 AbsBaso-0.00* ___ 02: 56AM BLOOD Neuts-80* Bands-1 Lymphs-11* Monos-4* Eos-1 Baso-0 ___ Metas-2* Myelos-1* NRBC-3* AbsNeut-10.13* AbsLymp-1.38 AbsMono-0.50 AbsEos-0.13 AbsBaso-0.00* ___ 05: 00AM BLOOD Neuts-81* Bands-2 Lymphs-6* Monos-9 Eos-0 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-12.45* AbsLymp-0.90* AbsMono-1.35* AbsEos-0.00* AbsBaso-0.00* ___ 06: 11AM BLOOD Neuts-80* Bands-5 Lymphs-4* Monos-6 Eos-0 Baso-1 Atyps-1* Metas-3* Myelos-0 AbsNeut-18.36* AbsLymp-1.08* AbsMono-1.30* AbsEos-0.00* AbsBaso-0.22* ___ 10: 25PM BLOOD Neuts-84* Bands-8* Lymphs-6* Monos-0 Eos-0 Baso-0 ___ Metas-1* Myelos-1* AbsNeut-17.94* AbsLymp-1.17* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 05: 15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-OCCASIONAL ___ 02: 56AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-OCCASIONAL Tear Dr-1+ ___ 06: 11AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ ___ 10: 25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL ___ 05: 15AM BLOOD Plt Smr-NORMAL Plt ___ ___ 02: 56AM BLOOD Plt ___ ___ 05: 00AM BLOOD Plt Smr-LOW Plt ___ ___ 06: 11AM BLOOD Plt Smr-LOW Plt ___ ___ 10: 25PM BLOOD Plt Smr-LOW Plt ___ ___ 10: 25PM BLOOD ___ PTT-30.3 ___ ___ 05: 15AM BLOOD Creat-0.6 ___ 02: 56AM BLOOD Creat-0.6 ___ 10: 25PM BLOOD Glucose-100 UreaN-7 Creat-0.6 Na-141 K-3.6 Cl-107 HCO3-24 AnGap-14 ___ 10: 25PM BLOOD estGFR-Using this ___ 10: 25PM BLOOD HCG-<5 ___ 05: 14AM BLOOD Vanco-9.1* ___ 10: 35PM BLOOD Lactate-0.8 <MEDICATIONS ON ADMISSION> taxol infusions q 2 weeks <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*25 Tablet Refills: *1 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #*28 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice per day Disp #*30 Capsule Refills: *1 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Severe RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 hours Disp #*10 Tablet Refills: *0 5. Ibuprofen 800 mg PO Q8H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp #*25 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> right vulvar cellulitis with concern for underlying 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 with right vulvar pain and were found to have a right vulvar cellulitis with concern for an underlying abscess. You underwent incision and drainage of the infection on ___, and have packing in place. You were also kept on antibiotics for your infection. You have recovered well and the team believes you are ready to be discharged home. You will continue on oral antibiotics at home (make sure you complete the whole course) and have daily packing changes. You will follow-up in Dr. ___ office in the next week. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. We also discussed removal of your Mirena IUD, and placement of a non-hormonal IUD (Paragard), which will be coordinated as an outpatient with Dr. ___. 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. * 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. * A visiting nurse ___ come to change your dressing once per day at home. You should have your dressing changed once per day until you see Dr. ___ in the office. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding or 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 with right vulvar swelling concerning for vulvar cellulitis with underlying abscess. Given concern for infection in the emergency department, she was started on IV vancomycin and IV unasyn (___). Her CT scan on ___ was notable for "stranding in the region of the right labia and groin likely compatible with cellulitis or inflammation" without "evidence of fluid collection." A bedside incision and drainage (given clinical suspicion that infection was coming to a head at site of abscess) was not able to be tolerated by the patient secondary to pain. She underwent incision and drainage in the operating room on ___, with intraoperative findings notable for an area of right groin cellulitis and right vulvar abscess that was ulcerated and spontaneously draining. Her wound was packed with 0.25 inch iodoform dressing, and dressings were changed twice per day until discharge. She was continued on her IV vancomycin until ___ and on her IV unasyn until ___. She was transitioned to PO augmentin 875BID for a 14 day course for discharge. Of note, she was maintained on ibuprofen, tylenol, and dilaudid for pain control. Her white blood cell counts and differential were trended during her stay. She initially had a white count of 19 with 8 bands on admission, which had improved to 8.4 with only one band by the time of discharge. Her wound cultures from ___ grew mixed flora and gram negative rods - final cultures were pending at the time of discharge. By ___, she was clinically improved, with stable vitals signs, and pain was controlled with oral medications. She was then discharged home in stable condition with ___ for once daily dressing changes and recommendations for infectious disease follow up and GYN follow up.
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10149624-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Clindamycin <ATTENDING> ___. <CHIEF COMPLAINT> left labial swelling and pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> left labial incision & drainage <HISTORY OF PRESENT ILLNESS> ___ ___ who presents with acutely worsening left labial swelling and pain last night starting at ___. She has been having mild left labial swelling and mild pain x2-3mo. Last night the pain worsened from ___ -> ___ intensity and the swelling seems to have increased 50% in size overnight. She has been having abnormal grey-ish vaginal discharge occasionally for the last ___ years with occasional itching. She has had a negative work-up by her primary gyn and is awaiting to be seen by a vulvar specialist in ___. She denies F/C, N/V, abd pain, dysuria, constipation, diarrhea. <PAST MEDICAL HISTORY> POBHX: - ___ trimester TAB x2 PGYNHX: - menarche ___ with clots - remote h/o abnl pap, last pap ___ was normal - denies h/o STIs or known fibroids - not currently sexually active PMH: - ulcerative colitis PSH: - D&C as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> 97.9 67 104/76 18 GENERAL: NAD CARDIO: RRR, no m/r/g PULM: CTAB ABDOMEN: +BS, soft, NTND EXTREMITIES: NTNE b/l EXTERNAL GENITALIA: markedly swollen left labia 3cm x 6cm, no obvious area of flutuance, edematous induration SSE: normal vaginal epithelium, mild yellow-ish discharge, cervix not visualized due to patient discomfort BME: cervix: NT, no masses; anteverted uterus, normal size, no masses, nontender; adnexae NT b/l, no palpable masses Rectal exam (per Dr. ___: no lesions or other signs of active colitis <PERTINENT RESULTS> ___ 03: 18PM WBC-10.8# RBC-4.25 HGB-12.8 HCT-37.0 MCV-87 MCH-30.0 MCHC-34.5 RDW-13.1 ___ 03: 18PM NEUTS-73.6* BANDS-0 ___ MONOS-4.9 EOS-2.0 BASOS-0.5 ___ 03: 18PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL . PELVIS LIMITED ___ 6: 03 ___ An anechoic structure measuring 33 x 9 x 18 mm is noted anterior to the left labia .This structure contains a low level debris. IMPRESSION: Small complex fluid collection within the anterior part of the left labia in the setting of cellulitis is consistent with an abscess. . ___ 11: 15 am ABSCESS Source: left labia. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Pending): ANAEROBIC CULTURE (Pending): <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 2 weeks. Disp: *30 Tablet(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain for 1 weeks: each percocet contains 325mg of acetaminophen, do not exceed 4000mg acetaminophen in 24 hours. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> left labial abscess <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * worsening pain, redness, or swelling from the wound * drainage from the wound * fever > 100.4 * shortness of breath or chest pain * worsening itching or tongue/throat swelling * pain with urination * 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. * Nothing in the vagina until follow-up with your doctor * You may eat a regular diet. Incision care: * You may pull the wick out tomorrow. * You can use gauze to cover the area losely. Warm packs as needed for comfort. * You may shower. No bath tubs for 6 weeks.
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After discussion with the infectious disease team, given her allergy to penicillin, Ms. ___ was admitted for IV antibiotics, vancomycin specifically. Her hospital stay was characterized by the following issues: . *) left labial abscess/infectious disease An ultrasound was obtained on HD#1 demonstrated an anechoic structure measuring 33 x 9 x 18 mm anterior to the left labia consistent with an abscess. The abscess was incised and drained on HD#2. Approximately 15cc of purulent fluid was drained; a sample was sent to microbiology for gram stain and culture. Gram stain demonstrated 4+ polymorphonuclear leukocytes but no micro-organisms. Culture results are pending at the time of this summary. . Infectious disease consultation was obatined. Ms. ___ was started on vancomycin/ciprofloxacin on admission, which was later changed to doxycycline secondary to itching, which eventually was also discontinued for pruritis. Please see below. Ms. ___ also consents to HIV testing (last tested in ___ but would like to follow-up with Dr. ___ this. . *) pruritis During Ms. ___ first infusion of vancomycin, she developed pruritis which completely resolved after benadryl IV 25mg x1. At the time, she denied swelling, shortness of breath, or chest pain. She received a second dose of vancomycin with prophylactic benadryl, however developed pruritis again. Vancomycin was then discontinued. Ciprofloxacin was also discontinued at that time as it was unclear as to whether or not the pruritis was related to ciprofloxacin as well. . The decision was made to start Ms. ___ on doxycycline for MRSA and gram negative coverage. She continued to have pruritis, though not obviously related to doxycycline administration (pruritis had resolved with additional benadryl after her second dose of vancomycin and restarted again but that was prior to administration of doxycycline and continued after administration of doxycycline) and doxycycline was also eventually discontinued. . As the abscess was already drained, it was decided that Ms. ___ would be discharged home without any antibiotics. She never exhibited any signs of anaphylaxis during her hospitalization. She was discharged on HD#3, tolerating regular diet; urinating without difficulty; and ambulating with controlled labial pain. She was afebrile during her hospitalization.
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10150118-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine <ATTENDING> ___ <CHIEF COMPLAINT> "Uterine Fibroids" <MAJOR SURGICAL OR INVASIVE PROCEDURE> Multiple Myomectomy Left ovarian cystectomy <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ gravida 2, para 2 with a known fibroid uterus. She has been complaining of pelvic pain and comes requesting operative management. The patient's last ultrasound was ___ and showed a uterus, which measured 6.9 x 5.6 x 6.3 cm, slightly decreased in size since the prior examination. The endometrium was distorted by multiple fibroids though on the visualized portion normal in appearance and measured up to 2 mm. Redemonstrated were the multiple calcified fibroids. The prominent fibroid demonstrated within the left fundal region and measured 5.5 x 1.3 x 1.4 cm. This is a little change since the prior examination. Both ovaries were normal. There was an exophytic fibroid arising from the right fundus and measured 1.5 x 1.6 x 2.3 cm. There was no pelvic free fluid. These results were discussed with the patient who voiced understanding. She denies any history of stress urinary incontinence though she does describe some pelvic pressure in addition to pelvic pain. OB/GYN HISTORY: Menarche at 13. She cycles monthly and usually bleeds for seven days with heavy flow for the first two to three days with the passage of clots. Of note, she has no recent history of anemia. Her last Pap smear was in ___. She has a remote history of abnormal Pap smears and is status post cervical LEEP in ___ and has had normal Paps since that time. She denies any sexually transmitted infections. She has had two pregnancies. In ___, she had a C-section secondary to placenta previa, gestational diabetes and hypertension. In ___, she had a cesarean delivery. That pregnancy was complicated by gestational diabetes and triple X syndrome. <PAST MEDICAL HISTORY> - Rheumatoid Arthritis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother deceased at ___, history of stomach cancer. Paternal grandmother deceased at ___, history of pneumonia. Paternal grandfather deceased at ___. Father deceased at ___, history of heart disease and diabetes. Paternal grandmother deceased in her ___. Paternal grandfather deceased at age ___. She has six brothers, all alive. There is no history of any female cancers. <PHYSICAL EXAM> Physical Examination was performed by Dr. ___ ___: This is a well-developed, well-nourished woman in no apparent distress. VITAL SIGNS: Blood pressure 122/80. Weight 190, last menstrual period ___. ABDOMEN: Soft, nondistended, and nontender. Negative hepatosplenomegaly, negative palpable masses. PELVIC: Normal female external genitalia. Bartholin, urethral, and Skene's glands were normal. Vaginal vault had normal-appearing discharge. Cervix had some blue hued lesions on the anterior cervix. Pap smear was updated. Uterus approximately 12 cm in maximal vertical dimension. Adnexa was without masses or tenderness bilaterally. <PERTINENT RESULTS> Ultrasound result included in history. <MEDICATIONS ON ADMISSION> - Etanercept (IV 2x/wk qM,F) - Fluticasone - Ibuprofen - Meloxicam - Misoprostol - Omepremazole - MVI - omega3 <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *0* 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Uterine Fibroids Left sided paratubal and Ovarian cyst <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 You may shower 24 hours after surgery -- do not scrub incisions, let water run over incisions and pat dry -- no tub baths/ hot tubs x 6 weeks No heavy lifting or strenuous activity x 6 weeks (or until cleared by Dr. ___. Otherwise, activity as tolerated. Nothing in your vagina x 6 weeks ( no sex, no tampons)
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Ms ___ was admitted into the gynecology service for routine post-operative care following her surgery. She had some issues with pain control and was kept in house for two days post-operatively for pain management. She was discharged on post-operative day 2 with adequate pain control, tolerating a regular diet and medications by mouth, voiding and ambulating without diffuclty.
| 1,087
| 77
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10150132-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right sided pain and tightenings <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Pt is a ___ y/o G5P0 with spontaneous di/di twins, known short cervix with pessary in place, now at 27w4d presents to triage c/o right sided abdominal pain and mild abd tightenings. States yesterday she developed right sided pain that wrapped to her back which was constant. States the pain felt like "gas pain" but it didn't go away so she called the office. She also does report feeling some occasional abd tightenings which are not uncomfortable. She otherwise feels well. No fevers/chills, n/v/d, dysuria, lob or vb. Reports active FM. <PAST MEDICAL HISTORY> PNC: *) ___ ___ by LMP *) Labs: O+/Abs-,RI,RPRNR,HBsAg-,HCV-,GC/CT-,HIV-,GBSunk *) nl ERA, nl fFS x 2 *) nl Hgb electrophoresis, neg CF *) nl GLT (78) *) ___: A 606g 46% B 629g 51% 3.7% discord ISSUES *) spont di/di twins *) hx MJ use early in pregnancy *) short cervix, pessary in place since ___ - SVE 1/long on ___ - s/p BMZ (complete ___ - s/p NICU consult at 24wks ObHx: - TAB x 3 - ?SAB vs ectopic -> D&C GynHx: R dermoid cyst, no STDs PMH: h/o depression/anxiety, migraines with aura, eczema, hemorrhoids, breast cysts s/p negative evaluation SurgHx: - D&C x 4 - hemorrhoidectomy ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) GEN: appears comfortable, NAD VS: 103/63, HR 87, T 97.8 Lungs: CTAB Heart: RRR Abd: soft, gravid, nontender. no CVAT SVE: 3cm/50%, pessary in place -> unchanged on rpt ___ later) GBS collected FHT: Twin A 140s, mod var, +accels, no decels Twin B 150s, mod var, +accels, quick variable x 1 to 110 (20sec) TOCO: occasional irritability U/S: vtx/vtx <PERTINENT RESULTS> ___ WBC-8.0 RBC-3.22 Hgb-11.0 Hct-33.8 MCV-105 Plt-173 ___ WBC-9.2 RBC-3.39 Hgb-11.4 Hct-35.2 MCV-104 Plt-166 ___ Neuts-74 Bands-0 ___ Monos-5 Eos-0 Baso-0 Atyps-0 ___ Myelos-2 AbsNeut-6.81 AbsLymp-1.66 AbsMono-0.46 AbsEos-0.00 AbsBaso-0.00 ___ GLT-78 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE Color-Straw Appear-Clear Sp ___ URINE CULTURE (Final ___: <10,000 organisms/ml. R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis NEISSERIA GONORRHOEAE, NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST <MEDICATIONS ON ADMISSION> PNV Miralax <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> di/di twins with short cervix and advanced cervical dilation <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 with advanced cervical dilation. You were observed in the antepartum service and were stable. You will now be discharged home. Please continue pelvic rest and light activity. 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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___ yo G5P0 with spont di/di twins and known short cervix with pessary in place admitted at ___ with advanced cervical dilatation (3cm/50%). On admission, she was afebrile and without any evidence of infection, abruption, or preterm labor. Although her cervix was noted to be 3cm dilated, it was unchanged on repeat exam and she remained comfortable. Her toco was mostly flat with occasional periods of irritability. Fetal testing was reassuring and they remained vertex/vertex. She was admitted to antepartum overnight for observation. She remained clinically stable and was discharged home the following day. She did not receive a rescue course of betamethasone given her clinical stability.
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10151628-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bupropion / Zoloft <ATTENDING> ___ <CHIEF COMPLAINT> menorrhagia, cystocele, and mixed incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, vaginal polyp excision (Dr. ___ service); I-stop sling, suprapubic catheter, cystoscopy (Dr. ___ service) <HISTORY OF PRESENT ILLNESS> Ms. ___ is a lovely ___ G2 P2-0-0-2, premenopausal Caucasian female with multiple medical problems, with menorrhagia requesting surgical intervention given the limited efficacy of her current Mirena IUD. Her abnormal uterine bleeding did improve somewhat with the Mirena IUD, but she continues to suffer from cyclic menorrhagia, which she would like further addressed. PUS (___) was unremarkable with a normal uterus and IUD in good position, normal ovaries bilaterally. An endometrial biopsy and endocervical curettage were obtained and were negative for endometrial hyperplasia or malignancy. After extensive counseling, the patient opted for definitive surgical treatment with a total laparoscopic hysterectomy. In addition, she was diagnosed with mixed urinary incontinence and a plan for a vaginal sling with possible anterior repair was made. <PAST MEDICAL HISTORY> OB History: G2, P2-0-0-2. 1. In ___, vaginal delivery, no complications. 2. In ___, vaginal delivery. GYN History: Menarche at age ___. LMP on ___. - Regular menses every month with seven to eight days of cyclic menorrhagia (even with Mirena IUD in place). Prior to the Mirena IUD, prolonged, almost daily abnormal uterine bleeding. The patient denies any dyspareunia. She does report discomfort with a full bladder. She denies pain with a bowel movement. - h/o abnormal Pap in ___ with cervical dysplasia requiring cold knife cone. last Pap, ___, negative SIL. - patient is not currently sexually active, is heterosexual. - s/p tubal ligation for contraception. - STD History: 1. Cervical dysplasia S/P CKC. 2. History of chlamydia in ___. Medical Problems: 1. Hypercholesterolemia. 2. Hypothyroidism, h/o depression related to hypothyroidism. 3. Lower back pain. 4. History of chlamydia in ___. 5. Cervical dysplasia, S/P CKC. 6. Mixed urinary incontinence (stress greater than urge), S/P prior "bladder surgery". The patient uncertain of exact details. 7. Menorrhagia, unresponsive to Mirena IUD. Surgical History: 1. ___, bilateral tubal ligation at ___. 2. ___, bladder surgery, cold knife cone, and Mirena IUD insertion at ___ by Dr. ___. 3. ___, left knee surgery, S/P MVA. <SOCIAL HISTORY> ___ <FAMILY HISTORY> - maternal aunt with breast and ovarian cancer, diagnosed in ___. No other GYN cancers in the family. - reports a maternal grandfather with colon cancer - mother with lung and brain cancer - hypertension, (mother and grandfather) - hypercholesterolemia (mother and grandfather). <MEDICATIONS ON ADMISSION> denies <DISCHARGE MEDICATIONS> 1. Percocet ___ 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 every ___ hours as needed for pain. Disp: *30 Tablet(s)* Refills: *2* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain. Disp: *60 Capsule(s)* Refills: *2* 4. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day. Disp: *11 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> menorrhagia, cystocele, mixed urinary incontinence <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) 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. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Please refer to your dishcharge sheet on how to care for your suprapubic catheter and bladder training.
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Ms. ___ ___ year old G2P2, was admitted ___ for total laparoscopic hysterectomy, I-stop sling, suprapubic catheter, vaginal polyp excision, and cystoscopy for menorrhagia, cystocele, and mixed incontinence. This was uncomplicated; please refer to Dr. ___ note for full details. Post-operatively, she had borderline urine output in the PACU, which responded to IV hydration and was thought to be due to bowel prep. On post-operative day 1, her vaginal packing was removed and foley catheter was removed. She passed a trial of voiding. She tolerated a regular diet, PO pain medications, and was ambulatory and voiding. She was discharged to home in good condition.
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10152866-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> increased blood pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> low transverse c-section <HISTORY OF PRESENT ILLNESS> ___ yo G10P2 at 30+2 WGA with increased BP in the office of 139/90 sent for ___ eval. She states that while in triage she has developed a mild h/a. Denies RUQ/epig pain and vision changes. Denies vaginal bleeding, contractions and leaking of fluid vaginally. +FM. <PAST MEDICAL HISTORY> PRENATAL COURSE *)Dating: EDC by ___ *)Routine testing: O+/Ab-,RPRNR,RNI,HbsAg- *)Screening: neg ERA, nl FFS, of note pt had paternity testing and the baby is from the same father as the other two children OBSTETRIC HISTORY G10P2, SVD x 2 term ___ & ___ 7lb13oz, SABx2, TABx5 GYNECOLOGIC HISTORY HPV s/p colpo during this pregnancy for rpt colpo/bx post partum PAST MEDICAL HISTORY none Surg Hx: breast augmentation D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) BP ___ CV: rrr w/o m/g/r Chest: CTA B ABDOMEN: gravid, soft, nontender BACK: - CVAT EXTREMITY: -edema B, - clonus, 2+ reflexes SVE: deferred External genitalia: without lesions, GBS done EFM: 135 ___, mod variability, +accels, no decels, reactive with 10x10's TOCO: no contractions TAUS today: cephalic, + fetal cardiac motion seen, BPP ___, AFI 10 <PERTINENT RESULTS> ___ 11: 07AM BLOOD WBC-8.2 RBC-3.32* Hgb-9.9* Hct-28.9* MCV-87 MCH-29.8 MCHC-34.2 RDW-13.7 Plt ___ ___ 05: 34AM BLOOD WBC-9.8 RBC-2.91* Hgb-8.8* Hct-25.5* MCV-88 MCH-30.2 MCHC-34.5 RDW-15.0 Plt ___ ___ 05: 34AM BLOOD Plt ___ ___ 11: 07AM BLOOD Plt ___ ___ 04: 19PM BLOOD ___ ___ 04: 57AM BLOOD ___ 11: 07AM BLOOD Creat-0.5 ___ 11: 07AM BLOOD ALT-19 ___ 09: 36AM BLOOD ALT-56* AST-70* LD(LDH)-337* ___ 05: 34AM BLOOD ALT-35 AST-32 ___ 04: 57AM BLOOD Mg-4.1* UricAcd-5.4 ___ 02: 17AM BLOOD Type-ART Temp-36.1 pO2-45* pCO2-37 pH-7.41 calTCO2-24 Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU <MEDICATIONS ON ADMISSION> PNV Unisom prn sleep (takes about every 2 weeks) <DISCHARGE MEDICATIONS> 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain for 3 weeks. Disp: *60 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 4 weeks. Disp: *60 Tablet(s)* Refills: *0* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for constipation for 4 weeks. Disp: *60 Capsule(s)* Refills: *0* 4. labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day for 4 weeks. Disp: *168 Tablet(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> primary cesarean section at 31 wk for pre-eclampsia/HELLP syndrome <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> follow routine post-partum / post-operative instructions
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Ms. ___ is a ___ year old G10P2 who presents at 30w2d with increased blood pressures from the office and mild headache. Initial evaluation is significant for hypertension to 170s/100s, elevated urine protein and mild thrombocytopenia of 118. She is sent to the ___ testing unit where her ultrasound is suggestive of early IUGR and recommendations are for hospitalization and betametasone for fetal lung maturity. She was made betamethasone complete on ___. On the morning of ___, the patient complained of headache and epigastric pain, and blood pressure was elevated to 180s/90. Labs showed platelets in the ___ and mild transamonitis, worrisome for HELLP syndrome. The patient was then transferred to Labor and Delivery and was started on magnesium to decrease the risk of eclampsia, and the patient was induced into labor with pitocin. After the induction failed, she underwent primary low transverse c-section on ___. Please refer to the operative note for full details. Intraoperatively, there was noted to be greater than average blood loss, and given thrombocytopenia, she was given multiple uterotonic agents and transfused 1 unit of packed red blood cells. Pre-op hct was preop HCT 27.5, EBL 1000, with appropriate rise in hct to 34. In the post-op holding area, she was noted to have an acute desaturation to 60% on room air. She was given 10mg IV lasix and diuresed rapidly. A chest xray was without gross abnormality and a stat CTA was negative for PO. Her pulmonary function improved after lasix and she was felt to have had flash pulmonary edema due to magnesium, pre-eclampsia, and blood transfusion, and fluid overload from intraoperative crystalloid. During the duration of her admission, she had O2 sats >96% on room air and had no respiratory complaints. She did receive 24 hours of postpartum magnesium for seizure prophylaxis. Her blood pressures were initially controlled in the 140-150/70-80s range with labetalol 200 TID. However, on POD 8, her BP remained elevated >150/90 and labetalol was increased to 300 TID. There she remained stable and she was discharged to home in good condition.
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10152943-DS-9
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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> total laparoscopic hysterectomy, bilateral salpingo-oopherectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ who was seen by her primary care physician complaining of some intermittent abdominal pain over the past couple of months. A pelvic ultrasound was ordered, which revealed a thin-walled cyst centrally and slightly to the right in the pelvis measuring 9.9 x 3.3 x 9 cm with vascular septations. The ovaries were not visualized. There was no free fluid in the pelvis. This was suspicious for malignancy likely from the ovary. She presents today to discuss management options without complaints. She denies any abdominal pain currently and denies any vaginal bleeding. Does admit to a history of chronic constipation, but nothing that has changed in the past six months. She denies early satiety, chest pain, or shortness of breath. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Significant for asthma. PAST SURGICAL HISTORY: Cholecystectomy in ___. OB/GYN HISTORY: She is a gravida 4, para 4, four spontaneous vaginal deliveries. Her last menstrual period was over ___ years ago. Her menarche was age ___ with regular periods lasting seven days. She denies any history of abnormal Pap smears. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denies any history of gyn malignancies. <PHYSICAL EXAM> Prior to admission: GENERAL: Well appearing. ABDOMEN: Soft, nontender, nondistended, and no masses appreciated. LYMPHATICS: There were some subcentimeter lymphadenopathy in the right inguinal, otherwise, no lymphadenopathy is appreciated. PELVIC: Normal external female genitalia. Speculum exam revealed normal uterus with cystic mass centrally and does appear mobile. There is no cul-de-sac nodularity. Rectovaginal exam confirmed these findings. On discharge: General: NARD, comfortable CV: RRR Lungs: CTAB Abdomen: Soft, appropriately tender, nondistended, no rebound or guarding Incisions: clean, dry, intact GU: Minimal spotting on pad Extremities: nontender <PERTINENT RESULTS> ___ 04: 00PM BLOOD WBC-17.3*# RBC-4.32 Hgb-12.4 Hct-37.0 MCV-86 MCH-28.8 MCHC-33.6 RDW-13.1 Plt ___ ___ 07: 00AM BLOOD WBC-8.1# RBC-3.82* Hgb-11.1* Hct-32.8* MCV-86 MCH-29.2 MCHC-34.0 RDW-13.1 Plt ___ ___ 04: 00PM BLOOD Glucose-130* UreaN-12 Creat-0.8 Na-140 K-4.2 Cl-103 HCO3-30 AnGap-11 ___ 07: 00AM BLOOD Glucose-92 UreaN-12 Creat-0.7 Na-138 K-4.1 Cl-103 HCO3-28 AnGap-11 ___ 04: 00PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.2 ___ 07: 00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q6H: PRN shortness of breath 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Ibuprofen Dose is Unknown PO Frequency is Unknown <DISCHARGE MEDICATIONS> 1. Fluticasone Propionate 110mcg 2 PUFF IH BID 2. 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 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Capsule Refills: *0 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 5. Albuterol Inhaler ___ PUFF IH Q6H: PRN shortness of breath 6. Senna 1 TAB PO BID: PRN constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #*60 Capsule Refills: *0 7. Bisacodyl 10 mg PO/PR DAILY: PRN constipation RX *bisacodyl 5 mg 1 tablet,delayed release (___) by mouth twice daily Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic 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 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 >10lbs for ___ 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. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. 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 * chest pain or difficulty breathing
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Ms. ___ was admitted to the gynecology oncology service after undergoing total laparoscopic hysterectomy, bilateral salpingo-oopherectomy for a large pelvic mass. 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 and toradol. Her diet was advanced without difficulty and she was transitioned to oral percocet and motrin. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She received lovenox for venous thromboembolism prevention. 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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10157810-DS-13
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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 myomectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a lovely ___ G3, ___ premenopausal ___ female, eight months postpartum from C-section delivery on ___. During her obstetrical ultrasound, she was noted to have uterine fibroids presents today for GYN consultation regarding this finding. On review of her presentation, she reports being asymptomatic prior to pregnancy with regular menses every one month with two and a half days of moderate flow and mild-to-moderate dysmenorrhea. She denies any significant pelvic pain or menorrhagia. During her obstetrical ultrasound, she was noted to have uterine fibroids. During her pregnancy, the fibroids grew quite large and was noted to measure 10.1 cm on obstetrical ultrasound ___ with central necrosis, suggesting fibroid degeneration. Postpartum, she had a pelvic ultrasound (___) with anteverted uterus measuring 12.1 x 6 x 7 cm with a 4.6 cm intramural fundal fibroid. There are multiple adjacent fibroids distorting the endometrium. The endometrium measured 6 mm. Normal ovaries bilaterally. The patient presents today specifically to discuss fibroid treatment options. She would like to conceive in the future. She has no other specific gynecologic complaints. <PAST MEDICAL HISTORY> OB History: G3, P1-0-2-1. 1. ___, C-section delivery, no complications. 2. SAB first trimester x2 (___). GYN History: Menarche at age ___. LMP ___. Regular menses every 28 days with two and a half days of moderate flow, some dysmenorrhea and no significant pelvic pain. The patient has noted some discomfort with vaginal intercourse mainly associated with dryness. Last Pap, ___ negative SIL, however, transformation zone absent. She reports a history of abnormal Paps in the remote past, but reports normal Pap since. The patient is sexually active, prefers opposite sex. Reports asexual partners throughout life. STD History: Genital warts age ___, no active issues. Medical Problems: 1. Obesity, status post laparoscopic lap band procedure initially with a 100-pound weight loss now regained all her weight back currently roughly 270 pounds. Surgical History: 1. ___ laparoscopic lap band procedure, Dr. ___. 2. D&C x1, first trimester miscarriage. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Reports a paternal grandmother with ovarian cancer. No other GYN cancer in the family. She reports a family history of hypertension, (mother, maternal grandmother). No other family medical conditions. <PHYSICAL EXAM> Physical Examination by Dr. ___ ___: Obese, pleasant ___ female in no acute distress, alert and oriented x3. BP 125/77, P 64, WT 270 pounds, height 5 feet 2 inches. 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 Extremities: no clubbing/cyanosis/edema Pelvic: Grossly normal external female genitalia. On bimanual exam, the cervix is nontender. There is no CMT. The uterus and adnexa are not palpable secondary to the patient's body habitus. There is no tenderness or significant masses. On deep palpation; however, the exam is limited. On speculum examination, there is a normal midline cervix with no unusual bleeding, lesions, or discharge. <PERTINENT RESULTS> ___ 07: 30AM BLOOD WBC-9.5 RBC-3.79* Hgb-9.5* Hct-31.6* MCV-84 MCH-25.1*# MCHC-30.1* RDW-14.2 Plt ___ Pelvic Ultrasound ___ FINDINGS: Transabdominal examination demonstrates an enlarged anteverted uterus which measures 12.1 x 6 x 7 cm. By transvaginal technique, the endometrial stripe measures 6 mm in thickness and is distorted by multiple adjacent fibroids with no definite submucosal involvement identified. The dominant intramural fundal fibroid currently measures 4.5 x 4.6 x 4.1 cm and has decreased in size when compared to the most recent ultrasound performed when the patient was pregnant. Additional smaller intraumral fibroids are noted. Bilateral ovaries are normal. There is trace pelvic free fluid. IMPRESSION: Fibroid uterus with multiple intramural fibroids as well as associated distorsion of the endometrial stripe. No definite submucosal extension is identified. <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: please do not exceed 4g of acetaminophen in 24 hours. Disp: *35 Tablet(s)* Refills: *0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Symptomatic Fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___ 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 2 weeks, no heavy lifting of objects >10lbs for 6 weeks. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You have staples. Please return to clinic on ___ to have them removed. 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 service for routine post-operative care following her abdominal myomectomy for symptomatic fibroids. Her case was uncomplicated. Please refer to operative notes for full details of the procedure. She did very well overnight on her first day. Her foley was discontinued on post-operative day 1 and she voided spontaneously. She was up and ambulating by post-operative day 1 and her diet was advanced as tolerated. She stayed overnight just one more day for adequate pain control. Ms. ___ was discharged on post-operative day 2 in good condition, tolerating a regular diet, adequate pain control, voiding and ambulating without difficulty. She will follow up next week ___ to have her staples removed.
| 1,542
| 152
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10157810-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> post-operative abdominal pain, wound seroma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Incision and drainage of wound seroma <HISTORY OF PRESENT ILLNESS> ___ is a ___ yo P1 F ___ s/p abd MMY who presents w/ worsening lower abdominal pain and CT findings suggestive of large wound seroma. Pt was seen last ___ by Dr. ___ had ___ removed. Exam suspicious for possible cellulitis vs seroma and pt was discharged home w/ Keflex. WBC at the time was 8.1. The next evening she developed a temperature to 101.2. Over the next few days, she did not have any more fevers however the abdominal pain continued to worsen. She has been using ibuprofen for pain relief with minimal success. Pain is severe and she is uncomfortable both at rest and w/ activity, limiting her ability to care for her baby. Prelim CT abd/pelvis from yesterday showed: In the lower abdominal wall, there is a 6.0 (CC) x 4.7 (AP) x 10.5 (left-right) fluid collection 10.8 Hounsfield units and containing two small air bubbles. This collection is superficial but neither well-formed nor encapsulated. Denies n/v, recent f/c, abnl vaginal discharge, vaginal bleeding. <PAST MEDICAL HISTORY> OB History: G3, P1-0-2-1. 1. ___, C-section delivery, no complications. 2. SAB first trimester x2 (___). GYN History: Menarche at age ___. Regular menses every 28 days with two and a half days of moderate flow, some dysmenorrhea and no significant pelvic pain. The patient has noted some discomfort with vaginal intercourse mainly associated with dryness. Last Pap, ___ negative SIL, however, transformation zone absent. She reports a history of abnormal Paps in the remote past, but reports normal Pap since. The patient is sexually active, prefers opposite sex. Reports asexual partners throughout life. STD History: Genital warts age ___, no active issues. Medical Problems: 1. Obesity, status post laparoscopic lap band procedure initially with a 100-pound weight loss now regained all her weight back currently roughly 270 pounds. Surgical History: 1. ___ laparoscopic lap band procedure, Dr. ___. 2. D&C x1, first trimester miscarriage. 3. abdominal myomectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Reports a paternal grandmother with ovarian cancer. No other GYN cancer in the family. She reports a family history of hypertension, (mother, maternal grandmother). No other family medical conditions. <PHYSICAL EXAM> on admission by Dr. ___: 130/86 75 265 lbs 5'2" Gen: tearful, appears uncomfortable Abd: obese, incision intact w/o erythema, large firm mass palpable superior to incision in midline approx 10 cm in greatest dimension w/ mild skin induration, exquisitely TTP; no rebound/guarding Pelvic: deferred <PERTINENT RESULTS> ___ 08: 50AM BLOOD WBC-7.6 RBC-3.61* Hgb-8.8* Hct-28.7* MCV-80* MCH-24.4* MCHC-30.8* RDW-13.6 Plt ___ ___ 11: 00AM BLOOD WBC-10.2 RBC-3.82* Hgb-9.4* Hct-31.1* MCV-81* MCH-24.7* MCHC-30.4* RDW-13.7 Plt ___ ___ 11: 00AM BLOOD Neuts-76.9* Lymphs-16.7* Monos-5.1 Eos-1.1 Baso-0.2 ___ wound culture (final): no growth ___ anaerobic culture (prelim): no growth <MEDICATIONS ON ADMISSION> Keflex, fluticasone <DISCHARGE MEDICATIONS> 1. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours. Disp: *50 Tablet(s)* Refills: *0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *30 Capsule(s)* Refills: *1* 3. Kerlix AMD Sig: One (1) rolls twice a day. Disp: *30 rolls* Refills: *1* 4. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days. Disp: *56 Capsule(s)* Refills: *0* 5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Take with meals . Disp: *50 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___: Wound seroma <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 further management of a wound seroma. You received antibiotics and had the seroma drained in the operating room. You will require twice-daily dressing/packing changes. A visiting nurse will be assisting with this. Please continue taking the antibiotic for 14 days.
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On ___, Ms. ___ was admitted for pain control prior to planned I&D of her abdominal wound seroma. Her pain was controlled with percocet, and she was continued on keflex. She was made NPO after midnight, and switched to IV dilaudid and IV kefzol. On ___, she underwent uncomplicated incision and drainage of the abdominal wound seroma. Please refer to Dr. ___ report for details of the procedure. The incision was packed with Kerlix and left to heal by secondary intention. Post-operatively, wound care was consulted and recommended twice daily dressing changes as the wound was not amenable to a wound vac placement. Ms. ___ was discharged home in stable condition on post operative day 2 in stable condition, afebrile, tolerating a regular diet, voiding spontaneously. She will complete a 14 day course of Keflex at home. ___ services were arranged for outpatient dressing changes.
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10158857-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Reglan / Seroquel / risperidone <ATTENDING> ___. <CHIEF COMPLAINT> community acquired pneumonia that has failed outpatient treatment <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G6P3 at ___ transferred from ___ to ___ ED worsening shortness of breath in setting of likely community acquired pneumonia that has failed outpatient treatment. Ms. ___ reports feeling congested with shortness of breath for the last ten days. She was started on a course of azithromycin ___ days ago, but despite antibiotics and symptomatic treatment, her symptoms worsened. She describes an inability to get a full breath of air. She also reports intermittent fevers as high as 101 two days ago. She also reports nausea that has persisted throughout the pregnancy requiring Zofran for relief. She also reports having diarrhea intermittently over the last three days that has since resolved. She has had a productive cough with green sputum. She reports that her grandmother has pneumonia and that she has been accompanying her to her appointments. Her grandmother has required IV antibiotics for treatment of pneumonia. She also reports that her mother is sick with similar symptoms. Given these symptoms, she presented to ___ for evaluation and after seeing an OB/GYN provider, was sent to ___ for further evaluation and care. She received one dose of IV ceftriaxone at the ED and one nebs treatment with some relief. She otherwise denies ctx, VB, LOF. Endorses +FM. ROS: Denies HA, vision changes, RUQ/epigastric pain. Denies chest pain, palpitations. Denies abd pain. Denies recent falls or abd trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. <PAST MEDICAL HISTORY> PNC: - ___ ___ - Labs pending OSH records/GBS pending - Screening: pending OSH records - FFS: wnl - GTT: pending OSH records - Issues #hx of opioid abuse on methadone with last use drugs 4 mo ago #Hep C #DV in pregnancy requiring move to DV shelter recently OBHx: - SVD x 3, last 9#12oz ___ - TAB x 2 GYNHx: - genital HSV not on suppression, no hx of STDs - hx of abnormal pap s/p colposcopy and most recent was in ___- normal - denies known fibroids or ovarian cysts PMH: - Hepatitis C - hx of opioid abuse on methadone - behavior health hx PSH: - laparoscopic cholecystectomy <SOCIAL HISTORY> Pt smokes ___ ppd (not in last week given pneumonia), denies alcohol use in pregnancy, reports hx of opioid abuse including Percocet (last use 4 mo ago) and sniffing MS ___ and heroin. Seen at a ___ clinic daily and also reports using suboxone occasionally. Hx of DV in pregnancy by FOB. She has recently moved out to live at a ___ with her children. Reports feeling safe now. <PHYSICAL EXAM> On admission: Vitals: ___ 02: 34BP: 123/73 (82) ___ ___: 84 ___ 02: 34MSpO2: 97% ___ ___: 85 ___ 02: 36Temp.: 98.8°F Gen: A&O, comfortable Pulm: expiratory wheezing and rhonchorous bilaterally with diminished lung fields on the R. Abd: soft, gravid, nontender EFW 5# by Leopolds Ext: no calf tenderness SVE: deferred (reported to be 1cm at OSH with negative FFN) SSE: deferred FHT: (difficult to assess given intermittent coughing) 130/mod var/+accels/-decels Toco: rare irregular <PERTINENT RESULTS> ___ 12: 27AM BLOOD WBC-20.0* RBC-3.08* Hgb-9.6* Hct-29.5* MCV-96 MCH-31.2 MCHC-32.5 RDW-14.6 RDWSD-50.1* Plt ___ ___ 12: 27AM BLOOD Neuts-73.5* Lymphs-17.7* Monos-6.8 Eos-1.1 Baso-0.2 Im ___ AbsNeut-14.71* AbsLymp-3.54 AbsMono-1.36* AbsEos-0.22 AbsBaso-0.04 ___ 12: 27AM BLOOD ___ PTT-28.9 ___ ___ 12: 27AM BLOOD Glucose-110* UreaN-5* Creat-0.4 Na-137 K-3.5 Cl-103 HCO3-22 AnGap-16 ___ 12: 27AM BLOOD ALT-11 AST-27 AlkPhos-115* TotBili-0.3 ___ 12: 27AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.3 Mg-1.7 ___ 01: 10PM BLOOD HIV Ab-Negative ___ 12: 34AM BLOOD ___ pO2-90 pCO2-40 pH-7.38 calTCO2-25 Base XS-0 Comment-GREEN TOP ___ 12: 34AM BLOOD Lactate-1.9 ___ 4: 29 am SWAB Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP. Please contact the Microbiology Laboratory (___) immediately if sensitivity testing to clindamycin is required on this patient's isolate. ___ 12: 27 am SEROLOGY/BLOOD ADDED RPR ___. **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. <MEDICATIONS ON ADMISSION> folic acid, Zofran, topomax, methadone, gabapentin <DISCHARGE MEDICATIONS> 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Continue this medication until ___ RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*5 Tablet Refills: *0 2. Azithromycin 250 mg PO Q24H Duration: 4 Days take until ___ RX *azithromycin 250 mg 1 tablet(s) by mouth Q24H Disp #*3 Tablet Refills: *0 3. Cyclobenzaprine 10 mg PO TID: PRN pain RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills: *0 4. Lidocaine 5% Patch 1 PTCH TD ONCE Duration: 1 Dose RX *lidocaine 5 % apply 12hrs on and 12hrs off Disp #*30 Patch Refills: *0 5. Albuterol Inhaler 2 PUFF IH Q4H: PRN wheezing 6. Benzonatate 100 mg PO TID 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Gabapentin 800 mg PO QID 9. Methadone 120 mg PO DAILY 10. Prenatal Vitamins 1 TAB PO DAILY 11. Topiramate (Topamax) 150 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Community acquired pneumonia <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 for pneumonia. You were given IV antibiotics and are now on oral antibiotics. Please continue to take these as directed. You were also treated with nebulizers and continued on your home medications for asthma. You were continued on methadone 120mg daily, as well as your other home medications. Your symptoms have improved and you are now safe to be discharged home. Please call the office for: - 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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___ G6P3 was admitted on ___ at 33w6d for community acquired pneumonia that has failed outpatient treatment. She had a chest x-ray at ___ showing early infiltrate in the right lower lobe. She had negative flu swab at ___. She was treated with duonebs q4hr and advair and albuterol prn, as well as incentive spirometry during her hospital stay. She was initially treated with IV ceftriaxone and IV azithromycin, then transitioned to PO augmentin and azithromycin on ___. She was given tylenol, flexeril and lidocaine patch for pain control. She was discharged home to continue PO antibiotics on ___ after she remained afebrile during her hospital course, not requiring any supplemental oxygenation, and symptomatically stable and improved. For her substance abuse history, she was continued on methadone 120mg daily, with the dose confirmed with Habit Opco at ___, until the day of her discharge on ___. She received a one time dose of 5mg oxycodone overnight ___ due to complaint of extreme pain with coughing. She was also continued on gabapentin 800mg QID, Topamax 150mg BID for mood with doses confirmed by her outpatient pharmacy. For her hepatitis C, she was s/p treatment and had an undetectable viral load in ___. She had normal LFTs on admission. Patient declined urine tox screen, but had negative STI screening. She was given acyclovir 400mg TID for her history of genital HSV. Social work followed her during her admission due to her substance abuse history and social stressors with DV in pregnancy, and recent move to shelter. She complained of constipation on ___ and was given fleet enema, dulcolax, and Colace. During her hospital stay, she had reassuring fetal testing.
| 1,868
| 394
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10159055-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lithium Carbonate / Depakote / Resperal / Haldol <ATTENDING> ___. <CHIEF COMPLAINT> elevated blood pressure in the office; agitation <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ y/o G6P2032 at 38+2 weeks with ___ ___. She presents from the office with elevated BP's. Pt denies HA, visual changes, epigastric or RUQ pain. Pt agitated in the office. <PAST MEDICAL HISTORY> PRENATAL COURSE *) DAting ___ ___ by LMP consistent w/9 W U/S. *) Labs: A pos/Ab neg/R-I/HbSag negRPR-NR/GBS pos *) U/S: FFS ISSUES *) plans adoption for this pregnancy, does not have custody of children. *) PSY issues on meds, H/O hospitalization and suicide attempt. followed at ___. *) lived ___ now in ___ *) H/O substance abuse and H/O incarceration OBSTETRIC HISTORY C/S X 2 TAB x 2 SAB x 1 GYNECOLOGIC HISTORY H/O HSV PAST MEDICAL HISTORY bipolar disorder sciatica SURGICAL HISTORY LTCS x 2 Past psychiatric history: -diagnosis of mood disorder NOS, cluster B traits -several past psychiatric hospitalizations, most recently on Deac-4 in ___ -two past SA; one in ___ by ___, one at age ___ by cutting wrists -psychiatrist Dr. ___ (has seen x 1 month; missed last appointment) -several past medication trials, including lithium (acne), lamictal, risperdal (rash), depakote (hair loss), and haldol (jaw tightening, ?dystonic reaction) <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: BP 129/78, HR 78, RR 18, T 97.6 po FHT: 140 ___, pos accels, no decels, mod var, reactive TOCO: irregular uterine ctx pt unaware TA U/S: BPP ___, AFI 14.2 cm, cephalic, placenta anterior, no previa, fetal cardiac motion noted <PERTINENT RESULTS> ___ WBC-10.9 RBC-3.79 Hgb-11.3 Hct-33.0 MCV-87 Plt-245 ___ Creat-0.5 ALT-9 UricAcd-3.6 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ URINE Hours-RANDOM Creat-96 TotProt-14 Prot/Cr-0.1 ___ URINE 24Creat-1778 24Prot-252 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG marijua-NEG <MEDICATIONS ON ADMISSION> PNV Lamictal D/C 2 wks ago <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 38+4 weeks gestation elevated blood pressure bipolar disorder <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> stay well hydrated
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___ y/o G6P2 at 38+2 weeks gestation with mildly elevated blood pressures and increased agitation in the office. On arrival to triage, she denied any preeclampsia symptoms and labs were normal. She was admitted for blood pressure monitoring, 24 hour urine collection, and psychiatric consultation. Her blood pressures were normal and the 24 hour urine collection was negative. She underwent daily NSTs which were reactive. . Psychiatry was consulted and recommended po Ativan (prn) while she was here in the hospital. They felt that there was no psychiatric contraindication to discharge. Please see notes in OMR for details. Social services also met with her and the plan was to discharge her on ___. Her case worker picked her up and brought her to her scheduled appointment with her outpatient psychiatrist, Dr ___. She will return on ___ for admission prior to her scheduled repeat cesarean section on ___.
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10159055-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lithium Carbonate / Depakote / Resperal / Haldol <ATTENDING> ___. <CHIEF COMPLAINT> pre-op admission <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat low transverse cesarean section <HISTORY OF PRESENT ILLNESS> ___ G6P2032 at 39 weeks gestation with extensive psychiatric history admitted for observation and social service involvement prior to her scheduled delivery by repeat cesarean section on ___. She denies SI/HI. Reports feeling anxious. She denies contractions, leaking of fluid, vaginal bleeding. Feels active FM. <PAST MEDICAL HISTORY> PRENATAL COURSE *) DAting ___ ___ by ___ consistent w/9 W U/S. *) Labs: A pos/Ab neg/R-I/HbSag negRPR-NR/GBS pos *) U/S: FFS ISSUES *) plans adoption for this pregnancy, does not have custody of children. *) PSY issues on meds, H/O hospitalization and suicide attempt. followed at ___. *) lived at ___ now in ___ *) H/O substance abuse and H/O incarceration OBSTETRIC HISTORY C/S X 2 TAB x 2 SAB x 1 GYNECOLOGIC HISTORY H/O HSV PAST MEDICAL HISTORY bipolar disorder sciatica SURGICAL HISTORY LTCS x 2 Past psychiatric history: -diagnosis of mood disorder NOS, cluster B traits -several past psychiatric hospitalizations, most recently on Deac-4 in ___ -two past SA; one in ___ by OD, one at age ___ by cutting wrists -psychiatrist Dr. ___ (has seen x 1 month; missed last appointment) -several past medication trials, including lithium (acne), lamictal, risperdal (rash), depakote (hair loss), and haldol (jaw tightening, ?dystonic reaction) <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) GENERAL: NAD VSS, afebrile LUNGS: CTAB HEART: RRR ABD: soft, gravid, nontender SVE deferred EXT: nontender <PERTINENT RESULTS> ___ BLOOD WBC-12.0 RBC-3.90 Hgb-11.8 Hct-33.9 MCV-87 Plt-263 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG marijua-NEG ___ 05: 40AM BLOOD Hct-29.2* <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours. Disp: *30 Tablet(s)* Refills: *2* 2. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp: *60 Tablet(s)* Refills: *2* 3. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp: *60 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> term pregnancy delivered <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <DISCHARGE INSTRUCTIONS> ROUTINE POST OP, CESAREAN SECTION AND post partum care discussed ___ Instructions: ___
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___ ___ admitted at 39+0 weeks gestation in preparation for her scheduled repeat cesarean section on ___. Social services was quite involved in her care given the adoption process. Please see OMR notes. She underwent an uncomplicated repeat LTCS and delivered a liveborn female, weighing 4295g, with apgars of 8 and 8. Please see operative report for details. . Postpartum, pt received routine postpartum care. She was followed extensively by social services regarding the adoption process and social support. Please see social service's notes for details. Pt also received Ativan as needed for anxiety throughout her hospital stay. She was started on Tripleptal as recommended by her outpatient psychiatrist. Pt was discharged home on ___ in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty.
| 779
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10159055-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lithium Carbonate / Depakote / Resperal <ATTENDING> ___. <CHIEF COMPLAINT> suicidal ideation, term pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean section <HISTORY OF PRESENT ILLNESS> ___ is a ___ yo G2P1 who was transferred from ___ at 38 weeks' gestation with suicical ideation. Her prenatal course was also remarkable for gestational diabetes. She was admitted for ongoing inpatient psychiattric care with a 24 hour sitter and planned to have a repeat cesarean during this hospitalization. <PAST MEDICAL HISTORY> bipolar disorder gestational diabetes prior cesarean section <SOCIAL HISTORY> single, lives at ___. <PHYSICAL EXAM> on madmission, vitals were stable, fetal heart rate was reassuring with a reactive nonstress test. abdomen was soft, nontender, gravid, consistent with 38 weeks' gestation. extremities were unremarkable. pelvic exam was deferred. <PERTINENT RESULTS> ___ 02: 10PM GLUCOSE-118* UREA N-7 CREAT-0.5 SODIUM-137 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16 ___ 02: 10PM estGFR-Using this ___ 02: 10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02: 10PM WBC-9.1 RBC-4.32 HGB-12.9 HCT-38.1 MCV-88 MCH-29.7 MCHC-33.8 RDW-13.7 ___ 02: 10PM NEUTS-74.1* ___ MONOS-3.1 EOS-0.7 BASOS-0.3 ___ 02: 10PM PLT COUNT-289 <MEDICATIONS ON ADMISSION> fluoxetine haldol <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *30 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> term delivery by repeat cesarean sectio bipolar disorder with acute suicidal ideation <DISCHARGE CONDITION> medically stable for transfer to ___ facility <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> call fro fever, increased pain, heavy vaginal bleeding, incisional problems, other concerns.
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Ms. ___ was followed by psychiatry and social work services, and remained with a sitter throughout her hospital stay. On ___ she became acutely agitated. Cesarean section was performed on this day. During the surgery an incidental finding of a left paratubal cyst was noted; this was removed at the same time. Her postoperative course was unremarkable. She remained afebrile throughout. On postoperative day 4 she was tolerating a regular diet, able to ambulate and void normally, and tolerating po pain medications with good control of her pain. She is medically cleared to be discharged from the postpartum unit to an inpatient psychiatric facility.
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10159383-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Lamictal / Wellbutrin <ATTENDING> ___. <CHIEF COMPLAINT> shortening cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G4P0030 at 26+1 WGA with didi twin gestation and cervical shortening sent to triage for evaluation and beta today. Pt had CL of 0.8cm with funneling from ___ and ___. Pt denies vaginal bleeding, cramping, contractions and SROM. +FM x2. PNC: - ___ ___ by LMP (___) c/w ___ trimeser u/s x 2 (see above discussion) - Labs: A+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/GBS neg on ___ - Genetics: low risk NIPT, neg CF, neg SMA - FFS: normal x 2. CL WNL at that time. - GLT: not yet done - Issues: -- ___ trimester bleeding, has since resolved -- campylobacter enteritis diagnosed in ___, likely from deli at ___ -- di-di twins as above --> most recent EFW performed today A 881g,47% male, cephalic; B 807g,37% female, breech <PAST MEDICAL HISTORY> GYNHx: - Denies STDs - Reports normal Pap testing - No known history of fibroids, endometriosis, gyn procedures - History of infertility, requiring letrozole, IUI OBHx: G3P0 - SAB in ___ at 11wk after assault (DV by partner at the time), did not require D&C - SAB at 6wk - SAB after pos pregnancy test (no confirmed IUP) after assault by sister's boyfriend --> pt reports has undergone recurrent pregnancy loss work-up that was all negative including antiphospholipid antibody syndrome testing, maternal and paternal chromosome and uterine imaging PMH: depression, anxiety, obesity (lost 230 pounds after gastric bypass) PSH: LSC gastric bypass (roux-en-Y), T&A <SOCIAL HISTORY> ___ <FAMILY HISTORY> Patient and FOB denied any history of Down's syndrome, neural tube defects, thalassemia, ___ disease, stillbirths, congenital anomalies, or mental retardation. Her mother has a history of DVT (smoker) <PHYSICAL EXAM> On admission: BP: 94/56 Heart Rate: 84 Resp. Rate: 17 T: 98.2 Gen: NAD Abd: nontender SSE: normal external female genitalia. Cervix appears closed, approx 1 cm in length, physiologic discharge. BV, yeast, GC, chlam swabs sent again. SVE: 1cm external os but narrows in cervical canal and can not get to internal os. Previously 1cm therefore no change/70/high/soft. On discharge: AF VSS Gen: NAD Abd: nontender, gravid SSE: on discharge, cervix visually closed, pessary in place Ext: nontender <PERTINENT RESULTS> ___ 01: 34PM BLOOD WBC-10.5* RBC-3.82* Hgb-11.2 Hct-34.4 MCV-90 MCH-29.3 MCHC-32.6 RDW-12.3 RDWSD-40.2 Plt ___ ___ 01: 00PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 01: 00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-300 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 01: 00PM URINE RBC-4* WBC-1 Bacteri-FEW Yeast-NONE Epi-1 ___ 12: 50 pm SWAB Source: Vaginal. **FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. ___ 12: 50 pm SWAB Source: Vaginal. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. ___ 1: 00 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> PNV, vaginal progesterone, colace <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. proGESTerone micronized 200 mg vaginally DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> twin pregnancy at 26w2d cervical shortening <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for observation due to a shortened cervix. Your cervix was not dilated and you had no evidence of preterm labor. A cervical pessary was placed given in attempt to stop the progression of cervical shortening. Fetal testing was reassuring. You received a course of betamethasone for fetal lung maturity and testing was reassuring while you were here. Please continue the vaginal progesterone. Avoid strenuous exercise and maintain pelvic rest. Stay hydrated.
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Ms. ___ was admitted to the antepartum service at 26w1d with di-di concordant twins with cervical shortening from 1.5-1.8 cm to 0.8 cm with funneling despite use of vaginal progesterone. On admission, she was without evidence of labor and was asymptomatic. She had initially been seen at 23 weeks and found to have a short cervix, at which time she was started on vaginal progesterone. Given persistent cervical shortening despite vaginal progesterone, it was recommended that she received antenatal steroids and admission for close observation. She was counseled re: a cervical pessary and agreed. A pessary was placed on hospital day #1. She received a course of betamethasone and was betamethasone complete on ___. She was seen by the NICU. She was continued on vaginal progesterone. She continued to be without evidence of labor. She had reassuring fetal testing with daily NSTs. On ___ when she was betamethasone complete, a sterile speculum exam was performed and her cervix remained visually closed. The pessary was left in place. She was discharged home in stable condition with close outpatient followup scheduled.
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10159748-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic Organ prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic Assisted Supracervical hysterectomy Bilateral Salpingo-oophorectomy Sacrocolpopexy Posterior Clporrhaphy Cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 5 Para 3023 who presents today in the office for a consultation requested by Dr. ___ ___ vaginal prolapse. She is complaining of worsening prolapse over the past year. She has seen Dr. ___ and was still contemplating conservative options but has been concerned recently regarding her vaginal spotting. She thinks it is rubbing against her underwear. She admits to daily periods of palpable prolapse. She reports to occasional urgency incontinence. She voids ___ times per day and ___ times per night. She uses no pads per day. She admits to some urgency, she denies any dysuria and reports bladder emptying with normal flow. She denies any admits to hematuria, UTI's, kidney stones or pyelonephritis. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Raynaud's 2. Osteopenia PAST SURGICAL HISTORY 1. Umbilical hernia repair 2. D&C x 2 PAST OB HISTORY G5P3023 Vaginal: 3 PAST GYN HISTORY She is Postmenopausal since ___ She admits to post-menopausal bleeding. Her last PAP smear was in ___ and reportedly normal <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> PHYSICAL EXAM ON ADMISSION BP: 128/84 Heart Rate: 87 Weight: 138 (With Clothes) Height: 65 (Patient Reported) Neuro/Psych: Oriented x3, Affect Normal, NAD. Nodes: No inguinal adenopathy. Heart: No pedal edema Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegaly, No hernia. Ext: No clubbing, cyanosis, edema. Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. Cervix: no lesions, no discharge Uterus: non-tender Adnexa: no masses non tender. PHYSICAL EXAM ON DISCHARGE Vitals: VSS Gen: NAD, A&O x 3, crepitus of chest and neck CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> * Pathology Pending * . ___ 10: 15PM BLOOD WBC-6.8 RBC-3.29* Hgb-10.3* Hct-31.3* MCV-95 MCH-31.3 MCHC-32.9 RDW-12.5 RDWSD-43.7 Plt ___ ___ 07: 00PM BLOOD WBC-7.4 RBC-3.24* Hgb-10.3* Hct-31.1* MCV-96 MCH-31.8 MCHC-33.1 RDW-12.5 RDWSD-43.4 Plt ___ ___ 10: 15PM BLOOD Neuts-85.3* Lymphs-10.1* Monos-4.1* Eos-0.0* Baso-0.1 Im ___ AbsNeut-5.79 AbsLymp-0.69* AbsMono-0.28 AbsEos-0.00* AbsBaso-0.01 ___ 07: 00PM BLOOD Neuts-88.3* Lymphs-6.9* Monos-4.2* Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.48* AbsLymp-0.51* AbsMono-0.31 AbsEos-0.01* AbsBaso-0.01 ___ 10: 15PM BLOOD Glucose-129* UreaN-8 Creat-0.7 Na-140 K-4.3 Cl-105 HCO3-26 AnGap-13 ___ 05: 45PM URINE Color-Straw Appear-Clear Sp ___ ___ 05: 45PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM ___ 05: 45PM URINE RBC-88* WBC-6* Bacteri-FEW Yeast-NONE Epi-1 ___ 05: 45PM URINE Mucous-RARE . URINE CULTURE (Final ___: <10,000 organisms/ml . Blood Culture Pending x2 <MEDICATIONS ON ADMISSION> calcium, vit D, colace, valacyclovir <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN pain Do not exceed 4g acetaminophen in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*40 Tablet Refills: *2 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN pain Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*40 Tablet Refills: *2 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive or drink alcohol while taking medication RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic Organ 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. * 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 robotic assisted supracervical hysterectomy, bilateral salpingo-oophorectomy, sacrocolpopexy, posterior colporrhaphy, revision of upper abdominal scar, and cystoscopy for pelvic organ prolapse. Please see the operative report for full details. . Her post-operative course was as follows. Immediately post-op, her pain was controlled with oral oxycodone, ibuprofen, and acetaminophen. Her diet was advanced and she was able to tolerate a regular diet without nausea or vomiting. . On post-operative day 1, her urine output was adequate so a urogyn trial of void was performed. The results are as follows: 300cc backfill, 20cc void, 193cc on PVR. Patient declined insertion of foley and time was allowed for her to void spontaneously. She then voided 200cc with 355cc on PVR. Her next void was 300cc with 100cc on PVR. She was then able to void spontaneously for the remainder of her hospitalization. . On POD 1, patient spiked a fever of 102.0 while tachycardic and O2 saturation of 94% on room air. An infectious workup was performed with labs, urinalysis, and blood culture, and chest xray. Patient defervesced and patient remained afebrile for the remainder of her hospitalization. . 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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10162760-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> amoxicillin / Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> High Grade Endometrial Cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, total pelvic lymphadenectomy, para-aortic lymph node dissection, omental biopsy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ YO who presented for management of high grade endometrial cancer. She noted vaginal bleeding that began in ___ was subsequently started on medroxyprogesterone 10mg daily which made her bleeding subside. She subsequently underwent a pelvic ultrasound on ___, which showed a small AV uterus measuring 4.8 x 3.78 x 3.47cm, endometrial thickness 9.8mm, R ovary measured 1.48 x 1.42 x 1.72cm and unremarkable. L ovary was not visualized.Given intolerance to pelvic exams, an office endometrial biopsy was not attempted and she underwent a hysteroscopy, dilation and curettage and a pap smear on ___. The outside pathology showed a high grade endometrial carcinoma. The histologic appearance is mixed with features of high grade endometrioid, serous, clear cell, and carcinosarcoma all noted. A CA-125 level was 16. Chest CT showed a solitary 5mm lung nodule and no obvious evidence of metastatic disease in the abdomen or pelvis. Thus, decision was made to move forward with a minimally invasive staging procedure. <PAST MEDICAL HISTORY> PGynHx: LMP/age of menopause 42 Periods prior: regular, normal flow - intermenstrual bleeding? denies - dysmenorrhea? denies - fibroids? denies - cysts? denies Last pap ___ denies h/o abnl pap smears STDs denies GYN procedures? D&C as above Denies h/o HRT use ___? unknown POBHx: G0 PMHx: - HTN - HLD - GERD - Diverticulosis - last episode of diverticulitis ___ years ago - ___ Esophagus - Osteoarthritis - Denies h/o heart or respiratory disease, thromboembolic disease - Denies h/o anesthesia complications PSHx: HSC, D&C as above <ALLERGIES> amoxicillin <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Father - colon CA - Brother - colon CA - Mother, brothers, sisters with diabetes - Brothers (4) with cardiac disease - denies h/o breast, cervical, endometrial, uterine CA - denies h/o bleeding or clotting disorder <PHYSICAL EXAM> PREOPERATIVE PHYSICAL EXAM <PHYSICAL EXAM> Weight 139 BP 150/92 P 64 CONSTITUTIONAL: NAD NEURO: AOx3 PSYCH: Appropriate mood and affect ENDO: No thyromegaly, no nodules CV: Normal rate, regular rhythm, no murmurs/rubs/gallops, normal S1, S2 PULM: Lungs clear, no crackles GI: Soft, nontender, nondistended, no masses MSK: No CVAT LYMPHATICS: No cervical or inguinal lymphadenopathy GU: deferred (at patient request) PHYSICAL EXAM ON DISCHARGE Gen: resting comfortably in bed, no acute distress Pulm: LCTAB, no wheezes, crackles, rhonchi CV: Regular rate and rhythm Abd: soft, nondistended,positive bowel sounds, laparoscopic incision sites clean, dry, intact with glue in place Ext: bilateral lower extremities nontender and nonedematous <PERTINENT RESULTS> --======== RELEVANT LABS: --======== ___ 10: 20AM GLUCOSE-106* UREA N-20 CREAT-1.1 SODIUM-137 POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-23 ANION GAP-18 ___ 10: 20AM BLOOD WBC-6.2 RBC-4.02 Hgb-12.4 Hct-37.1 MCV-92 MCH-30.8 MCHC-33.4 RDW-13.6 RDWSD-45.2 Plt ___ --======== LABS ON DISCHARGE --======== ___ 07: 25AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.8* Hct-32.6* MCV-92 MCH-30.3 MCHC-33.1 RDW-13.5 RDWSD-44.8 Plt ___ ___ 07: 25AM BLOOD Plt ___ ___ 07: 25AM BLOOD Glucose-96 UreaN-21* Creat-1.1 Na-137 K-4.0 Cl-100 HCO3-26 AnGap-11 ___ 07: 25AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9 <MEDICATIONS ON ADMISSION> - Omeprazole 20mg daily - Metoprolol 100mg daily - Furosemide 20mg daily - Losartan 50mg daily - Simvastatin 20mg daily - Allopurinol ___ twice daily - Fluticasone 50mg as needed - Aspirin 325mg daily - Zyrtec as needed - Medroxyprogesterone 10mg <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN Pain - Mild RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day 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 #*40 Capsule Refills: *1 3. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg ___ tablet(s) by mouth Q4HE Disp #*30 Tablet Refills: *0 4. Allopurinol ___ mg PO BID 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY: PRN congestion 6. Losartan Potassium 50 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Simvastatin 20 mg PO QPM <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrial 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: . Laparoscopic 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 8 weeks * No heavy lifting of objects >10 lbs for 4 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. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. * 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 ***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. ***Urine Output *You were urinating adequately after your foley was removed. On an ultrasound scan of your bladder, it appeared that you had extra urine in the bladder. However, given that you were urinating frequently and adequately, you were deemed appropriate for discharge. Please make sure to void every ___ hours to ensure that your bladder is not retaining urine.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, total pelvic lymphadenectomy, para-aortic lymph node dissection, and omental biopsy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilauidid and acetaminophen. All NSAIDS were held given her history of renal insufficiency. Her diet was advanced without difficulty and she was transitioned to PO oxycodone and acetaminophen for pain control. Day of surgery, her foley was removed, however, she had inadqequate urine output so her foley was replaced. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and underwent a voiding trial. She continued to urinate frequently however had PVRs between 150-200 with UOP 100-250. Her urine output was adequate at 250cc/hr. Given that she was voiding adequately and frequently, she was deemed appropriate for discharge. 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. *)Hypertension: Her home metoprolol was continued day of surgery. Home losartan was restarted on postoperative day 1. Other home antihypertensives were held. *)Gout: home allopurinol was continued day of surgery. *)GERD: home omeprazole was continued day of surgery. *)Hyperlipidemia: home statin was continued ay of surgery.
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10164309-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Phenergan <ATTENDING> ___. <CHIEF COMPLAINT> ___ yo G1 at 16w6d with proteinuria in setting of CHTN <MAJOR SURGICAL OR INVASIVE PROCEDURE> Primary low transverse C-section, ___ stitch bilaterally, excision of avulsed pedunculated fibroid. <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ yo G1P0 at 26w0d with cHTN and IgA nephropathy presents after having elevated BP at home and in ___ office yesterday, reports ranging 170s-200s/100s. Normally 150s/80s-90s. Reports mild headache. No visual changes. No CP/SOB, no RUQ pain. Reports normal fetal movement, no LOF, no painful contractions but some tightening since 1800. <PAST MEDICAL HISTORY> OBH: G1P0 GYNH: - hx of fibroids - Hx of LSIL, for PP f/u - Denies hx of STIs PMH: - cHTN: dx in ___, followed by her PCP ___ cardiologist Dr. ___, both at the ___. She had been on HCTZ and atenolol prior to pregnancy. - Depression/anxiety: had been on wellbutrin prior to pregnancy - IgA nephropathy with baseline 24 hr protein 9855mg (___) PSH: Labiaplasty <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother -hypertension Brother- polycythemia ___ ___ Exam: Physical Exam on Admission VS: T-98.3 HR-87 BP-146/90, 144/93 RR-16\ Gen: NAD CV: RRR, no murmurs Pulm: CTAB, no crackles Abd: soft, nontender, enlarged uterus ~20 weeks GA size Ext: nontender, trace b/l lower ext pitting edema. DTRs 2+ throughout. Bedside u/s: Breech, ant placenta, FHR 167 bpm on m-mode, multiple fibroids seen including a 6 cm posterior fibriod and a 10 cm ant LUS fibroid. Physical Exam on Discharge VSS Gen: NAD CV: RRR Pulm: CTAB Abd: soft nontender, icision C/D/I, mild distention, improving bruising around incision Ext: warm well perfused, nontender, decreased edema <PERTINENT RESULTS> ___ 11: 48PM BLOOD WBC-22.9* RBC-2.90* Hgb-9.5* Hct-27.0* MCV-93 MCH-32.7* MCHC-35.1* RDW-15.4 Plt ___ ___ 09: 56PM BLOOD WBC-22.6*# RBC-2.91*# Hgb-9.5*# Hct-27.1*# MCV-93 MCH-32.6* MCHC-35.0 RDW-15.7* Plt ___ ___ 08: 26PM BLOOD WBC-12.4* RBC-1.95* Hgb-6.4*# Hct-18.3* MCV-94 MCH-33.0* MCHC-35.1* RDW-15.6* Plt ___ ___ 11: 55AM BLOOD WBC-17.4* RBC-2.60* Hgb-8.7* Hct-24.4* MCV-94 MCH-33.5* MCHC-35.8* RDW-15.1 Plt ___ ___ 06: 15AM BLOOD WBC-16.5* RBC-2.54* Hgb-8.3* Hct-23.7* MCV-93 MCH-32.4* MCHC-34.8 RDW-15.2 Plt ___ ___ 11: 48PM BLOOD Plt ___ ___ 11: 48PM BLOOD ___ PTT-24.7* ___ ___ 09: 56PM BLOOD Plt Smr-NORMAL Plt ___ ___ 09: 56PM BLOOD ___ PTT-24.8* ___ ___ 08: 26PM BLOOD Plt ___ ___ 08: 26PM BLOOD ___ PTT-27.5 ___ ___ 11: 48PM BLOOD ___ 11: 48PM BLOOD Glucose-99 UreaN-61* Creat-3.8* Na-141 K-5.3* Cl-113* HCO3-18* AnGap-15 ___ 09: 56PM BLOOD ALT-13 AST-20 AlkPhos-47 ___ 11: 48PM BLOOD Calcium-8.4 Phos-6.9* Mg-2.7* ___ 09: 56PM BLOOD Albumin-2.2* Calcium-7.3* Phos-6.8* Mg-2.7* ___ 08: 26PM BLOOD Calcium-5.9* Phos-5.6* Mg-2.2 ___ 12: 41AM BLOOD Type-ART Temp-36.1 ___ Tidal V-450 PEEP-5 pO2-152* pCO2-35 pH-7.30* calTCO2-18* Base XS--7 -ASSIST/CON Intubat-INTUBATED ___ 07: 37PM BLOOD ___ pO2-47* pCO2-34* pH-7.30* calTCO2-17* Base XS--8 Intubat-NOT INTUBA ___ 07: 37PM BLOOD Glucose-83 Lactate-1.8 Na-136 K-4.5 Cl-114* <MEDICATIONS ON ADMISSION> Nifedipine CR 30mg PO daily <DISCHARGE MEDICATIONS> 1. Calcium Acetate 1334 mg PO TID W/MEALS RX *calcium acetate 667 mg 2 tablet(s) by mouth three times a day Disp #*42 Tablet Refills: *2 2. Captopril 12.5 mg PO HS RX *captopril 12.5 mg 1 tablet(s) by mouth once a day at night Disp #*28 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *2 4. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*28 Tablet Refills: *2 5. Insulin SC Sliding Scale Fingerstick pre-dinner Insulin SC Sliding Scale using HUM Insulin RX *blood sugar diagnostic ___ Active Test] Use with glucometer once a day Disp #*2 Not Specified Refills: *2 RX *blood-glucose meter ___ Active Care] Please check finger sticks once a day once a day Disp #*1 Kit Refills: *0 RX *insulin lispro [Humalog] 100 unit/mL Up to 10 Units per sliding scale once a day Disp #*2 Cartridge Refills: *2 RX *lancets Use to collect blood once a day Disp #*2 Not Specified Refills: *2 RX *insulin syringe-needle U-100 29 gauge x ___ once a day Disp #*7 Syringe Refills: *0 6. Labetalol 300 mg PO TID hold for sbp < 120/70 or HR < 60. Hold ___ dose on ___ RX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp #*40 Tablet Refills: *2 7. NIFEdipine CR 60 mg PO DAILY hold for sbp < 120/70. RX *nifedipine 60 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills: *2 8. OxycoDONE (Immediate Release) 10 mg PO Q3H: PRN pain hold for sedation or RR < 12. RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 9. PredniSONE 5 mg PO once a day Duration: 7 Days Start: After 10 mg tapered dose. RX *prednisone 5 mg 3 tablet(s) by mouth once a day Disp #*42 Tablet Refills: *0 10. Calcium Acetate 1334 mg PO 2X Take one in ___, one in AM. RX *calcium acetate 667 mg 2 tablet(s) by mouth three times a day Disp #*4 Tablet Refills: *0 11. Captopril 12.5 mg PO ONCE Duration: 1 Doses Take in evening RX *captopril 12.5 mg 1 tablet(s) by mouth once Disp #*1 Tablet Refills: *0 12. Furosemide 40 mg PO ONCE Duration: 1 Doses Take one in AM. RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills: *0 13. Labetalol 300 mg PO X2 Take 1 tab in ___, 1 tab in AM RX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp #*2 Tablet Refills: *0 14. PredniSONE 15 mg PO ONCE Duration: 1 Doses This is a new dose for AM. RX *prednisone 5 mg 3 tablet(s) by mouth daily Disp #*3 Tablet Refills: *0 15. NIFEdipine CR 60 mg PO DAILY Take one in AM RX *nifedipine 60 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> -pregnancy s/p cs with live born male infant -Ig A nephropathy -cHTN <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see d/c instructions. No swimming/baths/intercourse for 6 wks. no driving for 2weeks from c/s and while taking percocet. No heavy lifting
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___ G1 admitted at ___ G1 @ 26w0d with cHTN and IgA nephropathy presents after having elevated BP at home and in ___ office one day prior to admission, reports ranging 170s-200s/100s. Normally 150s/80s-90s. Reports mild headache. No visual changes. No CP/SOB, no RUQ pain. Reports normal fetal movement, no LOF, no painful contractions but some tightening since 1800. Patient was admitted to the antepartum service with acute on chronic renal failure vs superimposed preeclampsia. #Renal insufficiency: Patient was recently diagnosed with IgA nephropathy on prior ___ by renal biopsy. On this admission her creatinine had more than doubled from 1.3 on last admission to 3.6. Creatinine continued to slowly rise. Patient intially on prednisone 60mg daily, this was titrated down to 30mg PO daily. The patient had been followed with daily labs. Creatinine continued to rise and rose to over 4. On ___ creatinine was 4.3 and patient devloped epigastric pain. ___ ___ was consulted and decision was made to give rescue dose of betamethasone and proceed with delivery in 48 hours if no improvement in renal function or epigastric pain. On ___ her morning creatinine was 4.3 and given the worsening of her renal function, the decision was made to proceed with delivery by C-section. At the time of cesarean section patient was given stress dose steroids of hydrocortisone 100mg IV Q8h x 3 but transitioned to prednisone 30mg QD, which was then decreased to 20mg on POD 1 and will be further tapered as outpatient. Following delivery patient was started on captopril 12.5mg PO daily. Patient's creatinine was stable at 4.2 on the day of discharge. #Hypertension: History of chronic hypertension, worsened on admission with blood pressure elevated to 170's/100's patient was intially given 10mg IV labetalol then transitioned to 200mg PO BID in addition to patient's home regimen of Nifedipine CR 30mg BID. Difficult to establish if this represented superimposed preeclampsia due to patient's renal failure. Patient discharged on Nifedipine CR 60mg daily and labetalol 300mg TID. #Post-partum Hemorrhage: Patient had a LTCS on ___ with delivery of a live male infant 1160grams. Following delivery and closure of hysterotomy site, the patient continued to have bleeding from the hysterotomy site. Attempted to achieve hemostasis using interrupted stitches and figure-of-eight stitches, and this was not successful. At this point, decision was made to proceed with two ___ stitches bilaterally. For full detail see operative note. Patient had an EBL of 2000cc. Patient was transfused 4uPRBC from hct 17 -> 27 (baseline ___. On POD 1 hct downtrending to 24.9 and patient transfused with 1 additional unit with postransfusion hct 23.4 (from 23.6), and due to lack of response second unit was transfused with hct rise to 26. No obvious source of bleeding. #Hyperglycemia: On admission patient found to have elevated blood sugars. Patient diagnosed with GDMA2 and sugars controlled with NPH and humalog sliding scale. Started post-partum on insulin SS. Followed by ___ during hospitalization. Post partum blood sugars well controlled throughout day however continued to be high at dinner time. Discharged home on humalog sliding scale to do fingersticks once a day following evening meal. Patient will follow up with ___ as outpatient. #Respiratory failure: On ___ Ms ___ was not extubated post-operatively because pt was unstable. No h/o prior respiratory disease/impairment. ABG in FICU showed non-anion gap metabolic acidosis with appropriate respiratory constipation. Possible etiologies include RTA type IV/hypoaldo state given possible adrenal insufficiency with long term steroid use, and predisposition with gestational diabetes (although well controlled during pregnancy). Ms ___ was extubated ___ am. On ___ CXR read as left lower lobe consolidation, although unclear if alectasis. No additional antibiotics were given due to low suspicion for pneumonia given afebrile and lack of symptpms/signs other than leukocytosis (in setting of steroid use) and oxygen saturation 95% on RA (could be explained by atelectasis). Patient transferred out of the FICU on post op day 2. Patient oxygen saturation 99%RA at time of discharge. #Volume Overload: Patient had volume overload both pre and post partum. This was followed with daily weights and managed with fluid restriction and lasix. #Hyperphosphatemia: Contributed to by renal insufficiency and inability to adequately excrete phosphate. Started on phos binder and low phos diet. Patient had nutrition consult prior to discharge for teaching on low phos diet. #Hypocalcemia: ___ renal insufficiency. Calcium was repleted as needed. #UTI: Klebsilla UTI dx on ___ with UA showing 27WBC, started on bactrim ___ switched to ceftriaxone 1g q24hrs completed 7 day course. #)Post Partum: Patient intially in FICU post delivery. She was transferred out on post op day 2 in stable condition. Patient recovered well. She was followed by Renal team and ___ during recovery for above issues. She was discharged home on PPD8 with follow up with Dr. ___ and ___.
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| 1,233
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10164309-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Phenergan / vancomycin <ATTENDING> ___. <CHIEF COMPLAINT> ovarian torsion <MAJOR SURGICAL OR INVASIVE PROCEDURE> right IJ tunneled dialysis line ___ laparoscopic right ovarian cystectomy <HISTORY OF PRESENT ILLNESS> ___ G1P1 with ESRD secondary to IgA nephropathy on daily PD, HTN and s/p TAH for fibroids presents as ED transfer from ___ with acute onset RLQ pain this afternoon at 1300, radiating to back and gradually worsening throughout the day. Does not wax or wane. Pain is sharp. Associated with nausea. No fevers. On presentation to ___, ___. Labs demonstrated stable kidney function, Cr 15.8, K 5.2. WBC 10.3, PMN 77. Abd and pelvic u/s were obtained which showed findings consistent with right ovarian torsion. Per OSH report, "in the right adnexa, there is a complex mass which is echogenic measuring 6 x 5.2 x 5.7 cm. This could represent a hemorrhagic cyst or a solid ovarian mass. Color doppler shows a trace amount of color flow." She was given 1.5mg IV dilaudid. Given complex h/o ESRD on PD, pt was transferred to ___ for further management. On arrival to ___, she now states that her pain has decreased to ___. No fevers, nausea. She is unsure if she is having her period, but she does endorse breast tenderness over the last several days. <PAST MEDICAL HISTORY> GYN HISTORY: LMP: s/p hysterectomy HISTORY of Abnormal pap smears: yes, h/o LSIL HISTORY of STIs: denies ISSUES: fibroids; denies h/o ovarian cysts OB HISTORY: G1P1 - pLTCS for worsening renal IgA nephropathy at 29w6d, c/b intrapartum hemorrhage (2L) secondary to bleeding from multiple fibroids at hysterotomy site, requiring transfusion. Required ICU stay for respiratory failure, non-anion gap acidosis. Also had GDM PAST MEDICAL HISTORY: - Hypertension - History of hematuria - ESRD - IgA nephropathy diagnosed when patient was noted to have worsening proteinuria during pregnancy. Treated with steroids through pregnancy and then progressed to ESRD - h/o gestational diabetes - Depression/anxiety PAST SURGICAL HISTORY: - TAH, ___, for fibroid uterus - LSC PD cathether placement, ___ - pLTCS, as above, ___ - renal biopsy, ___ - labiaplasty, ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Brother with polycythemia ___. No family members with IgA nephropathy or renal disease. <PHYSICAL EXAM> PHYSICAL EXAM: 98.0 88 180/110 16 99% RA 98.2 81 166/98 16 98% RA Pain 0 98.3 78 162/100 16 98% RA CONSTITUTIONAL: NAD, AOx3 ABDOMEN: PD catheter in place RLQ port site dressing c/d/i. soft, completely nontender to deep palpation, no r/g PELVIC: Normal external genitalia, smooth vaginal epithelium, physiologic leukorrhea, intact apex both with visual inspection and on digital palpation, no left adnexal mass palpated, no left adnexal tenderness, mild right adnexal tenderness associated with right adnexal fullness Discharge physical exam Vitals: VSS BP 140s/80s Gen: NAD, A&O x 3 Neck: tunneled right IJ c/d/i CV: RRR Resp: no acute respiratory distress Abd: soft, mildly distended, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> PUS ___ IMPRESSION: 1. Right pelvic mass with only peripheral flow and no demonstrable internal flow, unchanged in size or appearance compared with recent exam may represent a right adnexal neoplasm versus a residual broad ligament fibroid partially seen in pre-hysterectomy MRI from ___. Further assessment with a pelvic MRI with contrast is recommended for complete evaluation. 2. Ascites slightly increased compared with recent exam. MRI ___ IMPRESSION: -Heterogenous 5.7 cm right adnexal mass with layering hemorrhage/ debris. This was not visualized on the prior renal MRA, with limited evaluation of the pelvis. Considerations include a degenerated or torsed broad ligament fibroid or degenerated ovarian neoplasm. Ovarian torsion, however, cannot be excluded, especially since the right ovary is not identified. -Small to moderate amount of free pelvic fluid, which may be secondary to the patient's peritoneal dialysis. Time Taken Not Noted Log-In Date/Time: ___ 4: 05 am URINE Site: NOT SPECIFIED **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 10: 56 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Preliminary): NO GROWTH. ___ 09: 20AM BLOOD WBC-9.5 RBC-2.47* Hgb-7.8* Hct-22.7* MCV-92 MCH-31.6 MCHC-34.5 RDW-15.7* Plt ___ ___ 04: 33AM BLOOD WBC-8.8 RBC-2.61* Hgb-8.2* Hct-23.9* MCV-91 MCH-31.2 MCHC-34.2 RDW-15.5 Plt ___ ___ 06: 55AM BLOOD WBC-9.6 RBC-2.79* Hgb-8.9* Hct-25.6* MCV-92 MCH-31.9 MCHC-34.7 RDW-15.2 Plt ___ ___ 12: 58AM BLOOD WBC-12.2*# RBC-2.81* Hgb-9.0* Hct-26.3* MCV-94 MCH-32.0 MCHC-34.1 RDW-16.1* Plt ___ ___ 09: 20AM BLOOD Neuts-85.7* Lymphs-7.7* Monos-4.6 Eos-1.7 Baso-0.2 ___ 06: 55AM BLOOD Neuts-76.1* Lymphs-14.8* Monos-5.2 Eos-3.4 Baso-0.5 ___ 12: 58AM BLOOD Neuts-76.9* Lymphs-14.5* Monos-5.8 Eos-2.3 Baso-0.5 ___ 04: 33AM BLOOD ___ PTT-27.4 ___ ___ 09: 20AM BLOOD Glucose-94 UreaN-74* Creat-15.2* Na-135 K-5.1 Cl-98 HCO3-22 AnGap-20 ___ 04: 33AM BLOOD Glucose-109* UreaN-74* Creat-15.2*# Na-135 K-5.1 Cl-99 HCO3-23 AnGap-18 ___ 06: 55AM BLOOD Glucose-78 UreaN-69* Creat-16.4*# Na-138 K-4.9 Cl-100 HCO3-23 AnGap-20 ___ 12: 58AM BLOOD Glucose-95 UreaN-65* Creat-14.9*# Na-135 K-5.0 Cl-95* HCO3-21* AnGap-24* ___ 09: 20AM BLOOD Calcium-7.9* Phos-12.2* Mg-2.3 ___ 04: 33AM BLOOD Calcium-8.2* Phos-10.7* Mg-2.5 ___ 06: 55AM BLOOD Calcium-8.1* Phos-11.5* Mg-2.7* ___ 12: 58AM BLOOD Calcium-8.1* Phos-10.9*# Mg-2.6 ___ 09: 20AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND ___ 01: 09AM BLOOD Lactate-1.0 ___ 09: 20AM BLOOD HCV Ab-PND ___ 01: 46AM URINE Color-Straw Appear-Hazy Sp ___ ___ 01: 46AM URINE Blood-TR Nitrite-NEG Protein->600 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR ___ 01: 46AM URINE RBC-9* WBC-42* Bacteri-MOD Yeast-NONE Epi-9 TransE-1 ___ 01: 46AM URINE CastHy-2* ___ 09: 20AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE ___ 09: 20AM BLOOD HCV Ab-NEGATIVE <MEDICATIONS ON ADMISSION> 1. Calcitriol 0.25 mcg PO DAILY 2. Calcium Acetate 1334 mg PO TID W/MEALS 3. Cinacalcet 30 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Nephrocaps 1 CAP PO DAILY <DISCHARGE MEDICATIONS> 1. Calcitriol 0.25 mcg PO DAILY 2. Calcium Acetate 1334 mg PO TID W/MEALS 3. Cinacalcet 30 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Nephrocaps 1 CAP PO DAILY 6. Acetaminophen ___ mg PO Q6H: PRN pain not to exceed 4 grams in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain do not drink alcohol or drive RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 8. Labetalol 150 mg PO BID RX *labetalol 100 mg 1.5 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 9. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*40 Tablet Refills: *1 10. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right adnexal mass ESRD <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 with right sided abdominal pain and concern for ovarian torsion and underwent surgery. You have recovered well and the team believes you are ready to be discharged home. Please call the OB/GYN office ___ with any questions or concerns. Please follow up with Dr. ___ for your dialysis care and for your high blood pressure. 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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On ___, Ms. ___ was admitted to the gynecology service for management of her likely right ovarian torsion. Her ovary likely spontaneously de-torsed as her pain had resolved by the time she arrived to the ___ emergency department. Repeat pelvic US showed right pelvic mass with only peripheral flow and no demonstrable internal flow, concerning for a right adnexal neoplasm versus a residual broad ligament fibroid. Follow up MRI showed possible degenerated or torsed broad ligament fibroid or degenerated ovarian fibroma or other neoplasm. Given the possibility of torsion and in order to prevent infectious sequelae of torsion, decision was made to proceed to the OR ___ for removal of the mass with laparoscopic RSO, possible laparotomy. Renal and transplant surgery were consulted for optimization of her ESRD in the setting of requiring surgical intervention. Her creatinine remained stable. She received peritoneal dialysis starting the evening of ___ until her surgery. She also received an right IJ tunneled dialysis line ___ by ___ for planned hemodialysis after her operation. She continued her home losartan and had asymptomatic, elevated blood pressures to the 180s/110s overnight on ___. She was restarted on labetolol 150mg PO BID per renal recommendations with improvement of her blood pressures. On ___, she underwent laparoscopic right ovarian cystectomy. 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 Zofran for narcotic related nausea. On post-operative day 1, she was voiding spontaneously. Her diet was advanced without difficulty and she was transitioned to PO Dilaudid/Zofran/acetaminophen. She was followed by Renal and Transplant surgery and she received her first hemodialysis on ___ and is scheduled for her next dialysis on ___. Her hematocrit and electrolytes remained stable. She declined social work consultation for resources during her stay. 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. She will follow up with Dr. ___ for her ESRD, anemia and blood pressure management.
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10165768-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Erythromycin Base / Benzyl Alcohol / Balsam ___ / Methylchloroisothiazolinone <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy lysis of adhesions cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 0 with a known uterus who has been having heavy periods, primary gynecologist, Dr. ___. The patient notes increased pressure in her pelvis as well. She had an ultrasound done on ___, which showed an enlarged fibroid uterus, difficult to measure accurately because of its size. The approximate length was 21 cm, fundal portion is 4 cm superior to the patient's umbilicus. There was a fibroid in lower uterine segment measuring 8.8 x 9.0 x 7.6 cm. There was an exophytic fundal fibroid, which measured 6.1 x 5.8 x 6.0 cm. The endometrium was visualized, measured 7 mm. The right ovary was normal and within the right ovary was an unilocular 2.2 cm cyst in the physiologic size range. The left ovary was not definitively visualized. These findings were discussed with the patient. We discussed treatment options for uterine fibroids including expected medical management, interventional radiology (uterine fibroid embolization), operative treatments including multiple myomectomy, supracervical hysterectomy, and total abdominal hysterectomy. The patient states that she will consider her options and may seek a second opinion at ___ ___. Of note, she has had hysteroscopic myomectomy x3 at ___. Those medical records have been requested. She represented after a successful endometrial biopsy. The patient was then counseled on her upcoming procedure after again outlining options for fibroid treatment including expectant management, medical management, and interventional radiology, and operative management. The patient is requesting a total abdominal hysterectomy with preservation of ovaries if they appear normal. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 10. She has menorrhagia and bleeds for seven to ten days. Her last endometrial biopsy was in ___ and was normal, the patient has a repeat with me. She does pass large clots. She descrinbes her clots as being from nickel to quarter size. When she bleeds heavily, she changes a pad approximately every 45 minutes to hour and a half for the first three days. She notes that at times she has bleeding between cycles. She denies postcoital bleeding with intercourse, does have amenorrhea, for which she takes Naprosyn 500 mg. Her last Pap was ___ and was normal. She denies any history of abnormal Pap smears. Mammogram in ___, she has had no significant abnormal findings on mammogram. Colonoscopy in ___, which showed small hemorrhoids, she gets a colonoscopy every ___ years secondary to a strong family history of colon cancer. She has never had a bone density. She has a history of herpes and gonorrhea. She uses no form of fertility control at this time. She is not sexually active. PAST MEDICAL HISTORY: Significant for asthma, seasonal allergies, anemia, eczema, borderline hypertension, retinal scarring, and knee injury. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Significant for diabetes, colon cancer, hypertension, stroke, and hypercholesterolemia. She has two living brothers, no sisters, one adopted son. <PHYSICAL EXAM> GENERAL: This is a well-developed, well-nourished woman in no apparent distress. Blood pressure 112/80, weight 187. ABDOMEN: Soft, nondistended, nontender. There was a palpable mass approximately one fingerbreadth above the umbilicus consistent with her fibroid uterus and was nontender. PELVIC: Normal female external genitalia. Bartholin, urethral, and Skene's glands were normal. Vaginal vault, normal appearing discharge. Cervix was without cervical motion tenderness. Uterus approximately 23 cm in maximal vertical dimension, irregularly contoured, again consistent with a multiple fibroid uterus. Adnexa was impossible to evaluate secondary to large pelvic abdominal mass. <MEDICATIONS ON ADMISSION> Medications - Prescription ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every ___ hours as needed for shortness of breath/wheezing ALBUTEROL SULFATE - (Prescribed by Other Provider) - Dosage uncertain EPINEPHRINE - 0.3 mg/0.3 mL (1: 1,000) Pen Injector - use as directed FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - Dosage uncertain NAPROXEN - 500 mg Tablet - one Tablet(s) by mouth twice daily if needed SPACER - - use as directed Medications - OTC FERROUS SULFATE - 324 mg (65 mg iron) Tablet, Delayed Release (E.C.) - one Tablet(s) by mouth three times a day <DISCHARGE MEDICATIONS> 1. albuterol sulfate Inhalation 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: take with food. Disp: *60 Tablet(s)* Refills: *0* 4. 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* 5. fluticasone Inhalation <DISCHARGE DISPOSITION> Home With Service Facility: ___ <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> You were discharged home with a foley catheter and leg bag. Please call Dr. ___ office on ___ to arrange for removal of this catheter. 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. 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 following a scheduled total abdominal hysterectomy; see operative report for details. She had an uncomplicated recovery and was discharged home in stable condition on post-operative day #3 with a Foley catheter in place and plan for outpatient trial of voiding.
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10167166-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> SVD <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 Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 11: 00AM BLOOD WBC-8.0 RBC-3.22* Hgb-8.8* Hct-27.5* MCV-85 MCH-27.3 MCHC-32.0 RDW-14.6 RDWSD-46.0 Plt ___ ___ 03: 31PM BLOOD Hct-27.2* ___ 10: 35AM BLOOD WBC-11.6* RBC-3.22* Hgb-8.7* Hct-27.0* MCV-84 MCH-27.0 MCHC-32.2 RDW-15.0 RDWSD-45.9 Plt ___ ___ 02: 45AM BLOOD WBC-13.0* RBC-3.10*# Hgb-8.5*# Hct-26.1* MCV-84 MCH-27.4 MCHC-32.6 RDW-14.9 RDWSD-45.4 Plt ___ ___ 02: 05PM BLOOD Hct-30.4* ___ 04: 55AM BLOOD WBC-9.7 RBC-4.48 Hgb-12.1 Hct-37.1 MCV-83 MCH-27.0 MCHC-32.6 RDW-14.6 RDWSD-44.3 Plt ___ ___ 11: 00AM BLOOD Plt ___ ___ 10: 35AM BLOOD Plt ___ ___ 02: 45AM BLOOD Plt ___ ___ 04: 55AM BLOOD Plt ___ ___ 02: 45AM BLOOD Creat-0.5 ___ 03: 39AM URINE Color-Straw Appear-Hazy Sp ___ ___ 03: 39AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 03: 39AM URINE RBC-5* WBC-14* Bacteri-FEW Yeast-NONE Epi-12 ___ 03: 39AM URINE Mucous-RARE URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION URINE CULTURE (Final ___: PRESUMPTIVE GARDNERELLA VAGINALIS. >100,000 CFU/mL. <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen (Liquid) 650 mg PO Q6H pain RX *acetaminophen 500 mg/5 mL 10 cc by mouth q 6 hours Refills: *0 2. Cyclobenzaprine 10 mg PO TID: PRN pain RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth q 8 hr Disp #*30 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID: PRN Constipation 4. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain take with food RX *ibuprofen 100 mg/5 mL 30cc suspension(s) by mouth q 6 hours Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth q 4 hrs Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> term pregnancy, vaginal birth of a female possible pelvic hematoma /fibroid uterine <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per written instructions reviewed by nursing
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Ms. ___ is a ___ G4P3 admitted the postpartum unit status post a spontaneous vaginal delivery that was complicated by a shoulder dystocia. Her postpartum course was complicated by the development of persistent LLQ pain that was refractive to conservative treatment. Given the history of shoulder dystocia, an internal vaginal exam was done that showed no evidence of rectovaginal hematoma. A CT abdomen and pelvis was done that showed a 9.8 x 12.1 x 7.8 cm left pelvic hematoma associated with the left posterior uterus thought to possibly represent a broad ligament hematoma. MRI imaging was recommended for better characterization. MRI showed a possible chronically torsed, non-viable left ovary vs a degenerated exophytic fibroid. PUS was done to exclude possible torsion. The results showed prominent blood flow in the periphery of the ovary making torsion unlikely. The PUS could not distinguish between broad ligament hematoma vs necrotic fibroid. Her hematocrit was trended with a nadir of 26. Her vital signs remained normal with no signs of bleeding. Given her clinical stability, follow-up imaging was recommended in the outpatient setting due to low concern for expansion of the hematoma. Her pain we treated with conservative measures including Tylenol, ibuprofen, flexeril, and oxycodone. The pain improved over the course of the admission. Urinalysis and urine were sent which showed no evidence of UTI. During her admission the patient revealed an unstable housing situation and past history of domestic violence. She met with social work and CVPR advocate who discussed housing options once she was discharged from the hospital and provided additional resources regarding shelters. By postpartum day 4, her abdominal pain was improving, 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 and plan for follow-up ultrasound imaging as an outpatient.
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10167765-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Cramping abdominal pain s/p UAE on ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ G4P3 who presented to GYN triage with increasing pain and vaginal bleeding status post a Uterine Artery Embolization on ___. She was kept overnight after the procedure at ___, received IV dilaudid for pain. She also received IV iron for repletion of iron stores (per pt, labs notable for iron deficiency). She was discharged to home in good condition on ___, intially with relatively minimal pain. Over ___, she became more uncomfortable, with pain not relieved with motrin and occasional percocet. Her pain is across her lower abdomen, mostly centrally. She was able to tolerate breakfast and lunch w/ out nausea or vomiting. She had a normal BM on day of presentation. She has also noted that when she voids she has a small amount of dark red bleeding from her vagina. On review of pelvic MRI from ___, the dominant fibroid is intramural within the anterior wall of the uterus, measuring 8.6 x 6.4 x 7.3cm. Ms ___ also had a recent hospitalization at ___ ___ ___ for rectal bleeding with menses. Had ___ at St E on ___ w/ gastric bx. Reportedly normal. She was told her HCT on d/c was 28, down from 32. Menses stopped on usual cycle. Rectal bleeding stopped spontaneously. <PAST MEDICAL HISTORY> OB Hx: SVD x 3, Sab x 1 GYN Hx: Endometriosis, fibroids. LMP ___. PMH: Fibroids PSH: Dx LSC ___ w/ excision of endometriosis (stage IV) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Admission physical exam: T: 98.7 HR 78 BP 116/67 RR 20 O2sat 100%RA General: NAD, but occasionally appears in distress with cramping pain Abdomen: soft, non-distended. Nontender upper abdomen. Externally,mildly tender lateral abdomen. Very TTP suprapubic area. Pelvic: Ext genitalia normal. Vagina normal, cervix normal. Scant amount of mucousy blood in vault and coming from cervix, not increased with valsalva. BME: No CMT. No fundal TTP; fundus ~14cm, bulky, c/w fibroids. Mild adnexal TTP. Very tender suprapubically, where a firm mass is palpated on the anterior aspect of uterus, consistent with fibroid. ___: NT/NE <PERTINENT RESULTS> ___ 03: 22PM BLOOD WBC-7.5 RBC-4.36 Hgb-11.5* Hct-35.3* MCV-81* MCH-26.3* MCHC-32.5 RDW-17.4* Plt ___ ___ 03: 45PM BLOOD WBC-7.2 RBC-3.71* Hgb-10.0* Hct-30.3* MCV-82 MCH-27.0 MCHC-33.1 RDW-17.5* Plt ___ ___ 03: 22PM BLOOD Neuts-81.8* Lymphs-11.1* Monos-4.7 Eos-1.9 Baso-0.4 ___ 03: 45PM BLOOD Neuts-80.7* Lymphs-10.2* Monos-6.2 Eos-2.3 Baso-0.5 ___ 03: 22PM BLOOD Glucose-105* UreaN-15 Creat-0.8 Na-139 K-4.2 Cl-103 HCO3-29 AnGap-11 ___ 03: 22PM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1 ___ 04: 14PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 01: 35AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 04: 14PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-3 TransE-<1 ___ 01: 35AM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-3 ___ 4: 14 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. <MEDICATIONS ON ADMISSION> Ibuprofen 600mg Q6hr prn pain, Percocet ___ tabs Q4-6hrs prn pain, Ferrous sulfate 325mg TID, Colace 100mg prn constipation <DISCHARGE MEDICATIONS> 1. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: ___ Tablets PO TID (3 times a day). 2. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO qday (). 3. 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* 4. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for urinary discomfort for 2 days. Disp: *6 Tablet(s)* Refills: *0* 5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp: *30 Capsule, Delayed Release(E.C.)(s)* Refills: *0* 7. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abdominal pain and urinary retention after uterine artery embolization <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please take your medications as prescribed. Do not drive while taking narcotics and do not combine with alcohol or other sedating medications. Take a stool softener such as colace while taking narcotics as they can cause constipation. Do not start taking your iron until you have had a bowel movement. Call your doctor's office if you are unable to urinate.
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Ms. ___ exam was consistent with a degenerating fibroid with focal tenderness over palpable fibroid. Other intra-abdominal processes such as peritonitis seemed unlikely with normal WBC, ability to tolerate PO, and normal BM on the day of presentation. However, given her symptoms, she was admitted overnight for pain control and observation. She was given IV hydration and IV toradol/dilaudid with some relief. The following day, the patient complained of abdominal pain with urination. A urinalysis was unremarkable and urine culture was contaminated. PVRs were monitored and noted to be 190-250cc. Her IV dilaudid was transitioned to PO and then switched to vicodin in an attempt to lessen her exposure to narcotics. She was monitored overnight. By hospital day 3, she was tolerating a regular diet, her pain was better controlled, and she voided. She was discharged to home in stable condition with follow-up.
| 1,644
| 200
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10169160-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Tetanus Vaccines & Toxoid / bee / Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> Advanced Mullerian adenocarcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Interval cytoreductive surgery including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, plasma jet ablation and resection of residual disease <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with a history of advanced mullerian origin carcinoma (dx ___ who received 4 cycles ___, ___ of chemotherapy (carboplatin/paclitaxel) prior to undergoing an interval cytoreductive surgery including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, plasma jet ablation and resection of residual disease on ___. <PAST MEDICAL HISTORY> PMH: HTN, HLD, asthma PSH: breast biopsy (right), D&C, tonsillectomy, wisdom teeth extraction OBHx: G3P3 (3 SVDs) GYNHx: Denies hx of STIs, fibroids, ovarian cysts, and gyn surgeries, never had an abnormal pap smear, never had abnormal pap smear, no hx of abnormal mammograms Meds: 4 cycles of carboplatin 6AUC/paclitazel ___, dexamethasone, fluticasone, HCTZ, lorazepam, ondansetron, prochlorperazine, aspiring, calcium-vitD3, docusate, loratadine, senna <ALLERGIES> Bactrim (hives), bee (arm swelling), tetanus vaccines & toxoid <SOCIAL HISTORY> ___ <FAMILY HISTORY> Relative Status Age Problem Comments Mother ___ ___ STROKE CORONARY ARTERY DISEASE ALZHEIMER'S DISEASE BREAST CANCER Postmenopausal Father ___ ___ HYDROCEPHALUS MGM Deceased MGF Deceased PGM Deceased PGF Deceased APPENDICITIS Brother ___ ___ Son Living ___ Son Living ___ Daughter Living ___ Son Living ___ CORONARY ARTERY s/p stent DISEASE Comments: 6 grandchildren - 5 girls and 1 boy. The boy is autistic. <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM --======== General: Patient appears well, interactive, pleasant and in good spirits. Mildly anxious. HEENT: Sclera anicteric, MMM, oropharynx clear, healed laceration on the lower back of her head on the right side with mild swelling. No bruising, mildly tender. Lungs: Clear to auscultation bilaterally, no wheezes, rales or rhonchi appreciated CV: Regular rate and rhythm, S1 and S2 clear and of good quality, no murmurs, rubs or gallops appreciated. No edema Abdomen: soft, non-distended, NT, no fluid wave, + bowel sounds throughout, no rebound or guarding. Lymphatics: No cervical, supraclavicular, axillary or inguinal LAD bilaterally. Musculoskeletal. No tenderness on right knee. Right ankle with soft tissue swelling on the lateral side with no bruising or erythema. Tender on palpation. +PP bilaterally. Neuro: Alert and oriented Speech fluent, gait steady. upper and lower extremity strength ___ bilaterally, negative Romberg. no tremors. --======== PHYSICAL EXAM ON DISCHARGE: --======== General: NAD, resting comfortably in bed, A&Ox3 CV: RRR Lungs: LCTAB Abd: soft, nontender, nondistended, normoactive bowel sounds Incision: C/D/I Extremities: no calf tenderness/erythema, tender to palpation on lateral aspect of right foot, r ankle edema less than yesterday, <PERTINENT RESULTS> ___ 08: 45AM BLOOD WBC-6.7 RBC-2.79* Hgb-9.0* Hct-28.4* MCV-102* MCH-32.3* MCHC-31.7* RDW-15.9* RDWSD-59.5* Plt ___ ___ 08: 00AM BLOOD WBC-9.7 RBC-2.52* Hgb-8.3* Hct-25.6* MCV-102* MCH-32.9* MCHC-32.4 RDW-16.2* RDWSD-60.4* Plt ___ ___ 07: 22AM BLOOD WBC-13.5* RBC-2.82* Hgb-9.1* Hct-27.9* MCV-99* MCH-32.3* MCHC-32.6 RDW-16.7* RDWSD-59.7* Plt ___ ___ 08: 45AM BLOOD Plt ___ ___ 08: 00AM BLOOD Plt ___ ___ 07: 22AM BLOOD Plt ___ ___ 08: 45AM BLOOD Glucose-108* UreaN-7 Na-141 K-4.0 Cl-101 HCO3-28 AnGap-12 ___ 08: 00AM BLOOD Glucose-97 UreaN-13 Creat-0.5 Na-136 K-3.6 Cl-99 HCO3-27 AnGap-10 ___ 07: 22AM BLOOD Glucose-109* UreaN-24* Creat-0.6 Na-140 K-3.7 Cl-104 HCO3-25 AnGap-11 ___ 08: 45AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7 ___ 08: 00AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.6 ___ 07: 22AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.6 IMAGING: ___ CT abdomen & pelvis w/contrast to assess chemotherapy response 1. Lymphadenopathy, ascites, omental and peritoneal metastatic disease are moderately improved in comparison to the prior examination, suggesting treatment response. 2. Please see CT chest from the same date for evaluation of the chest. ___ CT chest w/contrast to assess chemotherapy response 1. Nonspecific 6 mm right lower lobe subpleural pulmonary nodule. Close attention on follow-up is recommended to evaluate stability. 2. Focal area of active bronchiolitis in the right middle lobe. 3. Coronary artery disease. PATHOLOGY/CYTOLOGY: ___ omentum resection for tumor 1. Pending ___ omentum biopsy 1. Metastatic high grade mullerian carcinoma ___ cytology from peritoneal fluid 1. Adenocarcinoma of mullerian origin <MEDICATIONS ON ADMISSION> 1. Dexamethasone 4mg PO BID 2. Fluticasone 110mcg 2 puffs Daily 3. HCTZ 12.5mg PO Daily 4. Lorazepam 0.5mg PO q6H PRN 5. Ondansetron 8mg PO 2 days following chemotherapy & then q8H 6. Pravastatin 40mg PO qHS 7. Prochlorperazine 10mg PO q8H 8. Aspirin 81mg PO Daily 9. Calcium-vitD3 600mg-500U Po Daily 10. Colace 100mg PO qHS 11. Loratadine 10mg PO Daily 12. Senna 8.6mg 2 tablets PO qHS <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY dvt prophylaxis 4. Ibuprofen 400 mg PO Q6H PRN 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H PRN 6. Fluticasone Propionate 110mcg 2 PUFF IH EVERY MORNING asthma 7. Hydrochlorothiazide 12.5 mg PO DAILY 8. Pravastatin 40 mg PO QPM <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Advanced Mullerian Adenocarcinoma <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. * 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. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. * 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 once a day Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. *Your lovenox injections were given to you in the hospital. You will be taking once a day lovenox injections. Your last injection will be on ___. ***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 interval cytoreductive surgery including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, plasma jet ablation and resection of residual disease. Please see the operative report for full details. *) Postoperative course: Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural managed by Acute Pain Service and toradol. On postoperative day 2, her epidural was removed by the Acute Pain service and she was transitioned to PO pain medications oxycodone, acetaminophen, and ibuprofen. Given that she was ambulating and hadadequate urine output, her Foley catheter was removed and she voided spontaneously. Her diet was slowly advanced to a clear liquid diet on postoperative day 1. She was maintained on a clear liquid diet until she passed flatus on postoperative day 3, when her diet was advanced to a regular diet without difficulty. 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. *) Hypertension: patient was restarted on home hydrochlorothiazide while in the hospital *) Hyperlipidemia: patient was restarted on home pravastatin *) Acute blood loss anemia: Patient's preoperative HCT was 35. Her hematocrit was then 27.9 and then 25.6 on 8.8. Hematocrit went up to 28.4 on ___. Her hematocrit stabilized while in the hospital and started to trend upwards without need for intervention. *) VTE Prophylaxis: Patient was on heparin preop and while epidural was in place. She was then transitioned to lovenox injections BID. Patient was discharged with lovenox to complete a 28 day course of prophylaxis since surgery. She also had pneumoboots and used incentive spirometry in the hospital.
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10169178-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P0 at ___ who presents with abdominal pain. Pain started at 6am, in the lower back and comes across the lower abdominal region; constant in nature. Denies VB. +FM. She endorses urinary urgency and has possibly been leaking fluid but is unsure if it's urine or not. +mild nausea. +mucous-like vaginal discharge. Denies fevers, chills,, vomiting, dysuria. Has also had severe HA this AM which improved after taking Tylenol at 7am. Denies visual changes or RUQ pain. Denies vaginal intercourse in the last 24h. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ by ___ Labs: O+/Ab neg EFW (___) 911 grams(43%) PAST OBSTETRIC HISTORY IUFD approximately 20 weeks (per pt due to oligo and HTN) PAST MEDICAL HISTORY - cHTN with R renal artery stenosis - severe kyphosis PAST SURGICAL HISTORY spinal surgery with bone graft at age ___ in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: T 98.8, HR 100, RR 20, BP 123/94, 130/97, 137/61 GENERAL: uncomfortable with ctx, o/w NAD CARDIO: RRR PULM: CTAB ABDOMEN: soft, diffusely TTP, no rebound or guarding EXTREMITIES: NT b/l SSE: thick, white vag d/c; cervix appears closed SVE/BME: L/C/P soft TVUS: 1.52cm with funneling TOCO: q5-6min FHT: 140, mod var, +accels, no decels, AGA BPP: ___, AFI 16.6, oblique lie - fetal head in RLQ <PERTINENT RESULTS> ___ WBC-9.6 RBC-4.18 Hgb-12.6 Hct-36.0 MCV-86 Plt-285 ___ WBC-13.3 RBC-4.19 Hgb-12.3 Hct-35.9 MCV-86 Plt-323 ___ WBC-10.4 RBC-3.92 Hgb-11.7 Hct-33.3 MCV-85 Plt-313 ___ WBC-10.8 RBC-4.09 Hgb-12.0 Hct-35.4 MCV-87 Plt-293 ___ ___ PTT-23.0 ___ ___ Creat-0.7 ALT-11 UricAcd-3.9 ___ Creat-0.7 ALT-8 UricAcd-4.3 ___ Creat-0.7 ALT-21 UricAcd-3.9 ___ Glu-89 BUN-11 Cre-0.6 Na-138 K-3.7 Cl-100 HCO3-26 ___ TSH-3.0 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria Gonorrhoeae by PCR. SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHA YEAST VAGINITIS CULTURE (Final ___: YEAST SPARSE GROWTH URINE CULTURE (Final ___: <10,000 organisms/ml SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS YEAST VAGINITIS CULTURE (Final ___: YEAST. MOD GROWTH <MEDICATIONS ON ADMISSION> Labetalol 100mg BID PNV <DISCHARGE MEDICATIONS> 1. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp: *60 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 29+2 weeks gestation preterm contractions chronic hypertension <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> continue modified bedrest at home. drink plenty of fluids. call your doctor with any leaking of fluid, vaginal bleeding, regular or painful contractions, or decreased fetal movement.
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___ G2P0 admitted at ___ who presents with PTL. . Ms ___ was contracting every ___ minutes on arrival. Her cervix was long and closed, however, her cervical length was 1.5cm and had previously been 3.8cm. Fetal fibronectin was negative. She had no signs or symptoms on infection and fetal testing was reassuring. She was started on Nifedipine for tocolysis and she responded well. She was given a course of betamethasone for fetal lung maturity (complete on ___. The NICU was consulted. In regards to her chronic hypertension, her blood pressures ranged 120-130s/61-97. She denied any preeclampsia symptoms and labs were normal. A 24 hour urine collection was obtained and was negative with 117mg of protein. She was continued on Labetolol (100mg bid). She underwent close monitoring on labor and delivery and was clinically stable. Her contractions spaced out significantly and her cervix was unchanged on repeat exam. She was transferred to the antepartum floor for further management. . The Nifedipine was discontinued on ___ due to palpitations. Once it was stopped, she had no further complaints of palpitations. She did report a sinus headache which was relieved with bendadryl. The Labetolol was increased to 200mg bid. Off tocolysis, she continued to have occasional, nonpainful contractions. Fetal testing was reassuring. At 29+2 weeks gestation, she was discharged home and will continue to have close outpatient followup. Her cervix remained closed/long at the time of discharge. Her blood pressures ranged 120-144/80-90.
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10170151-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Pt is a ___ G2P0010 at 22+1 weeks gestation who presents to triage with vaginal bleeding. States the bleeding started at approximately 4: 00am today, bleeding was bright red and passed some small clots. Reports some cramping earlier which spontaneously resolved. No pain or cramping now. Denies back pain, dysuria, fevers. Pt feels well otherwise. No dizzyness. Has been out of work for the past few weeks. Pt has had multiple episodes of vaginal bleeding since approximately 10 weeks. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ (2)Labs: O neg, RPRNR, RI, HepB neg, VZV immune, HIV neg, CF neg, +PPD ___, pap WNL ___ (3)Screening: - quad: T21=1: 10K, T18 not increased, AFP=1.12 MoM - FFS as above + 2 fibroids (4)Transfer of care at 21+6wks from ___ - diagnosed with short cervix, CL 2.2cm, at FFS; seen by Dr ___ pt declined cerclage - U/S by Dr ___ on ___: breech, nl AFI, anterior placenta with no previa, CL 4.4cm, EFW 407g ISSUES *)vaginal bleeding: multiple episodes since ~10wks, likely chronic abruption *)possible fetal cardiac anomaly; pericardial effusion at time of FFS; nl cardiac views at ___ on ___ *) SS trait: fob not tested *) +ppd; needs CXR, referral to ID *) Rh negative, s/p rhogam ___ OBHX: G2P0 G1 SAB at 10wks, no D&C GYNHX: denies hx STDs, abn paps PMH: none SurgHx: none <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> PE: Gen: appears well, NAD VS: T 98.0, BP 98/64, HR 97, RR 18 LUNGS: CTAB HEART: RRR ABD: soft, gravid, nontender SSE: (by Dr ___ cervix appears closed; not friable; no active bleeding from os. ping-pong ball size clot removed FH: spot check 140s TOCO: no ctxs <PERTINENT RESULTS> ___ 01: 07PM BLOOD WBC-13.6* RBC-3.92* Hgb-11.0* Hct-30.8* MCV-79* MCH-28.1 MCHC-35.8* RDW-14.8 Plt ___ ___ 07: 53AM BLOOD WBC-15.4* RBC-3.77* Hgb-10.4* Hct-29.7* MCV-79* MCH-27.5 MCHC-35.0 RDW-14.7 Plt ___ . ___ 01: 07PM BLOOD ___ PTT-26.3 ___ ___ 07: 53AM BLOOD ___ PTT-27.5 ___ ___ 01: 07PM BLOOD ___ ___ 07: 53AM BLOOD ___ ___ 08: 21PM BLOOD FetlHgb-0 <MEDICATIONS ON ADMISSION> Meds: colace, iron, Keflex, PNV <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4-6H () as needed for Pain. Disp: *20 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> fetal loss at 22 weeks, abruption <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> given
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Ms. ___ is a ___ G2P0 who was admitted at ___ with vaginal bleeding, presumed secondary to chronic abruption. Hct and coags were stable upon admission and given previability, she was transferred to the antepartum unit for further monitoring and evaluation. On HD#2, she complained of significant cramping and increased vaginal bleeding. She was transferred back to L&D, where the option of termination of the pregnancy was discussed. She and her husband did wish to end the pregnancy, but while arrangements were being made, she began to contract every 2 minutes and subsequently precipitously delivered the fetus in caul, with the placenta expelled at the same time. Post-delivery bleeding was minimal and labs were stable. She was seen by social work and support was offered. She and her husband appeared to be coping appropriately with the loss. On HD#3, she was discharged home in stable condition, to follow up with MFM.
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10170151-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Preterm labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal delivery <HISTORY OF PRESENT ILLNESS> Patient presented in preterm labor. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ (2)Labs: O neg, RPRNR, RI, HepB neg, VZV immune, HIV neg, CF neg, +PPD ___, pap WNL ___ (3)Screening: - quad: T21=1: 10K, T18 not increased, AFP=1.12 MoM - FFS as above + 2 fibroids (4)Transfer of care at 21+6wks from ___ - diagnosed with short cervix, CL 2.2cm, at FFS; seen by Dr ___ pt declined cerclage - U/S by Dr ___ on ___: breech, nl AFI, anterior placenta with no previa, CL 4.4cm, EFW 407g ISSUES *)vaginal bleeding: multiple episodes since ~___, likely chronic abruption *)possible fetal cardiac anomaly; pericardial effusion at time of FFS; nl cardiac views at ___ on ___ *) SS trait: fob not tested *) +ppd; needs CXR, referral to ID *) Rh negative, s/p rhogam ___ OBHX: G2P0 G1 SAB at 10wks, no D&C GYNHX: denies hx STDs, abn paps PMH: none SurgHx: none <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Patient presented in florid preterm labor. Cervix fully dilated. Breech presentation. AF, VSS <PERTINENT RESULTS> ___ 03: 07AM WBC-9.7 RBC-4.53 HGB-9.5* HCT-29.0* MCV-64*# MCH-21.0*# MCHC-32.9 RDW-18.4* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications <DISCHARGE MEDICATIONS> 1. Other 2. hospital grade breast pump N=Baby in nicu 3. Docusate Sodium 100 mg PO BID: PRN Constipation 4. Ibuprofen 600 mg PO Q6H: PRN Pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pregnancy delivered Premature labor and delivery <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Given
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Precipitous vaginal delivery, breech, afer ruptured membranes durin gadmission. Uncomplicated postpartum course.
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10170742-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Singulair <ATTENDING> ___. <CHIEF COMPLAINT> Elevated blood pressure at 38w2d <MAJOR SURGICAL OR INVASIVE PROCEDURE> forceps-assisted vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1 @ ___ who presents from clinic for evaluation of elevated BP. No complaints. Denies headache, vision changes, RUQ pain. Active fetal movement. No ctx, VB, LOF. On review of record, booking BP 129/88 at 4wk, 110/70 at IOB visit, normal throughout pregnancy until 34wk at which time was 123/93. Normal again until today 136/91 in clinic, repeated and DBP still > 90. <PAST MEDICAL HISTORY> PRENATAL COURSE: ___ ___ by LMP PRENATAL LABS: A pos, ab neg, HIV neg, HBsAg neg, RPR NR, Rub ___, VZ EQUIVOCAL, GBS neg Normal Hbg electro, declined CF Low risk ERA Normal FFS, boy Normal GLT s/p TDap, flu ordered but no documentation that given Most recent US today ___: 3613g (76%ile), cephalic, BPP ___, AC 94%ile OB HISTORY: G1 current <PAST MEDICAL HISTORY> asthma (no hospitalizations or intubations, back pain, seasonal allergies, migraine headaches, constipation, dizziness (underwent vestibular testing at start of pregnancy, equivocal, plans to f/u postpartum) Surgical History (Last Verified ___ by ___, MD): WISDOM TEETH EXTRACTION THUMB SURGERY <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> ___ 07: 55AM BLOOD WBC-20.5* RBC-3.35* Hgb-8.8* Hct-25.9* MCV-77* MCH-26.3 MCHC-34.0 RDW-15.8* RDWSD-42.8 Plt ___ ___ 08: 05AM BLOOD WBC-25.1* RBC-3.35* Hgb-8.9* Hct-25.9* MCV-77* MCH-26.6 MCHC-34.4 RDW-15.5 RDWSD-42.7 Plt ___ ___ 04: 17PM BLOOD WBC-27.1* RBC-3.39*# Hgb-9.0*# Hct-26.3*# MCV-78* MCH-26.5 MCHC-34.2 RDW-15.4 RDWSD-42.5 Plt ___ ___ 06: 01AM BLOOD WBC-22.6* RBC-2.38* Hgb-6.0* Hct-18.2* MCV-77* MCH-25.2* MCHC-33.0 RDW-14.6 RDWSD-40.7 Plt ___ ___ 04: 18AM BLOOD WBC-20.8* RBC-2.43*# Hgb-6.1*# Hct-18.6*# MCV-77* MCH-25.1* MCHC-32.8 RDW-14.6 RDWSD-40.9 Plt ___ ___ 12: 28AM BLOOD WBC-20.8*# RBC-3.50* Hgb-8.7* Hct-27.6* MCV-79* MCH-24.9* MCHC-31.5* RDW-14.8 RDWSD-42.4 Plt ___ ___ 04: 05PM BLOOD WBC-11.7* RBC-4.17 Hgb-10.5* Hct-31.6* MCV-76*# MCH-25.2* MCHC-33.2 RDW-14.6 RDWSD-39.3 Plt ___ ___ 09: 59AM BLOOD ___ PTT-39.7* ___ ___ 06: 01AM BLOOD ___ PTT-41.0* ___ ___ 12: 28AM BLOOD ___ PTT-32.8 ___ ___ 09: 59AM BLOOD ___ 06: 01AM BLOOD ___ 12: 28AM BLOOD ___ 07: 55AM BLOOD Glucose-68* UreaN-15 Creat-1.0 Na-135 K-4.3 Cl-102 HCO3-22 AnGap-15 ___ 08: 05AM BLOOD Glucose-73 UreaN-20 Creat-1.2* Na-134 K-4.4 Cl-102 HCO3-22 AnGap-14 ___ 04: 17PM BLOOD Glucose-99 UreaN-19 Creat-1.4* Na-130* K-4.6 Cl-101 HCO3-19* AnGap-15 ___ 09: 59AM BLOOD Glucose-117* UreaN-18 Creat-1.6* Na-130* K-4.3 Cl-103 HCO3-18* AnGap-13 ___ 04: 18AM BLOOD Glucose-126* UreaN-18 Creat-1.5* Na-131* K-4.2 Cl-103 HCO3-19* AnGap-13 ___ 12: 28AM BLOOD Creat-1.8* ___ 04: 05PM BLOOD Creat-0.9 ___ 08: 05AM BLOOD ALT-11 AST-39 ___ 04: 17PM BLOOD ALT-11 AST-44* ___ 09: 59AM BLOOD ALT-10 AST-40 LD(LDH)-176 ___ 04: 18AM BLOOD ALT-8 AST-28 ___ 12: 28AM BLOOD ALT-8 AST-23 ___ 04: 05PM BLOOD ALT-9 AST-14 ___ 08: 05AM BLOOD Calcium-7.3* Mg-3.5* ___ 04: 17PM BLOOD Calcium-7.1* Phos-4.5 Mg-4.1* ___ 09: 59AM BLOOD Calcium-7.1* Phos-4.9* Mg-4.1* UricAcd-8.6* ___ 04: 18AM BLOOD Calcium-6.9* Phos-4.2 Mg-3.3* UricAcd-8.5* ___ 12: 28AM BLOOD UricAcd-8.6* ___ 04: 05PM BLOOD UricAcd-7.0* ___ 09: 59AM BLOOD Hapto-69 ___ 12: 41AM BLOOD Hgb-8.9* calcHCT-27 ___ 04: 55PM URINE Color-Straw Appear-Clear Sp ___ ___ 04: 55PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 04: 55PM URINE Hours-RANDOM Creat-25 TotProt-9 Prot/Cr-0.4* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 respiratory distress 2. Prenatal Vitamins 1 TAB PO DAILY 3. Loratadine 10 mg PO DAILY 4. albuterol sulfate 90 mcg/actuation inhalation Q4H <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever 2. Dermoplast Spray 1 SPRY TP Q6H: PRN perineal pain 3. Docusate Sodium 100 mg PO BID Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 4. Hydrocortisone Acetate Suppository ___ID: PRN hemorrhoid pain 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Moderate to Severe Pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp #*10 Tablet Refills: *0 6. albuterol sulfate 90 mcg/actuation inhalation Q4H 7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 respiratory distress 8. Loratadine 10 mg PO DAILY 9. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preeclampsia with severe features acute kidney injury chorioamnionitis acute urinary retention 3rd degree perineal laceration forceps-assisted vaginal delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see OB packet
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On ___, Ms. ___ was admitted to labor & delivery for induction of labor after she presented in clinic with elevated blood pressures and subsequently diagnosed with preeclampsia given urine P:C ratio of 0.4 without severe features. After receiving 5 vaginal cytotecs, a foley balloon was inserted. She experienced a slight headache which was treated with tylenol. She was then started on pitocin for augmentation of labor per protocol. She was subsequently AROM'ed. She was then diagnosed with chorioamnionitis and started on ampicillin/gentamicin on ___. After pushing for 3 hours, she underwent a forceps-assisted vaginal delivery complicated by 3rd degree perineal laceration. She was brought to the operating room for repair of the perineal laceration. Please see operative dictation for full details. She had a postpartum hemorrhage of 700cc and was given cytotec and pitocin. During the repair, she had elevated BPs in the severe range to the 170s/110s which required 80mg of IV labetalol by Anesthesia. In addition, she was also noted to be oliguric. She was also given a 6g Magnesium bolus for eclampsia prophylaxis. Repeat CBC, coags and ___ labs were also sent, which were notable for Cr of 1.8, HCT of 27.6, uric acid of 8.6. Maintenance dose of Mg was deferred due to elevated creatinine. She was ruled in for preeclampsia with severe features by BPs and ___. Mg level was noted to be subtherapeutic on repeat labs and she was given an additional Mag bolus of 4g. Her ___ improved to 1.5. She was noted to have acute blood loss anemia to HCT 18.5 and was transfused 2 units of pRBCs. She was also kept on a bowel regimen and kefzol for ABX prophylaxis after third degree laceration. Her creatinine continued to improve to 1.4. Her Mg continued to be subtherapeutic and she was given another 2g of Magnesium bolus. Her post-transfusion HCT improved to 26.3 appropriately without any evidence of ongoing bleeding or hematoma. She was then transferred to the postpartum floor on PPD#1. On the postpartum floor her creatinine improved to 1.0 and her BP remained in the mild to moderate range without anti-hypertensive requirement. On PPD#3, she was noted to have increased abdominal pressure due to urinary retention. A foley catheter was replaced draining 1L. It was kept in for 24 hours and she was able to void spontaneously after removal. 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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10172278-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, bilateral salpingo-oophrectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ G0 presenting for consultation regarding recent diagnosis of endometrial cancer. Patient presented to Dr. ___ with irregular vaginal bleeding and had a PUS that showed an abnormal endometrial stripe. She subsequently underwent a Hsc, D&C on ___ that showed grade 1 endometrioid endometrial adenocarcinoma. PUS on ___ showed a 8.4x4.3x6.0cm mildly enlarged uterus, normal ovaries. She currently has daily spotting, no heavy bleeding. 10 point ROS positive for occasional pelvic pain and lower back pain, otherwise negative. <PAST MEDICAL HISTORY> Obstetrical History: G0 . Gynecologic History: - Unsure LMP, almost daily bleeding for the past several months - Menses previously regular every month. Denies history of menorrhagia or dysmenorrhea - Denies history of abnormal Pap tests. Last Pap test ___ negative - Denies history of pelvic infections of sexually transmitted infections - Denies history of HRT . <PAST MEDICAL HISTORY> Depression with ?manic symptoms (folowed by Dr ___ at ___ and therapist ___ Hypothyroidism; carpal tunnel syndrome . Past Surgical History: Several knee surgeries, Hsc/D&C, appendectomy . Health Maintenance: -Last Mammogram ___ yrs ago normal -Last Colonoscopy: no -Last bone density scan: no . All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> First cousin with breast cancer. No fam hx of GYN/colon cancer <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 <PERTINENT RESULTS> ___ 07: 55AM BLOOD WBC-7.6 RBC-3.79* Hgb-10.9* Hct-31.4* MCV-83 MCH-28.8 MCHC-34.8 RDW-12.9 Plt ___ ___ 07: 55AM BLOOD Neuts-71.7* ___ Monos-8.2 Eos-0.3 Baso-0.1 ___ 07: 55AM BLOOD Glucose-93 UreaN-13 Creat-0.8 Na-139 K-4.1 Cl-103 HCO3-30 AnGap-10 ___ 07: 55AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9 <MEDICATIONS ON ADMISSION> topical betamethasone, bupropion SR 150 2 tabs daily, fluoxetine 20mg dialy, Lamictal 100mg 2 tabs in AM, 1 tab in afternoon at 14: 00; Synthroid ___, olanzapine 2.5mg daily prn anxiety, trazodone 150mg QHS <DISCHARGE MEDICATIONS> 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. BuPROPion (Sustained Release) 150 mg PO DAILY 3. Fluoxetine 20 mg PO DAILY 4. Ibuprofen 600 mg PO Q6H pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *1 5. LaMOTrigine 200 mg PO QAM 6. LaMOTrigine 100 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. OLANZapine 2.5 mg PO DAILY: PRN anxiety 9. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not drive or drink alcohol while using this medication. RX *oxycodone-acetaminophen 5 mg-325 mg 1 to 2 tablet(s) by mouth every 4 to 6 hours Disp #*30 Tablet Refills: *0 10. TraZODone 150 mg PO HS: PRN insomnia 11. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*50 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial cancer *final pathology still 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: . Laparoscopic 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 4 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 steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . 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 a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and cystoscopy. Please see the operative report for full details. . Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with one dose of IV dilaudid and PO ibuprofen and percoset. Her diet was advanced without difficulty. On post-operative day 1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. . She was maintained on her home psychiatric medications and was seen by Social Work during her hospitalization. . 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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10172388-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: Abdominal pain, hemodynamically unstable <MAJOR SURGICAL OR INVASIVE PROCEDURE> emergent exploratory laparotomy and left salpingectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G3P1011 who presented to ___ with sudden-onset abdominal pain about 2.5 hours ago. She was driving and had to pull over due to pain. she then presented to ___. On presentation to ___, ___ was positive and SBP was 80. Note, patient previously unaware of pregnancy. PIV x 2 was placed and she was sent to ___ without further work-up. No labs were sent. In ___, VS notable for tachycardia to 120s, SBPs in ___ on arrival. FAST scan was positive for intra-abdominal fluid and patient was quite uncomfortable. Ultrasound was attempted and abandoned due to patient discomfort. Two units of blood were hung given VS abnormalities. She triggered on two occasions for VS abnormalities during her first 30 minutes of arrival. <PAST MEDICAL HISTORY> POBHx: SAB x1 no comps SVD x1 PGynHx: LMP ___. Regular menses. Denies history of abnormal Paps or STIs. PMH: Denies PSH: LSC appy, breast reduction <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory. <PHYSICAL EXAM> In ___: VS: Afeb ___ 118 comfortable on room air Gen: NAD Abd: Soft, +guarding, +rebound, maximal in RLQ Speculum: Deferred Bimanual: Deferred Ext: NT, NE <PERTINENT RESULTS> ___ 01: 24AM WBC-13.9* RBC-1.79* HGB-5.4* HCT-16.9* MCV-94 MCH-30.4 MCHC-32.3 RDW-13.4 ___ 01: 24AM PLT COUNT-195 ___ 01: 24AM HCG-1876 <MEDICATIONS ON ADMISSION> None <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: *2* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ruptured 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 for emergent surgery with a ruptured ectopic (tubal pregnancy). You had extensive bleeding and were transfused 7 units of packed red blood cells. Part of your left fallopian tube was removed in order to remove the pregnancy. Post-operatively you did 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 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. 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. ___ was taken emergently from the ___ to the OR for exploratory laparotomy, evacuation of 2.5L hemoperitenuem, and partial left salpingectomy. She was transfused 7 units of PRBCs. Post-operatively she was stable and admitted to the gynecology service. She remained hemodynamically stable with stable labs. Her post-operative course was overall uncomplicated. She was discharged home on POD 2.
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10175498-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> carcinosarcoma of the uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omental biopsy, pelvic and paraaortic lymph node dissection, and cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is lovely ___ year old G3P3 with known personal history of breast cancer diagnosed in ___ s/p lumpectomy, chemotherapy and radiation (No tamoxifen). Patient has been menopausal since then. In ___ she had her first episode of postmenopausal bleeding that was bloody and watery at times. She was in ___ at the time so she sought evaluation once she returned to the ___. During exam, her PCP noted ___ cervical mass and she was referred to GYN (Dr. ___ for further evaluation. Mass was seen again during exam and a tissue piece was sent for pathology evaluation which showed a carcinosarcoma. a pap smear was obtained at the same time and was negative with negative HPV. She is scheduled for pelvic US and was referred here for further management. Patient reports ongoing bleeding which is moderate with ~ 2 pads per day. No abdominal pain, nausea, vomiting, loss of appetite or weight loss. She is urinating without problems and having normal bowel movements. No chest pain or SOB. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> -Breast cancer -Acanthosis nigrican -Goiter -Hyperthyroidism -Obesity Past Surgical History: -Left breast lumpectomy with LNBx in ___ -Tubal ligation Past GYN History: -Postmenopausal since ___ -No prior abnormal pap smears -No hx of STIs Past Obstetric History: G3P3 NSVD at full term x 3 <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast or GYN cancers in the family <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM --======== Vital Signs sheet entries for ___: Weight: 177.8. Height: 60. BMI: 34.7. GENERAL: No acute distress, well developed, well nourished, appears younger than stated age. HEENT: NC/AT, sclera anicteric SKIN: Warm and dry. NEUROLOGIC: Alert and oriented x 4. NECK: Supple no mass LYMPHATICS: No palpable supraclavicular, cervical, or inguinofemoral lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, obese, nontender, nondistended, no hepatosplenomegaly. EXTREMITIES: Nontender, no edema bilaterally. PELVIC: -External female genitalia: normal -Vagina: normal mucosa, small amount of watery blood tinged foul smeeling discharge -Cervix: dilated with necrotic mass protruding through the os causing it to be dilated. We are able to follow the cervix circumferentially on exam. There is a necrotic mass protruding through the cervix. The visible portion is about 3-4 cm. -Uterus: mobile, small, AV. -Bimanual: Unable to feel adnexa given body habitus. RECTAL: no masses --======== PHYSICAL EXAM ON DISCHARGE: --======== On day of discharge: Afebrile, vitals stable Gen: No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incisions clean/dry/intact, no rebound/guarding GU: Pad dry ___: nontender, nonedematous <PERTINENT RESULTS> ___ 03: 10PM GLUCOSE-167* UREA N-10 CREAT-0.7 SODIUM-140 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16 ___ 03: 10PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-1.9 ___ 03: 10PM WBC-13.1*# RBC-4.53 HGB-13.1 HCT-39.8 MCV-88 MCH-28.9 MCHC-32.9 RDW-13.3 RDWSD-42.9 <MEDICATIONS ON ADMISSION> Multivitamin <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours 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 #*40 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six hours Disp #*40 Tablet Refills: *0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Carcinosarcoma * 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: . * 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 ___ weeks. * No heavy lifting of objects >10 lbs for 4 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. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. . 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 a robotic assisted total laparoscopic hysterectomy, bilateral salpingoophorectomy, omental biopsy, pelvic and paraaortic lymph node dissection and cystoscopy for carcinosarcoma of the uterus. 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 and IV toradol. Her diet was advanced without difficulty and she was transitioned to PO ibuprofen, Tylenol and oxycodone as needed for pain (pain meds). 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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10177094-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> hemorrhage from cervical/cesarean scar ectopic <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curettage <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___, gravida 7, para 2, who had a known ectopic pregnancy located either a high in her cervix or low in her cesarean section scar or both. She had previously been admitted to the obstetric service and treated with a multidose methotrexate injection directly into the pregnancy sac. After 4 doses of intra pregnancy methotrexate injection, her HCG dropped appropriately and she was observed in the inpatient service. She remained stable and was discharged home on ___. She developed an acute hemorrhage approximately 10 days after discharge and presented immediately to the emergency department on ___. On arrival, her blood pressure was 77/50 and heart rate was 89. She was resuscitated and received 1 unit of emergency release blood in the emergency department. An exam at the bedside was attempted but the cervix was not able to be visualized given the profuse hemorrhage, an attempts to place an intracervical Foley balloon catheter to tamponade her bleeding was attempted, but not possible due to the lack of dilation of her external os. She was therefore taken emergently to the operating room for exam under anesthesia, curettage of the pregnancy under ultrasound guidance, and possible further procedures including laparotomy and hysterectomy. <PAST MEDICAL HISTORY> PMH: depression/anxiety PSH: C/S x 2, D&C x 4 GynH: no STIs or abnormal Paps OBH: ___ - 1LTCS, CPD, term, 9lb 3oz ___ - RLTCS, term, 9lb 13oz ___ trimester SAB with D&C x 2 ___ trimester TAB with D&C x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On discharge: Gen: NAD CV: RRR Lungs: CTAB Abdomen: soft, nontender, no r/g GU: voiding spontaneously, minimal spotting on pad Ext: non-tender <PERTINENT RESULTS> ___ 06: 30AM BLOOD WBC-6.2 RBC-2.55* Hgb-8.0* Hct-23.7* MCV-93 MCH-31.3 MCHC-33.6 RDW-13.9 Plt ___ ___ 02: 10AM BLOOD WBC-8.4 RBC-2.73* Hgb-8.4* Hct-25.3* MCV-93 MCH-30.8 MCHC-33.2 RDW-13.9 Plt ___ ___ 09: 20PM BLOOD WBC-9.7 RBC-2.90* Hgb-8.7* Hct-27.1* MCV-93 MCH-30.1 MCHC-32.2 RDW-13.8 Plt ___ ___ 11: 20AM BLOOD WBC-7.0 RBC-3.66* Hgb-11.2* Hct-34.1* MCV-93 MCH-30.6 MCHC-32.9 RDW-13.3 Plt ___ <MEDICATIONS ON ADMISSION> bone <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain do not take over 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h: prn Disp #*40 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 #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ectopic 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 for observation after your procedure. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks * Use a reliable form of contraception at least until you follow up with your primary OB/GYN doctor. * No heavy lifting of objects >10 lbs for 2 weeks. * You may eat a regular diet To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was taken from the emergency department to the operating room for an ultrasound guided D&C which resulted in the removal of the suspected gestational sac. Ultrasound showed a think cervical stripe and c-section scar at the end of the case. She was admitted for observation overnight. Her bleeding was minimal. Serial HCTs were drawn and were stable. She had no symptoms of anemia. She was discarged home on post-operative day #1 in good condition with outpatient follow-up.
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10178554-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> epigastric pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G1P0 at ___ with a history of three prior episodes of pancreatitis and T1DM who presents with one day of worsening epigastric pain. She reports pain started this morning around 10 am. She describes pain as sharp, non-radiating, ___, exacerbated by eating and movement (her own, as well as fetal movement). While eating made the pain worse, she denies nausea and vomiting and last ate soup for lunch. Taking a bath did not help. She says this is unlike heartburn she has experienced before; and is also different from her experience of DKA. She denies fevers, chills, new/raw food exposures, animal exposures, insect bites, travel out of the state or country. Bowel movements are regular. No dysuria, hematuria, frequency. She is joined by her mother at the bedside, who emphasized that the patient has a genetic predisposition to pancreatitis, but could not recall the exact disorder. The patient first had pancreatitis at age ___, the last episode was approximately ___ years ago. She denies ctx, VB, LOF. Active fetal movement. <PAST MEDICAL HISTORY> OBHx: - G1 current GynHx: - denies history of STI - has never had a pap PMH: - T1DM: >> HbA1c 6.6% (___) >> retinopathy dating back to exam in ___ exam with mild non-proliferative retinopathy >> Followed by ___ - pancreatitis (___) >> Patient states she has a genetic predisposition, ikely hyperlipidemia/hypertriglyceridemia ("triggered by fatty foods"), though confirmation of this is not available in the current medical record - HLD PSH: - rhinoplasty - hymemectomy - teeth implants <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, no edema FHR: present at a normal rate <PERTINENT RESULTS> Labs on Admission: ___ 05: 09PM BLOOD WBC-7.9 RBC-4.15 Hgb-12.3 Hct-36.9 MCV-89 MCH-29.6 MCHC-33.3 RDW-12.4 RDWSD-40.2 Plt ___ ___ 05: 09PM BLOOD Neuts-70.6 Lymphs-15.8* Monos-11.2 Eos-1.8 Baso-0.1 Im ___ AbsNeut-5.56 AbsLymp-1.24 AbsMono-0.88* AbsEos-0.14 AbsBaso-0.01 ___ 05: 09PM BLOOD Glucose-173* UreaN-7 Creat-0.4 Na-140 K-3.8 Cl-105 HCO3-22 AnGap-13 ___ 05: 09PM BLOOD ALT-9 AST-15 AlkPhos-105 TotBili-0.2 ___ 11: 54PM BLOOD ALT-7 AST-12 AlkPhos-87 ___ 05: 09PM BLOOD Lipase-1497* ___ 05: 09PM BLOOD Calcium-8.8 Mg-1.6 ___ 09: 00PM BLOOD Triglyc-232* ___ 05: 09PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 05: 09PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-1000* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM* ___ 05: 09PM URINE RBC-1 WBC-6* Bacteri-FEW* Yeast-NONE Epi-15 ___ 05: 09PM URINE AmorphX-RARE* ___ 05: 09PM URINE Mucous-RARE* Relevant Labs: ___ 06: 05AM BLOOD WBC-7.1 RBC-3.60* Hgb-10.7* Hct-32.8* MCV-91 MCH-29.7 MCHC-32.6 RDW-12.7 RDWSD-42.0 Plt ___ ___ 06: 05AM BLOOD Glucose-120* UreaN-4* Creat-0.4 Na-141 K-4.1 Cl-109* HCO3-22 AnGap-10 ___ 07: 05PM BLOOD Glucose-145* UreaN-4* Creat-0.4 Na-139 K-3.8 Cl-105 HCO3-23 AnGap-11 ___ 06: 05AM BLOOD ALT-7 AST-12 AlkPhos-86 ___ 06: 05AM BLOOD Lipase-506* ___ 06: 05AM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.6* Mg-1.5* ___ 07: 05PM BLOOD Calcium-8.9 Phos-2.9 Mg-1.5* ___ 07: 50AM BLOOD WBC-8.2 RBC-3.93 Hgb-11.7 Hct-35.4 MCV-90 MCH-29.8 MCHC-33.1 RDW-12.5 RDWSD-41.4 Plt ___ ___ 05: 40PM BLOOD Glucose-88 UreaN-3* Creat-0.4 Na-143 K-3.6 Cl-109* HCO3-23 AnGap-11 ___ 07: 50AM BLOOD ALT-7 AST-13 AlkPhos-95 TotBili-0.2 ___ 05: 40PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.5* ___ 07: 50AM BLOOD WBC-8.2 RBC-3.93 Hgb-11.7 Hct-35.4 MCV-90 MCH-29.8 MCHC-33.1 RDW-12.5 RDWSD-41.4 Plt ___ ___ 07: 46AM BLOOD Glucose-72 UreaN-2* Creat-0.4 Na-141 K-3.7 Cl-108 HCO3-22 AnGap-11 ___ 07: 46AM BLOOD ALT-7 AST-13 AlkPhos-91 TotBili-0.2 ___ 07: 46AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8 <MEDICATIONS ON ADMISSION> PNV, insulin pump, baby ASA <DISCHARGE MEDICATIONS> 1. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0800: 1.2 Units/Hr 0800 - 2200: 1.05 Units/Hr 2200 - 0000: 1.05 Units/Hr Meal Bolus Rates: Breakfast = 1: 5 Lunch = 1: 4 Dinner = 1: 4 High Bolus: Correction Factor = 1: 40 Correct To ___ mg/dL <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pancreatitis <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 antepartum service with pancreatitis. The gastrointestinal team was consulted. We continued to monitor your labs and slowly advanced your diet. The GI team recommended you continue to maintain a low fat, low residue diet. You will follow up with their team outpatient. ___ was consulted regarding your Type I diabetes. Your blood sugars were low so they decreased your basal rate of insulin. You will follow up with their team as an outpatient. We think it is now safe for you to go home. Please follow the instructions below: - Attend all appointments with your obstetrician and all fetal scans - Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ was admitted to the antepartum service with pancreatitis. Her Lipase on admission was 1497. She was made NPO with IVF. Ultrasound of abdomen, pancreas, and liver US showed cholelithiasis without evidence of cholecystitis. The common bile duct was not dilated. Gastrointestinal was consulted and recommended slowly advancing her diet to a low fat, low residue diet. Nutrition was consulted and provided patient further information regarding this diet. Her labs were trended and lipase downtrended to 506. In regards to her T1DM, ___ was consulted and patient was continued on home insulin pump. Patient had multiple low FSBG related to her limited dietary intake. ___ was consulted and decreased her basal insulin. Patient will follow up with ___ as an outpatient. She was stable during her hospitalization and did not have any vaginal bleeding or signs preterm labor or rupture of membranes. She tolerated a regular diet and was deemed stable for discharge. She was given precautions with close follow up scheduled.
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10180796-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> yellow dye / latex / Percocet / opiates / avacardo / banana / cantaloupe / cashews / coconut / eggplant / kiwi / pineapple / stevia / sweet potatoes / soy / tomato / cheese <ATTENDING> ___ <CHIEF COMPLAINT> gender dysphoria <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopy hysterectomy bilateral salpingo-ophorectomy cystoscopy <HISTORY OF PRESENT ILLNESS> ___ is a ___ gravida 0 transgender man who presents to discuss gender confirming surgery. He is not interested in future pregnancy nor harvesting his eggs. He has been on testosterone since ___. He has had vaginal bleeding/spotting after starting testosterone. In addition, he has experienced postcoital bleeding and has had bleeding after orgasm. This abnormal bleeding is often accompanied by uterine cramping. Because of his history of abnormal uterine bleeding, a Mirena IUD was placed; however, there has not been much improvement. On ___ an ultrasound which showed an anteverted uterus that measured 6.4 x 3.6 x 4.3 cm. The endometrium was homogenous and measured 9 mm. The ovaries were normal with bilateral follicular activity including an involuting corpus luteum on the right that measured 1.5 cm. There is a trace amount of free fluid. These findings were reviewed with the patient and his questions were answered. He is very happy with the testosterone effects. He has experienced deepening of his voice, reduction in his body fat, and increase in facial/body hair and the chiseling of his facial features. <PAST MEDICAL HISTORY> OB/GYN history: Menarche at 13. Bleeding pattern as above. He has had an abnormal Pap smear and the treatment was observation. Last Pap was ___ He is gay, has sex with men. He is not currently sexually active secondary to his bleeding pattern. First intercourse was at age ___. He uses condom. And the Mirena IUD for fertility control, prevention of sexually transmitted infections and treatment of irregular vaginal bleeding. He has never had a pregnancy. Medical history: Gender dysphoria Depression Anxiety PTSD Suspected mass cell disease-being evaluated ___ Asthma, has never been hospitalized. He has had nebulizer treatments Migraine headaches Atypical chest pain-under evaluation, potentially related to mast cell disease as per patient reporting Occipital neuralgia Postural orthostatic tachycardia syndrome Fibromyalgia Suspected narcolepsy or idiopathic hypersomnia GERD Chronic constipation-he takes MiraLAX twice per day and Dulcolax Iron deficiency anemia treated with daily iron supplements Breakthrough bleeding despite hormonal therapy Possible gastroparesis-cannot do fiber products <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <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, appropriately tender, no rebound/guarding; incisions clean, dry, intact Ext: no tenderness to palpation <PERTINENT RESULTS> ___ 07: 15AM BLOOD WBC-10.2* RBC-4.73 Hgb-14.8 Hct-41.8 MCV-88 MCH-31.3 MCHC-35.4 RDW-12.0 RDWSD-38.8 Plt ___ <MEDICATIONS ON ADMISSION> clonazepam 0.5mg prn, fluoxetine 40mg qd, fluticasone HFA 220mcg BID, hydroxyzine 25mg prn, xopenex HFA 54mcg pen, xyzal 5mg bid, remerom 15mg qhs, macrobid ___ prn, prazosin 2mg qd. lyrica 50mg bid, ranitidine 150mg bid, sumatriptan 25mg prn, testosterone, topiramate 15mg qhs <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild do not exceed 4g in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 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 #*40 Capsule Refills: *1 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN Pain - Severe Reason for PRN duplicate override: Alternating agents for similar severity don't drive or drink alcohol while taking. partial fill upon patient request. RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H: PRN shortness of breath 5. ClonazePAM 0.5 mg PO Q6H: PRN anxiety 6. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU Q8H 7. FLUoxetine 60 mg PO DAILY 8. HydrOXYzine 25 mg PO Q8H: PRN itching 9. levocetirizine 5 mg oral BID 10. levocetirizine 5 mg oral BID 11. levocetirizine 5 mg oral BID 12. Mirtazapine 15 mg PO QHS 13. Prazosin 2 mg PO DAILY 14. Pregabalin 50 mg PO BID 15. Ranitidine 150 mg PO BID 16. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush 17. Sumatriptan Succinate 25 mg PO Q6H: PRN MIGRAINE 18. Topiramate (Topamax) 30 mg PO QHS <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> gender identity disorder <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___ ___ 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 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. * ___ 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. * Since ___ have steri-strips, leave them on. They will fall off on their own or be removed during your followup 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 ___ 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 ___, ___ was admitted to the gynecology service after undergoing TLH, BSO, and cystoscopy. Please see the operative report for full details. His post-operative course was uncomplicated. Immediately post-op, his pain was controlled with PO tramadol, Tylenol, and IV dilaudid (given mast cell disorder and inability to tolerate ibuprofen or oxycodone). On post operative day 1, his pain was not well controlled, and he was transitioned to PO dilaudid and Tylenol with good effect. His foley was removed following surgery and he voided with adequate urine output. His diet was advanced without difficulty. He was maintained on his home medications for asthma, depression, and anxiety. He was seen by social work who confirmed his placement at ___. 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 to ___ in stable condition with outpatient follow-up scheduled.
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10180971-DS-10
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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> Laparascopic Left salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 LMP ___ presents to the ED with LLQ pain. Pt reports hx of left ovarian cyst (had LLQ pain, US showed cyst around ___. She was started on OCP by Primary OB for this cyst. Since then, she continued to experience intermittent left lower quadrant pain and back pain, intensity and frequency increasing. The OCP did not have any effect on the pain. The pain was most intense this morning, constant and sharp, ___, radiates to the back and down her left leg. She took Alleve earlier, and with minimum effect. She also vomit once earlier this morning. In addition, pt reported abnormal vaginal bleeding since she was started on the OCP in ___ (menstruation q 2 wks). ROS: reports night sweat for the past few months, no wt loss, no change of appetite, no fever, no chills, no HA, no SOB, no CP, no dysuria, no constipation. <PAST MEDICAL HISTORY> PObHx: G2P1, uncompliated SVD x1 at full term in ___ TAB at 7 wks GA with D&C in ___. PGynHx: menarche age ___, Q6 wks, light, ?hx of fibroid, denies dysmenorrhea, menorrhagia, however she started to experience abnormal vaginal bleeding since she started taking the OCP; denies Hx abnormal Paps; denies history of STIs; Has used the following contraceptive methods: IUD ___ yr ago (removed d/t discomfort). PMHx: anxiety, ADHD PSHx: D&C x1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Physical Examination by Dr. ___ ___: VS: T98.3 BP 120/73 HR 68 RR 18 O2 sat 100%RA General: NAD (after 2 dose of morphine 4 mg IV) Neuro: alert, appropriate, oriented x 3 Cardiac: RRR, no m/g/r Pulm: CTAB Abdomen: soft, no rebound, no guarding, TTP in LLQ Pelvic: Normal external anatomy, pink vaginal mucosa, bright red blood in the vaginal vault, cleared with 3 scopettes, no active bleeding Bimanual: AV uterus, normal size, mobile; no CMT; no right adnexal mass; left adnexal mass appreciated, nodular, immediate next to the uterus, tender to deep palpation. Ext: NTTP, warm <PERTINENT RESULTS> ___ 11: 50AM ___ PTT-21.8* ___ ___ 11: 20AM GLUCOSE-106* UREA N-15 CREAT-0.9 SODIUM-139 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 ___ 11: 20AM estGFR-Using this ___ 11: 20AM WBC-6.4 RBC-4.04* HGB-13.4 HCT-38.5 MCV-95 MCH-33.2* MCHC-34.8 RDW-11.2 ___ 11: 20AM NEUTS-62.3 ___ MONOS-2.4 EOS-5.5* BASOS-0.9 ___ 11: 20AM PLT COUNT-242 ___ 11: 00AM URINE HOURS-RANDOM ___ 11: 00AM URINE HOURS-RANDOM ___ 11: 00AM URINE UCG-NEGATIVE ___ 11: 00AM URINE GR HOLD-HOLD ___ 11: 00AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11: 00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 11: 00AM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE EPI-5 TRANS EPI-<1 ___ 11: 00AM URINE MUCOUS-RARE Pelvic Ultrasound: IMPRESSION: 1. Large complex left ovarian cystic structure, largely unchanged from prior studies. Consider further evaluation with MRI if not already performed. GYN follow-up. 2. Arterial and venous flow demonstrated in both ovaries. 3. Trace amount of pelvic free fluid. <MEDICATIONS ON ADMISSION> - Paxil 25mg daily <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 2. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: please do not exceed 4g of acetaminophen in 24 hours. Disp: *30 Tablet(s)* Refills: *0* 3. paroxetine HCl 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO daily (). 4. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp: *20 Tablet, Rapid Dissolve(s)* Refills: *0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *10 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Left Complex Ovarian cyst <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 * No heavy lifting until cleared by your physician * Please keep your scheduled follow up appointment.
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Ms. ___ was admitted into the gynecology service for serial abdominal examinations. However, her pain was not improved and getting worse in severity. The decision was made to proceed with surgery. Her surgery was uncomplicated and she came back to the floor for routine post-operative care. She did very well and was discharged on hospital day 2 with adequate pain control, voiding and ambulating without difficulty. She was scheduled for a follow up appointment with Dr. ___.
| 1,469
| 95
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10181008-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Thiazides / Enalapril / Sulfa(Sulfonamide Antibiotics) / Biguanides / seasonal allergies <ATTENDING> ___. <CHIEF COMPLAINT> Symptomatic Fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salpingoophorectomy for symptomatic fibroids and ventral hernia repair <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ P1 who presented to ___ clinic regarding consultation by her gynecologist for an increased size of her known fibroid. Of note, the patient has had a history of fibroids for over ___ years. She had a mirena IUD placed in ___ for control of bleeding associated with her fibroids. In ___, she had a pelvic ultrasound, which demonstrated a 14x14cm fibroid. Recently, patient saw her gastroenterologist for complains of frequent gastrointestinal upsets. She has a history of IBS and was having numerous episode of bloating, diarrhea and gas. She also has a known ventral hernia. She had a CT scan on ___ for GI complaints which showed an interval increase in her fibroid size to approximately 20x17x15.4cm. No evidence of extrauterine disease. Given this new finding of an increase in size, she was counselled about the small risk of an underlying leiomyosarcoma by her gynecologist and was referred to GYN oncology. Decision was made to manage surgically. <PAST MEDICAL HISTORY> Past Med Hx: - T2DM - HTN - Hyperlipidemia - Irritable Bowel syndrome - Depression - Obesity - Ventral Hernia Past Surgical History - Open Appendectomy for ruptured appendix (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family Hx: - Diabetes (Father) - HTN (Mother and father including siblings are relatives) - Esophageal cancer (Father) - ?Breast Cancer (Paternal Grandmother) - Colon Cancer (Cousins) <PHYSICAL EXAM> Physical Exam on Discharge: VSS General: NAD, Comfortable CV: RRR Pulm: Lungs CTAB Abd: Obese, soft, +bs, nontender, incision clean dry intact Ext: warm well perfused, no tenderness to palpation <PERTINENT RESULTS> ___ 06: 40AM BLOOD WBC-4.6 RBC-3.67* Hgb-10.9* Hct-32.1* MCV-88 MCH-29.7 MCHC-33.9 RDW-14.2 Plt ___ ___ 12: 21PM BLOOD ___ PTT-26.8 ___ ___ 06: 40AM BLOOD Glucose-136* UreaN-5* Creat-0.6 Na-142 K-3.7 Cl-107 HCO3-26 AnGap-13 ___ 06: 40AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9 <MEDICATIONS ON ADMISSION> Medications: - Glipizide 5mg PO daily - Pravastatin 20mg PO daily - Atenolol 25mg (2 tabs QAM, 1 tab QPM) - Dicyclomine 10mg PO TIDPRN <DISCHARGE MEDICATIONS> 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 5. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <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 ___ ___ were admitted to the gynecologic oncology service after undergoing the procedures listed below. ___ have recovered well after your operation, and the team feels that ___ 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. * ___ may eat a regular diet Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * ___ should remove your port site dressings ___ days after your surgery. If ___ have steri-strips, leave them on. If they are still on after ___ days from surgery, ___ may remove them. * If ___ 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 on ___ s/p TAH, BSO for symptomatic fibroids and a ventral hernia repair. For full detail please see operative note. Post operatively an epidural was placed for pain management. The initial epidural was unsucessful in providing pain relief and had to be replaced. Patient recovered well on POD 1 and the epidural was removed and she ambulated and tolerated PO. However late on POD 1 patient developed emesis and was placed back on NPO. Nausea vomiting continued on POD 2 and an NGT was placed. Patient also developed a fever on POD 2 and a CXR was obtained which showed possible left lower lobe atelectasis. Patient also developed a severe headache relieved only by laying down which was consistent with a spinal headache. Chronic pain service was then consulted in the management of the post epidural headache. On POD 3 nausea vomiting diminished with decreased NGT fluid. On POD 4 the NGT was clamped with very little residual and the NGT was then pulled. Patient's nause and vomiting resolved. Ms ___ blood pressure was elevated on the afternoon of POD4 to 180's/120's. IV Metoprolol 5mg was given x2 with little effect. 10mg of hydralazine was then pushed and patient given PO home dose of atenolol. Patient's blood pressure improved on home dose of atenolol. She was able to tolerate PO after NGT was pulled and on POD 7 the patient was tolerating PO, ambulating, with no headache and baseline blood pressures. Patient at that point felt comfortable going home and was discharged in stable condition with ___ care set up.
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10182430-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Heavy uterine bleeding, dizziness <MAJOR SURGICAL OR INVASIVE PROCEDURE> Hysteroscopy, dilation and curettage, placement of Mirena IUD, blood transfusion <HISTORY OF PRESENT ILLNESS> ___ yo G2P1001 presents with exacerbation of her 8 month history of DUB. She has been followed for this Dr. ___ at ___. She states she has had daily bleeding x 6 months with intermittent episodes of significantly heavy bleeding. Had prev been started on Provera. Had normal pelvic u/s and previously had had neg EMB. Labs revealed FSH 12, LH 3.6, PRL 22, TSH 3.9. She was seen on ___ in GYN Triage. She was HD stable with hct 32.5. HCG <5 at that time and no intercourse since. Recommended increased provera to 10mg BID and inpt admission for observation and serial hct which was declined. She was then seen by Dr. ___ started her on norethinedrone which did not help her bleeding. She was seen by by Dr. ___ second opinion on ___ who discussed management options with her. Her hct on ___ was 29.8. She was started on provera 10 mg BID. . She comes into today because her bleeding has continued and continues to be heavy. She fills a full pad in 45min-2 hours. Today she had an episode of soaking through her pants at work as well as increased dizziness. Denies syncope. Has had exertional dyspnea. Is not taking an iron supplement because makes her stomach feel unwell. The physician that she works for therefore recommended that she present to ED for eval. She has been taking occasional motrin for uterine cramping. Denies fevers, chills. <PAST MEDICAL HISTORY> OBHx: ___ - ectopic s/p laparoscopy - LTCS, term, male (___) GynHx: - endometriosis, ovarian cysts - menarche age ___ q monthly x 8 days until abnormal bleeding commenced - last Pap ___ NILM -HPV - remote h/o abnormal Paps - ovarian cysts s/p lsc cystectomy (unsure which side) - normally sexually active with male partner; but no intercourse since irregular bleeding started PMH: Infertility, T2DM PSHx: exploratory laparoscopy, laparoscopic cystectomy, low transverse cesarean section All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family h/o cervical, uterine, ovarian, colon or breast cancers. Denies family h/o bleeding or clotting disorders. <PHYSICAL EXAM> Afebrile, VSS NAD, Comfortable Lungs CTAB CV RRR Abdomen soft, nontender, ND, no r/g Minimal vaginal bleeding Extremities with no edema or erythema <PERTINENT RESULTS> ___ 09: 10PM BLOOD WBC-6.5 RBC-3.04* Hgb-8.5* Hct-25.7* MCV-85 MCH-28.0 MCHC-33.1 RDW-15.2 Plt ___ ___ 09: 10PM BLOOD Neuts-67.4 ___ Monos-6.5 Eos-1.4 Baso-0.4 ___ 09: 00AM BLOOD WBC-8.5 RBC-3.42* Hgb-9.8* Hct-28.6* MCV-84 MCH-28.7 MCHC-34.2 RDW-14.9 Plt ___ ___ 06: 40AM BLOOD Neuts-75.4* ___ Monos-4.9 Eos-1.2 Baso-0.5 ___ 06: 40AM BLOOD WBC-7.1 RBC-3.57* Hgb-10.4* Hct-29.9* MCV-84 MCH-29.1 MCHC-34.7 RDW-15.0 Plt ___ ___ 09: 00AM BLOOD Neuts-64.7 ___ Monos-8.5 Eos-1.2 Baso-0.4 ___ 09: 00AM BLOOD WBC-5.0 RBC-3.38* Hgb-9.7* Hct-28.9* MCV-85 MCH-28.7 MCHC-33.7 RDW-15.1 Plt ___ ___ 09: 10PM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-138 K-3.9 Cl-104 HCO3-21* AnGap-17 ___ 09: 00AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-138 K-4.3 Cl-110* HCO3-21* AnGap-11 ___ 09: 00AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0 ___ 09: 10PM URINE Color-Red Appear-Hazy Sp ___ ___ 09: 10PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 09: 10PM URINE RBC->182* WBC-42* Bacteri-FEW Yeast-NONE Epi-1 ___ 05: 55AM URINE Color-Straw Appear-Clear Sp ___ ___ 05: 55AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD ___ 05: 55AM URINE RBC->182* WBC-11* Bacteri-NONE Yeast-NONE Epi-<1 ___ 11: 19AM URINE Color-Red Appear-Hazy Sp ___ ___ 11: 19AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 11: 19AM URINE RBC->182* WBC->182* Bacteri-MOD Yeast-NONE Epi-1 . ___ 5: 55 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . ___ 12: 42 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> Provera 10 mg BID, metformin 500 mg BID <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H pain do not take more than 4000mg acetaminophen in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*100 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 3 Days RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth every 12 hours Disp #*3 Capsule Refills: *0 5. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN severe pain do not drink alcohol or drive while taking RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*45 Tablet Refills: *0 6. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE: PRN anaphylaxis 7. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *0 8. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp #*25 Tablet Refills: *0 9. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour apply 1 patch daily Disp #*30 Patch Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Heavy uterine bleeding, anemia, Mirena IUD placement, possible UTI <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. 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 for worsening abnormal uterine bleeding causing symptomatic anemia. She received 2 units of pRBCs with improvement in her anemia symptoms. On ___, she underwent a hysteroscopy, D&C, and placement of Mirena IUD. Pleas see operative report for full details. . Her postoperative course was complicated by a fever in the immediate post-operative period. Her exam at the time was benign, and she spontaneously defervesced without further fevers and the fever was attributed to a drug reaction. The exact drug leading to the fever was not identified. Her course was also complicated by suprapubic pain, which had been chronic, for which a UA and urine culture were sent. She was started on Macrobid for presumptive treatment of her symptoms until her urine culture was finalized (first culture consistent with contamination). A pelvic ultrasound was also performed given the recent IUD placement and distorted contour of her uterus due to her fibroid uterus. The ultrasound confirmed correct intrauterine placement of the IUD. . Immediate post-op, her pain was controlled with oral acetaminophen, a Dilaudid PCA, and Toradol. On post-operative day 2, she was transitioned to oral ibuprofen, Dilaudid, and acetaminophen. . She was placed on an insulin sliding scale until she was tolerating a regular diet, at which point she was restarted on her home metformin. She was placed on a nicotine patch given her smoking history. . On post-operative day 3, she was tolerating a regular diet, voiding spontaneously, and her pain was controlled with oral pain medications. She was then discharged home in stable condition with outpatient follow up scheduled.
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10182430-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> right lower quadrant pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> diagnostic laparoscopy, lysis of adhesions <HISTORY OF PRESENT ILLNESS> This is a ___ yo G2 ___ who diagnosed with endometriosis in the late ___, when she had a laparoscopic removal of an ectopic pregnancy. Patient recently status post on ___ hysteroscopic evaluation, D&C, and placement of Mirena IUD for heavy uterine bleeding. She has been treated previously with Provera with little relief. There is a history of a normal pelvic ultrasound and negative endometrial biopsy prior to this last operative procedure. Her bleeding has improved. On ___, she was treated for bacterial vaginosis per patient reporting. Patient has been seeing myself and physicians via the resident practice. Patient states that she wants to be evaluated by me. We discussed that she should pick one Practice for consistency. Because of her chronic pelvic pain, we discussed diagnostic laparoscopy, question operative laparoscopy depending on the findings. <PAST MEDICAL HISTORY> OBHx: ___ - ectopic s/p laparoscopy - LTCS, term, male (___) GynHx: - endometriosis, ovarian cysts - menarche age ___ q monthly x 8 days until abnormal bleeding commenced - last Pap ___ NILM -HPV - remote h/o abnormal Paps - ovarian cysts s/p lsc cystectomy (unsure which side) - normally sexually active with male partner; but no intercourse since irregular bleeding started PMH: Infertility, T2DM PSHx: exploratory laparoscopy, laparoscopic cystectomy, low transverse cesarean section All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family h/o cervical, uterine, ovarian, colon or breast cancers. Denies family h/o bleeding or clotting disorders. <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> pantoprazole 40mg QD, dicyclomine ___ TID prn, zofran prn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain do not drive or drink alcohol, causes sedation RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours Disp #*20 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 4. Pantoprazole 40 mg PO Q24H <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> intraabdominal adhesions <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. 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 operative laparoscopy, lysis of adhesions. There were extensive and thick adhesions involving the anterior uterine wall, bladder and abdominal wall. She was admitted for pain control. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with Dilaudid PCA. On post-operative day 0, 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 dilaudid, oxycodone. She was put on an humalog insulin sliding scale. 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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10187075-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Ovarian Mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, bilateral salpingectomy, hysterectomy <HISTORY OF PRESENT ILLNESS> ___ yo female presents for surgical consultation for pelvic mass found on imaging. She was experiencing LLQ pain and has a h/o diverticulitis. She underwent a CT Scan which revealed large mixed solid and cystic mass 15.3 x 7.3 x 9.9 cm. She was put on abx. However, her LLQ pain persisted and she then underwent a pelvic ultrasound, ___, that showed a right large cystic mass, 96mm and left complex cyst, 27mm. She was also given another course of abx. She had an MRI of the pelvis, revealing a large complex mass with solid enhancing components measuring 8.5 x 10.7 x 16 cm. A left ovarian complex cystic lesion was also identified. It measured 2.6 x 2.7 cm. She has not had any tumor markers done. Since then, her LLQ pain has improved. Detailed questioning reveals no symptoms suggestive of disease recurrence. She denies any abdominal pain, anorexia, or gastrointestinal symptoms. She denies any vaginal bleeding, discharge, lower extremity swelling or pain. <PAST MEDICAL HISTORY> PMH: Hypothyroid PSH: None OB/GYN: G2P2-NVD x 2, LMP: ? age ___, no PMB, no HRT use, Last Pap Smear: ___, no h/o abnl pap smears <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: ___ Cancer dx age ___ and deceased age ___, HTN Sister: ? colon CA, Father: CAD No ovarian or uterine cancer <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, incision clean/dry/intact ___: nontender, nonedematous <PERTINENT RESULTS> ___ 01: 10PM BLOOD WBC-5.8 RBC-2.80* Hgb-8.4* Hct-25.3* MCV-90 MCH-30.1 MCHC-33.4 RDW-16.9* Plt ___ ___ 04: 40AM BLOOD WBC-4.3 RBC-2.71* Hgb-8.1* Hct-24.6* MCV-91 MCH-29.8 MCHC-32.8 RDW-16.8* Plt ___ ___ 04: 40AM BLOOD WBC-6.3 RBC-2.99* Hgb-9.0* Hct-27.5* MCV-92 MCH-30.0 MCHC-32.6 RDW-17.0* Plt ___ ___ 05: 50AM BLOOD WBC-6.3# RBC-3.15* Hgb-9.3* Hct-29.1* MCV-92 MCH-29.6 MCHC-32.0 RDW-16.4* Plt ___ ___ 04: 40AM BLOOD Glucose-93 UreaN-5* Creat-0.6 Na-143 K-3.3 Cl-107 HCO3-29 AnGap-10 ___ 04: 40AM BLOOD Glucose-103* UreaN-6 Creat-0.6 Na-144 K-3.5 Cl-107 HCO3-29 AnGap-12 ___ 05: 50AM BLOOD Glucose-101* UreaN-12 Creat-0.5 Na-139 K-3.8 Cl-102 HCO3-28 AnGap-13 ___ 04: 40AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9 ___ 04: 40AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.1 ___ 05: 50AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.7 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY <DISCHARGE MEDICATIONS> 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 3. Ibuprofen 400 mg PO Q8H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills: *0 4. 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: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic 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 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 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. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. * 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 gynecology oncology service after undergoing exploratory laparotomy, bilateral salpingo-oophorectomy, hysterectomy for pelvic mass. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with Dilaudid PCA and IV Toradol. Her diet was advanced without difficulty and she was transitioned to Percocet and ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She received spiritual care during her post-operative stay. She had intermittently elevated blood pressures to 160-170s/80-90s without symptoms which resolved without intervention. She did not require antihypertensive medications during her post-operative course. Her PCP was contacted and will follow-up as an outpatient. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. Her hematocrit was stable. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10187075-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Wound infection <MAJOR SURGICAL OR INVASIVE PROCEDURE> wound exploration and debridement x 4 wound debridement and abdominoplasty for wound closure <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old s/p laparoscopic -> ex-lap, TAH, BSO with concern for borderline ovarian tumor on ___ who presented today for staple removal and was found to have a concerning exam for a wound infection. She was thus admitted directly fromclinic. She first started to feel abdominal discomfort and have more drainage from the wound overnight. Of note, she was seen in the office for a blood pressure check with a primary care doctor on ___, and per review of visit summary and with patient, there was only slight serous drainage with no sign of infectionat that time. She reports a low grade temp at home, starting last night up to 100.4, as well as occasional chills. She did note some swelling around her incision site. Pain was controlled on oral medications. Denies nausea, vomiting, bowel changes, chest pain or shortness of breath. <PAST MEDICAL HISTORY> PAST MEDICAL / SURGICAL HISTORY: - R ovarian mass, found to be serous borderline tumor. Smaller tumor on L ovary. s/p ex-lap, TAH/BSO on ___. - Hypothyroid - diverticulosis - anemia (unspecified cause) - obesity - osteopenia OB/GYN: G2P2-NVD x 2, LMP: ? age ___, no PMB, no HRT use, Last Pap Smear: ___, no h/o abnl pap smears <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: ___ Cancer dx age ___ and deceased age ___, HTN Sister: ? colon CA, Father: CAD No ovarian or uterine cancer <PHYSICAL EXAM> On admission: T 99.0, BP 149/52, HR 119, O2sat 100% on RA, RR 22 Gen: NAD, but appears slightly uncomfortable, bending over CV: Regular rhythm, tachycardic Lungs: Clear to auscultaion bilaterally Abd: soft, non-distended. There is bilateral bruising with skin changes with bullae and skin sloughing that extended across entire lower abdomen with surrounding erythema. There is also induration and erythematous area is tender to palpation. There is mucopurulent discharge from the wound, which is still intact. Ext: non-tender, trace edema On discharge: Vital signs stable, afebrile Gen: NAD, confortable CV: Regular rate and rhythm Lungs: Clear to auscultaion bilaterally Abd: soft, non-distended, appropiately tender to palpation, no rebound/guarding, + BS, low tranverse abdominal incision extending across abdomen clean/dry/intact with tegaderm. Two abdominal wound JP drains in place with serosanguinous output Ext: ___: non-tender, trace edema, symmetric, no increased warmth, PICC line in place in R arm <PERTINENT RESULTS> ___ CT Abd/Pelvis 1. Status post hysterectomy and bilateral oophorectomy. Postsurgical changes are present within the pelvis but there is no drainable fluid collection. Large open anterior midline surgical wound without peritoneal dehiscence. 2. Incidental 1.3 cm nodule along the left adrenal medial limb is nonspecific on the current examination, but appears compatible with adenoma on the previous outside hospital CT. ___ Surgical pathology: Skin and fibroadipose tissue with ulceration, scar formation, acute inflammation and necrosis. ___: new diagnosis of Anti-Jka antibody. In the future, Ms. ___ should receive ___ negative products for all red cell transfusions ___ Lower extremity vein doppler study: No evidence of lower extremity DVTs ___ right thigh punch biopsy: Superficial fungal infection associated with subcorneal pustules ___ 05: 34AM BLOOD WBC-2.5* RBC-3.32*# Hgb-10.0*# Hct-29.4*# MCV-89 MCH-30.2 MCHC-34.0 RDW-15.8* Plt ___ ___ 05: 45AM BLOOD WBC-2.4* RBC-2.47* Hgb-7.4* Hct-22.1* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.8* Plt ___ ___ 05: 51AM BLOOD WBC-3.5* RBC-2.75* Hgb-8.2* Hct-24.2* MCV-88 MCH-29.7 MCHC-33.8 RDW-15.7* Plt ___ ___ 11: 15PM BLOOD WBC-3.0* RBC-2.59* Hgb-7.7* Hct-22.9* MCV-88 MCH-29.6 MCHC-33.5 RDW-15.8* Plt ___ ___ 05: 18AM BLOOD WBC-3.7* RBC-2.83*# Hgb-8.4*# Hct-25.2*# MCV-89 MCH-29.6 MCHC-33.2 RDW-16.0* Plt ___ ___ 04: 15PM BLOOD WBC-3.2* RBC-2.07* Hgb-6.1* Hct-18.4* MCV-89 MCH-29.4 MCHC-33.1 RDW-16.0* Plt ___ ___ 12: 18PM BLOOD WBC-3.0* RBC-2.18*# Hgb-6.5*# Hct-19.5*# MCV-90 MCH-29.7 MCHC-33.1 RDW-15.9* Plt ___ ___ 08: 00PM BLOOD WBC-2.5* RBC-3.48* Hgb-10.1* Hct-31.5* MCV-91 MCH-29.0 MCHC-32.0 RDW-15.7* Plt ___ ___ 05: 45AM BLOOD WBC-2.6* RBC-2.86* Hgb-8.3* Hct-25.6* MCV-90 MCH-29.0 MCHC-32.3 RDW-15.6* Plt ___ ___ 06: 40AM BLOOD WBC-2.4* RBC-2.96* Hgb-8.8* Hct-26.7* MCV-90 MCH-29.6 MCHC-32.8 RDW-15.4 Plt ___ ___ 07: 25AM BLOOD WBC-2.3* RBC-3.26* Hgb-9.3* Hct-29.8* MCV-91 MCH-28.6 MCHC-31.3 RDW-15.7* Plt ___ ___ 07: 00AM BLOOD WBC-2.3* RBC-3.20* Hgb-9.3* Hct-28.6* MCV-89 MCH-29.0 MCHC-32.5 RDW-16.0* Plt ___ ___ 08: 15AM BLOOD WBC-2.9* RBC-3.34*# Hgb-9.8*# Hct-29.9*# MCV-90 MCH-29.5 MCHC-33.0 RDW-15.7* Plt ___ ___ 07: 45AM BLOOD WBC-4.3 RBC-2.33*# Hgb-6.9*# Hct-21.7*# MCV-93 MCH-29.5 MCHC-31.7 RDW-16.3* Plt ___ ___ 04: 03AM BLOOD WBC-7.7 RBC-3.17* Hgb-9.5* Hct-29.3* MCV-92 MCH-29.9 MCHC-32.4 RDW-15.9* Plt ___ ___ 08: 55AM BLOOD WBC-8.4 RBC-2.64* Hgb-7.8* Hct-24.6* MCV-93 MCH-29.6 MCHC-31.8 RDW-16.0* Plt ___ ___ 07: 20AM BLOOD WBC-8.4 RBC-2.58* Hgb-7.6* Hct-24.1* MCV-94 MCH-29.6 MCHC-31.7 RDW-15.9* Plt ___ ___ 09: 05AM BLOOD WBC-13.1* RBC-3.23* Hgb-9.5* Hct-29.7* MCV-92 MCH-29.5 MCHC-32.1 RDW-16.5* Plt ___ ___ 02: 45AM BLOOD WBC-9.9 RBC-3.15* Hgb-9.2* Hct-28.6* MCV-91 MCH-29.2 MCHC-32.1 RDW-15.9* Plt ___ ___ 06: 38AM BLOOD WBC-12.4* RBC-3.12* Hgb-9.3* Hct-28.8* MCV-92 MCH-29.8 MCHC-32.3 RDW-16.0* Plt ___ ___ 09: 41PM BLOOD WBC-13.5* RBC-2.90* Hgb-8.6* Hct-26.6* MCV-92 MCH-29.7 MCHC-32.5 RDW-16.0* Plt ___ ___ 06: 30AM BLOOD WBC-12.5* RBC-2.50* Hgb-7.6* Hct-23.4* MCV-93 MCH-30.3 MCHC-32.5 RDW-15.8* Plt ___ ___ 06: 30AM BLOOD WBC-12.5* RBC-2.50* Hgb-7.6* Hct-23.4* MCV-93 MCH-30.3 MCHC-32.5 RDW-15.8* Plt ___ ___ 01: 05AM BLOOD WBC-13.2* RBC-2.61* Hgb-7.7* Hct-24.0* MCV-92 MCH-29.6 MCHC-32.2 RDW-16.2* Plt ___ ___ 11: 45AM BLOOD WBC-19.7*# RBC-2.44* Hgb-7.3* Hct-22.2* MCV-91 MCH-30.1 MCHC-33.1 RDW-16.2* Plt ___ ___ 05: 51AM BLOOD Neuts-69 Bands-0 ___ Monos-11 Eos-0 Baso-0 ___ Myelos-0 ___ 05: 18AM BLOOD Neuts-76* Bands-0 Lymphs-13* Monos-8 Eos-1 Baso-2 ___ Myelos-0 ___ 12: 18PM BLOOD Neuts-69 Bands-0 ___ Monos-6 Eos-2 Baso-1 Atyps-3* ___ Myelos-0 ___ 08: 00PM BLOOD Neuts-67 Bands-0 ___ Monos-6 Eos-1 Baso-1 Atyps-2* ___ Myelos-0 ___ 05: 45AM BLOOD Neuts-50 Bands-0 ___ Monos-6 Eos-10* Baso-2 ___ Myelos-0 ___ 06: 40AM BLOOD Neuts-60 Bands-2 ___ Monos-6 Eos-3 Baso-0 ___ Myelos-0 ___ 07: 25AM BLOOD Neuts-71* Bands-4 Lymphs-17* Monos-7 Eos-1 Baso-0 ___ Myelos-0 ___ 07: 00AM BLOOD Neuts-72* Bands-2 Lymphs-17* Monos-8 Eos-1 Baso-0 ___ Myelos-0 ___ 08: 15AM BLOOD Neuts-74.5* Lymphs-14.6* Monos-9.1 Eos-1.7 Baso-0.1 ___ 07: 45AM BLOOD Neuts-87* Bands-1 Lymphs-6* Monos-4 Eos-2 Baso-0 ___ Myelos-0 ___ 04: 03AM BLOOD Neuts-84* Bands-0 Lymphs-8* Monos-5 Eos-0 Baso-3* ___ Myelos-0 ___ 08: 55AM BLOOD Neuts-84.0* Lymphs-10.0* Monos-4.9 Eos-0.5 Baso-0.5 ___ 07: 20AM BLOOD Neuts-83.1* Lymphs-9.4* Monos-6.0 Eos-0.4 Baso-1.2 ___ 02: 45AM BLOOD Neuts-86.2* Lymphs-6.2* Monos-7.1 Eos-0.1 Baso-0.3 ___ 06: 38AM BLOOD Neuts-84.9* Lymphs-9.0* Monos-5.7 Eos-0.2 Baso-0.2 ___ 06: 30AM BLOOD Neuts-87.6* Lymphs-7.5* Monos-4.6 Eos-0.1 Baso-0.1 ___ 11: 45AM BLOOD Neuts-89.1* Lymphs-6.1* Monos-4.5 Eos-0.1 Baso-0.1 ___ 05: 51AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ ___ 10: 30AM BLOOD ___ PTT-31.2 ___ ___ 10: 30AM BLOOD ___ ___ 05: 51AM BLOOD Ret Aut-1.1* ___ 05: 34AM BLOOD Glucose-95 UreaN-11 Creat-0.8 Na-139 K-3.8 Cl-105 HCO3-25 AnGap-13 ___ 05: 51AM BLOOD Glucose-93 UreaN-9 Creat-0.8 Na-137 K-3.9 Cl-103 HCO3-30 AnGap-8 ___ 05: 18AM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-138 K-4.1 Cl-105 HCO3-26 AnGap-11 ___ 12: 18PM BLOOD Glucose-130* UreaN-10 Creat-1.0 Na-135 K-4.1 Cl-103 HCO3-25 AnGap-11 ___ 08: 00PM BLOOD Glucose-109* UreaN-8 Creat-1.0 Na-140 K-4.0 Cl-107 HCO3-26 AnGap-11 ___ 05: 45AM BLOOD Glucose-93 UreaN-8 Creat-1.0 Na-139 K-4.3 Cl-107 HCO3-27 AnGap-9 ___ 06: 40AM BLOOD Glucose-93 UreaN-9 Creat-1.1 Na-140 K-4.3 Cl-107 HCO3-27 AnGap-10 ___ 07: 25AM BLOOD Glucose-91 UreaN-7 Creat-1.0 Na-140 K-4.2 Cl-105 HCO3-29 AnGap-10 ___ 07: 00AM BLOOD Glucose-103* UreaN-6 Creat-1.0 Na-139 K-4.2 Cl-106 HCO3-27 AnGap-10 ___ 07: 45AM BLOOD Glucose-99 UreaN-10 Creat-0.8 Na-138 K-3.6 Cl-104 HCO3-29 AnGap-9 ___ 04: 03AM BLOOD Glucose-107* UreaN-12 Creat-1.1 Na-137 K-3.2* Cl-102 HCO3-27 AnGap-11 ___ 08: 55AM BLOOD Glucose-97 UreaN-14 Creat-1.0 Na-143 K-3.4 Cl-106 HCO3-28 AnGap-12 ___ 07: 20AM BLOOD Glucose-92 UreaN-14 Creat-1.0 Na-139 K-3.5 Cl-103 HCO3-29 AnGap-11 ___ 09: 05AM BLOOD Glucose-110* UreaN-12 Creat-0.9 Na-139 K-3.3 Cl-102 HCO3-27 AnGap-13 ___ 06: 38AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-138 K-3.7 Cl-102 HCO3-27 AnGap-13 ___ 06: 30AM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-137 K-4.1 Cl-102 HCO3-24 AnGap-15 ___ 11: 45AM BLOOD UreaN-14 Creat-0.7 ___ 05: 51AM BLOOD LD(LDH)-238 TotBili-0.6 DirBili-0.2 IndBili-0.4 ___ 05: 34AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.7 ___ 05: 45AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.7 ___ 05: 51AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8 Iron-62 ___ 05: 18AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0 ___ 12: 18PM BLOOD Calcium-7.8* Phos-2.7 Mg-2.0 ___ 07: 45AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.9 ___ 04: 03AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.7 ___ 08: 55AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.8 ___ 06: 38AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9 ___ 06: 30AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8 ___ 05: 51AM BLOOD calTIBC-190* VitB12-___* Folate-9.9 ___ Ferritn-670* TRF-146* ___ 11: 00AM BLOOD %HbA1c-5.9 eAG-123 ___ 11: 00AM BLOOD TSH-0.51 ___ 11: 00AM BLOOD HIV Ab-NEGATIVE ___ 08: 15AM BLOOD Vanco-19.6 ___ 04: 03AM BLOOD Vanco-29.3* ___ 02: 45AM BLOOD Vanco-14.3 ___ 05: 00PM BLOOD Vanco-7.4* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Calcium Carbonate 1200 mg PO DAILY 3. Ibuprofen 800 mg PO HS: PRN leg pain 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain <DISCHARGE MEDICATIONS> 1. CefePIME 2 g IV Q12H RX *cefepime 2 gram 2g IV every twelve (12) hours Disp #*15 Vial Refills: *0 2. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *2 3. OxycoDONE (Immediate Release) ___ mg PO Q3H: PRN pain do not drive or drink alcohol while taking narcotics/percocet. RX *oxycodone 5 mg ___ tablet(s) by mouth q3h Disp #*60 Tablet Refills: *0 4. Acetaminophen ___ mg PO Q6H: PRN pain do not take more than 4000mg acetaminophen/tylenol in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Calcium Carbonate 1200 mg PO DAILY 7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 9 Days RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*23 Tablet Refills: *0 8. Ferrous Sulfate 325 mg PO BID take with food. may take colace if constipated. do not take at the same time as levothyroxine RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *2 9. Famotidine 20 mg PO BID RX *famotidine [Acid Controller] 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 10. Docusate Sodium 100 mg PO BID please use while taking iron or narcotics/percocet. Hold for loose stool RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 11. econazole 1 % topical BID apply to rash over groin avoiding the genitals, keep area dry RX *econazole 1 % apply to vulvar and groin rash twice a day Refills: *3 12. Terconazole 0.4% Vag. Cream 1 Appl VG DAILY Duration: 7 Days <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> surgical wound infection, necrotizing cellulitis vulvar fungal infection drug rash anemia with h/o B thalasemia <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 a surgical wound infection and underwent 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 6 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. * Do not remove the plastic dressing over your abdominal incision or your two abdominal drains until after your follow-up appointment with the plastic surgery service * Please follow the instructions for wound care and drain care per the plastic surgery recommendations * You may shower with plastic wound dressing in place. Do not scrub dressing. Pat dry after shower. No baths. * Please regularly empty and record the amount and color of the drain fluid. Bring the recorded values to your follow-up Plastics appointment. Call the plastic surgery office if the drainage increases, is bright red or have any concerns. * Right upper thigh biopsy site care: apply vaseline and change bandage every day Skin care *) For the biopsy site on your thigh, place a new bandaid with a small amount of vaseline daily *) You can use the triamcinolone cream twice daily in a thin layer on your arms and legs, not your face. You can use hydrocortisone as needed on your face . 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 * increased abdominal drainage or bright red drainage
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Ms. ___ was admitted to the gynecology oncology service for surgical wound infection with consultations from infectious disease, colorectal surgery and plastic surgery. Her wound was found to have purulent discharge, was dusky in appearance, with bubbles, and induration of about 30cm around the wound. There was a concern specifically for the possibility of necrotizing fasciitis and she was started on vancomycin, zosyn. and clindamycin. The patient was admitted immediately and taken expeditiously to the operating room for exploration. Prior to being brought to the operating room, the patient was noted to have a fever to 103.0. Please see the operative report for full details. Surgical pathology on ___ was notable for ulcer with dermal necrosis, florid neutrophilic infiltrate with abscess formation in dermis and subcutaneous tissue, and abundant bacteria present in gangrenous dermis. Due to increasing dusky margins at the upper and lateral edges of her wound, her abdomen was surgically debrided 3 additional times on ___ and ___, ultimately down to the fascia. Her wound dressing was changed twice daily with Dakin's ___ strength solution. Surgical pathology from ___ showed skin and fibroadipose tissue with ulceration, scar formation, acute inflammation and necrosis. Her wound culture grew out pseudomonas, group B strep, coag+ staph aureus. Sensitivities were done. Her clindamycin was stopped ___. Vancomycin was stopped ___ secondary to leukopenia which nadired at 2.3 and subsequently improved after vancomycin was discontinued. She continued on IV Zosyn until she developed a diffuse rash and was switched to IV cefepime ___ with PO Flagyl ___ that will be continued until ___ per ID recommendations. Her rash improved on cefepime. She had an episode of ___, likely ATN secondary to vancomycin, with creatinine 0.7 to 1.1 and adequate urine output. Episode resolved after discontinuation of vancomycin and IV fluid hydration with creatinine of 0.8 on discharge with adequate urine output. Her HgA1C was within normal limits. She received a total of 10 units pRBC for blood loss anemia during her hospital stay. She tolerated the transfusions well. After her 6th unit of blood, she was noted to have developed Anti-Jka antibody. She was recommended to have ___ negative products for all future red cell transfusions. LFT and hemolysis labs were unremarkable on ___. Hematology was consulted for her anemia. She has a history of B thalassemia with chronic anemia. Her hematocrit was stable on discharge with improved symptom of fatigue. She will have follow-up CBC/differential with ___ for anemia to be followed by hematology. On ___ she was noted to be hypertensive to the 160s SBP so lisinopril 5 was started with improved blood pressures and no severe range blood pressures. On ___, she received a right PICC line for IV antibiotics and has nursing PICC care after discharge. On ___, plastic surgery performed an abdominoplasty and reconstruction. Two abdominal wound JP drains was placed with stable serosanginous output. Follow-up planned for a week after discharge. Her diet was advanced without difficulty following her abdominoplasty and she was transitioned to PO percocet. Her urine output was adequate so her Foley catheter was removed post-operatively and she voided spontaneously. On ___, she underwent a lower extremity vein doppler study that was negative for lower extremity DVTs. On ___, a vulvar rash was noted concerning for fungal infection vs drug reaction. Dermatology was consulted and a punch biopsy was performed. Preliminary pathology is consistent with fungal infection. She was started on topical antifungal cream. On ___, she had a 10 minute run of tachycardia to the 180s during which she had a stable BP though felt anxious. It resolved spontenously. EKG was normal. Pt reported multiple similar episodes over the course of her lifetime. Cardiology was consulted and they recommended outpatient followup if her episodes become more frequent or worsen. She was seen by social work and physical therapy during her hospital course. By hospital day ___, she was tolerating a regular diet, voiding spontaneously, ambulating with assistance, and pain was controlled with oral medications. She was then discharged home in stable condition with wound care and IV antibiotic nursing services, physical therapy and outpatient follow-up scheduled.
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10189774-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Painful contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> CS <HISTORY OF PRESENT ILLNESS> presented with painful contractions and spotting has already received betamethasone due to hx and cervix <PAST MEDICAL HISTORY> Dating: EDC of ___ by LMP of ___ AB+, Ab-, RPR NR, RI, pap wnl, HbSag- PMH: none PSH: oral surgery PGyn: benign <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Physical exam: Afebrile VSS Gen: Well NAD although breathing through contractions Card: RRR Resp: CTAB Abd: Soft, non-tender to palpation over site of prior scar. Contractions moderately firm to palpation SVE: 1/L/high Ext: NT, NE NST: ___ 125, mod var, +accels, no decels, no audible arrythmia Toco: q10 TAUS: Breech, BPP ___, DVP 8cm, anterior placenta without retro-placental collection <PERTINENT RESULTS> ___ 12: 10AM BLOOD WBC-13.1* RBC-3.89* Hgb-10.7* Hct-32.6* MCV-84 MCH-27.4 MCHC-32.8 RDW-13.3 Plt ___ ___ 12: 26AM BLOOD ___ PTT-24.1 ___ ___ 12: 10AM BLOOD Plt ___ ___ 12: 26AM BLOOD ___ ___ 12: 10AM BLOOD ___ 12: 26AM BLOOD Glucose-76 UreaN-4* Creat-0.4 Na-135 K-3.7 Cl-105 HCO3-20* AnGap-14 ___ 12: 26AM BLOOD Calcium-7.2* Phos-2.6* Mg-4.1* <MEDICATIONS ON ADMISSION> magnesium sulfate <DISCHARGE MEDICATIONS> 1. Hospital Grade Breast Pump- Prolonged separation- INFANT IN NICU 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for Pain. Disp: *50 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Preterm labor and delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> given
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She was admitted and the magnesium sulfate was continued. SHe progressed rapidly with every 10 min contractions and since the baby was breech adn she was 9 cm, she underwent an urgent CS under spinal anesthesia. She named the baby ___ and she went home on POD#4 with an uneventful postpartum course.
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10194191-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / ciprofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> RUQ pain, vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> Repeat C-section and tubal ligation <HISTORY OF PRESENT ILLNESS> ___ G4P1 with history of CKD, solitary pelvic kidney, recurrent UTIs, fibroid uterus, shortened cervix presented to routine visit today w/ worsening RUQ and new onset vomiting. She has been seen for the pain in Triage multiple times. She reports that the pain hasn't improved w/ Tylenol, heat/cold, Flexeril, position changes. She has vomited almost every meal in the last 2 days, although she was able to keep down a donut today. No diarrhea, constipation, fevers, sick contacts. She is also feeling dizzy. PEC labs have been stable over multiple presentations in Triage, although her uric acid and P: C ratios have increased. <PAST MEDICAL HISTORY> PNC: ___ ___ PN labs: Apos, Ab neg, RI, RPR NR, HIV neg, HBV sAg neg CHRONIC KIDNEY DISEASE (single kidney. Baseline Creat 1.0): baseline proteinuria 2g CONTRACEPTION (Desires tubal ligation) GBS COLONIZATION (needs prophylaxis in labor or with SROM) HYPERTENSION (Nifedipine 90 CR daily, baseline 24 hr urine = 2grams[ ] baseline EKG, echo) SOLITARY PELVIC KIDNEY (referred to Dr. ___ in ___ - on Macrobid suppression SHORT CERVIX: on vag progesterone AMA: low-risk panorama, nl ___ ANEMIA ObHx: G4P1 - pLTCS ___, pLTCS, term, meconium ?aspiration NICU observation for several hours but no intubation or CPAP, 6lb 7 oz, 21 inches, boy, he has polyarticultar RA seen at ___, ADD, asthma - TAB x 2 GynHx: - LMP ___ - last pap ___, neg with neg HPV - denies h/o STIS, including HSV - history of uterine fibroids <PAST MEDICAL HISTORY> - CKD, Stage 2, baseline Cr 1.0-1.2 - solitary pelvic kidney - HTN: amlodipine pre-preg - recurrent UTIs and pyelo, last ___, followed by Dr. ___ in urology - sickle cell trait - ___, found during eval for joint swelling, SLE w/u neg - mitral regurgitation (trace on echo in ___ - hyperlipidemia Past Surgical History: c-section <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Physical Exam on Admission: Vital Signs sheet entries for ___: BP: 134/92. Weight: 187 (With Clothes). BMI: 35.3. Urine dip: no ketones Gen: NAD Cor: RRR Pulm: CTAB Abd: gravid, no fundal tenderness; +RUQ tenderness no rib tenderness Ext: nontender, trace BLE edema <PERTINENT RESULTS> ___ WBC-8.6 RBC-3.33 Hgb-8.8 Hct-27.5 MCV-83 Plt-237 ___ WBC-11.6 RBC-2.66 Hgb-6.8 Hct-22.0 MCV-83 Plt-253 ___ WBC-13.6 RBC-3.12 Hgb-7.8 Hct-24.9 MCV-80 Plt-261 ___ WBC-14.1 RBC-3.56 Hgb-8.9 Hct-28.7 MCV-81 Plt-351 ___ WBC-8.0 RBC-3.18 Hgb-8.0 Hct-25.6 MCV-81 Plt-267 ___ Glucose-83 UreaN-9 Creat-1.1 Na-137 K-3.9 Cl-104 HCO3-22 AnGap-15 ___ Glucose-79 UreaN-10 Creat-0.7 Na-136 K-3.9 Cl-106 HCO3-21 AnGap-13 ___ Glucose-85 UreaN-9 Creat-1.1 Na-138 K-4.1 Cl-106 HCO3-21 AnGap-15 ___ Glucose-78 UreaN-7 Creat-1.2* Na-132* K-3.7 Cl-98 HCO3-22 AnGap-16 ___ UreaN-7 Creat-1.1 Na-137 K-3.9 Cl-105 HCO3-22 AnGap-14 ___ ALT-16 AST-19 UricAcd-6.7 ___ ALT-8 AST-12 LDH-173 UricAcd-6.4 ___ ALT-8 AST-12 LDH-199 TotBili-0.2 UrAcd-6.5 Iron-377 ___ ALT-10 AST-14 UricAcd-6.3 ___ ALT-9 AST-12 ___ Albumin-3.0*Calcium-8.6 Mg-1.8 UricAcd-6.7* ___ Folate-6 Hapto-150 ___ calTIBC-446 ___ Ferritn-103 TRF-343 ___ TSH-0.83 ___ URINE pH-5 Hours-24 Volume-1300 Creat-79 TotProt-519 Prot/Cr-6.6* ___ URINE 24Creat-1027 24Prot-6747 . LIVER OR GALLBLADDER US (SINGLE ORGAN) Final Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm. GALLBLADDER: Cholelithiasis is noted with a contracted gallbladder. Of note, patient recently had a meal before the exam. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: The spleen measures 9.8 cm and is unremarkable. KIDNEYS: Limited views of the congenitally single left kidney show no hydronephrosis. IMPRESSION: Cholelithiasis is noted with a contracted gallbladder. Of note, the patient recently had a meal prior to the exam. <MEDICATIONS ON ADMISSION> Nifedipine 30mg bid PNV macrobid <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: *0 2. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 3. NIFEdipine CR 30 mg PO BID 4. NIFEdipine CR 60 mg PO BID RX *nifedipine [Adalat CC] 60 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills: *0 5. Hydrocortisone Cream 2.5% 1 Appl TP BID PRN hemorrhoid pain 6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic kidney disease, superimposed preeclampsia w/ severe features, pregnancy Cesarean delivery with tubal ligation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call for bleeding, contractions, leakage of fluid, decreased fetal movement, severe headache, chest pain, shortness of breath, nausea/vomiting, abdominal pain, vision changes
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Ms ___ is a ___ G4P1021 with prior C/S, single kidney, chronic renal insufficiency, recurrent UTIs, chronic HTN and fibroids admitted to antepartum at 33w4d for worsening RUQ pain and new onset vomiting. Her blood pressures at the time of presentation were in the mild range while continuing on home dose of Nifedipine. Preeclampsia labs were notable for a Cr or 1.1 (baseline 1.0) and worsening proteinuria (6747mg). She was also noted to be anemic and received a dose of IV ferrous gluconate. Nephrology was consulted and followed during her admission. Fetal testing was reassuring. She was given a course of betamethasone for fetal lung maturity (___) and the NICU was consulted. Her RUQ pain resolved, however, she developed a persistent headache that was unresponsive to Tylenol, Fioricet, Reglan, and Compazine. Given the concern for severe preeclampsia, delivery was recommended. She was started on Magnesium for seizure prophylaxis and underwent a repeat LTCS with BTL on ___ and delivered a liveborn female weighing 1840 grams with Apgars of 8 and 9. NICU staff was present for delivery and transferred the neonate for prematurity. Please see operative report for details. . She was continued on Magnesium postpartum for eclampsia prophylaxis. Her blood pressures were closely monitored and the Nifedipine was uptitrated to 60mg bid. She otherwise had an uncomplicated postop course and was discharged to home in stable condition on POD#5.
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10195096-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Dysuria <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ guided drainage of pelvic abscess <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ with a PMH pertinent for Factor V Leiden on coumadin who presents as a transfer from ___ with an intraabdominal abscess 10 days s/p robot-assisted hysterectomy. Patient originally underwent the procedure on ___ for fibroids and excessive uterine bleeding. She initially did well, but on ___ at home she started developing constipation, abdominal pain and cramps. Her symptoms persisted until she developed dysuria and hematuria on ___, prompting her to present to the ED at ___. There she underwent non-con CT which visualized the abscess and raised concern for communication between the abscess cavity and the colon. A CT scan with PO but no IV contrast was then performed which revisualized the previous pathology. Following this she was started on Zosyn and transferred to ___ for definitive care. Here she was found to be hemodynamically appropriate and mentating well. She endorsed anorexia and diarrhea without hematochezia. She denied lightheadedness, SOB, chest pain, and paresthesias. Notably her hysterectomy specimen at ___ showed invasive adenocarcinoma (endometroid type) of the lower uterine segment without serosal invasion. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Factor V Leiden (Followed by Dr. ___ Multiple RLE DVTs R breast DCIS Cholelithiasis PAST SURGICAL HISTORY: Robot-assisted hysterectomy ___, ___ Lap CCY ___ R partial mastectomy ___, with reexicsion of margin (___) IVC Filter placement <SOCIAL HISTORY> Works as a ___ for grades ___. Lives at home with husband and ___ year old son. ___ on the weekends, ~3 drinks/session. Denies EtOH and recreational drugs. <PHYSICAL EXAM> 24 HR Data (last updated ___ @ 307) Temp: 97.5 (Tm 98.1), BP: 113/74 (94-114/55-74), HR: 53 (53-74), RR: 18, O2 sat: 98% (95-98), O2 delivery: Ra, Wt: 141.1 lb/64 kg Fluid Balance (last updated ___ @ 516) Last 8 hours Total cumulative 201ml IN: Total 216ml, IV Amt Infused 216ml OUT: Total 15ml, Urine Amt 0ml, left glute ___ drain 15ml Last 24 hours Total cumulative 867ml IN: Total 1587ml, PO Amt 440ml, IV Amt Infused 1147ml OUT: Total 720ml, Urine Amt 700ml, left glute ___ drain 20ml <PERTINENT RESULTS> ___ 10: 00PM ___ PTT-24.1* ___ ___ 02: 04PM ___ PTT-26.4 ___ ___ 11: 30AM URINE HOURS-RANDOM ___ 11: 30AM URINE UCG-NEGATIVE ___ 11: 30AM URINE COLOR-Straw APPEAR-Hazy* SP ___ ___ 11: 30AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM* ___ 11: 30AM URINE RBC-9* WBC-11* BACTERIA-NONE YEAST-NONE EPI-3 ___ 04: 32AM ___ COMMENTS-GREEN TOP ___ 04: 32AM LACTATE-0.8 ___ 04: 26AM GLUCOSE-91 UREA N-8 CREAT-0.6 SODIUM-136 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-21* ANION GAP-14 ___ 04: 26AM estGFR-Using this ___ 04: 26AM ALT(SGPT)-63* AST(SGOT)-109* ALK PHOS-183* TOT BILI-0.6 ___ 04: 26AM LIPASE-34 ___ 04: 26AM ALBUMIN-3.6 ___ 04: 26AM WBC-9.3 RBC-4.01 HGB-10.4* HCT-33.2* MCV-83 MCH-25.9* MCHC-31.3* RDW-13.7 RDWSD-41.6 ___ 04: 26AM NEUTS-81.4* LYMPHS-11.7* MONOS-5.9 EOS-0.3* BASOS-0.2 IM ___ AbsNeut-7.55* AbsLymp-1.09* AbsMono-0.55 AbsEos-0.03* AbsBaso-0.02 ___ 04: 26AM PLT COUNT-325 ___ 04: 26AM ___ PTT-38.3* ___ <DISCHARGE INSTRUCTIONS> Dear ___ ___ were admitted to the gynecologic oncology service after undergoing the procedures listed below. ___ have recovered well after your operation, and the team feels that ___ are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. We recommend ___ take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As ___ start to feel better and need less medication, ___ should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. ___ were prescribed Colace. If ___ continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital ___ 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. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet. * It is safe to walk up stairs. Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * ___ should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, ___ may remove them. * If ___ 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 ___ 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 ___ 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. ___ 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 ___ in administering these injections.
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Ms ___ was admitted to the Gynecology Oncology service on ___ after undergoing an ___ drainage of her pelvic abscess. She was continued on IV zosyn during her stay and transitioned to metronidazole and levofloxacin for discharge. Her labs were trended and noted to have an improving leukocytosis and remained afebrile during her stay. Her JP drain remained in place while draining serosanguineous fluid and was co-managed with colorectal surgery. For her incompletely staged, at least stage IB endometrial adenocarcinoma, FIGO grade ___, she was counseled on importance of outpatient follow up for additional surgical intervetions. No intrathoracic metastasis were noted on CT imaging. Spiritual care was offered to the patient. She was continued on 60mg Lovenox BID per CRS and hematology recommendations for her factor V leiden and reccurent LLW DVT. She was then discharged to home on HD3 in stable condition w/ close follow up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild RX *ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 4. LevoFLOXacin 750 mg PO Q24H RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 5. LOPERamide 2 mg PO ONCE MR1 Duration: 1 Dose 6. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 8. Enoxaparin Sodium 60 mg SC Q12H RX *enoxaparin 60 mg/0.6 mL 1 q12 Disp #*60 Syringe Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: endometrial adenocarcinoma pelvic abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10195096-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Incompletely staged endometrioid adenocarcinoma of the endometrium <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic-Assisted right oophorectomy, para-aortic and pelvic lymphadenectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a lovely ___ year-old woman with Factor V Leiden deficiency on life long anticoagulation with IVC filter in place who on ___ underwent a Robotic Assisted-total laparoscopic hysterectomy, left salpingo-oophorectomy, right salpingectomy, and right cystectomy for DUB found to have a grade 1 endometrioid and is now s/p Robotic Assisted Right Oophorectomy and Pelvic/Paraaortic Lymphadenectomy for staging of adenocarcinoma of the endometrium <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Factor V Leiden (Followed by Dr. ___ Multiple RLE DVTs R breast DCIS Cholelithiasis PAST SURGICAL HISTORY: Robot-assisted hysterectomy ___, ___ Lap CCY ___ ___ R partial mastectomy ___ ___, with reexicsion of margin (___) IVC Filter placement <SOCIAL HISTORY> Works as a ___ for grades ___. Lives at home with husband and ___ year old son. ___ on the weekends, ~3 drinks/session. Denies EtOH and recreational drugs. <PHYSICAL EXAM> Vital signs: Ins/Outs: 24 HR Data (last updated ___ @ 334) Temp: 97.9 (Tm 98.2), BP: 91/55 (91-133/55-82), HR: 59 (56-74), RR: 14 (___), O2 sat: 94% (93-96), O2 delivery: RA Fluid Balance (last updated ___ @ 613) Last 8 hours Total cumulative 360ml IN: Total 560ml, PO Amt 360ml, IV Amt Infused 200ml OUT: Total 200ml, Urine Amt 200ml Last 24 hours Total cumulative 625ml IN: Total 1975ml, PO Amt 1560ml, IV Amt Infused 415ml OUT: Total 1350ml, Urine Amt 1350ml General: NAD CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, tender to palpation (R>L) without rebound or guarding, dressing clean/dry/intact Extremities: no edema, non-tender <PERTINENT RESULTS> ___ 05: 37PM WBC-8.7 RBC-4.17 HGB-11.1* HCT-34.9 MCV-84 MCH-26.6 MCHC-31.8* RDW-15.3 RDWSD-47.1* ___ 05: 37PM PLT COUNT-257 <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: Laparoscopic 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 ___ weeks * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. 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 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. Follow up labs: Please follow up at Signature to get your blood drawn on ___
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Ms. ___ was admitted to the gynecologic oncology service after undergoing robotic assisted right oophorectomy and pelvic/para-aortic lymphadenectomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postop on POD0, the patient had an episode of chest pain after voiding. She had an EKG which showed normal sinus rhythm and non-specific T wave changes. Troponins and CK-MB were negative. On POD1, her chest pain improved although her abdominal pain was poorly controlled with p.o. pain medications so was started on a Dilaudid PCA with IV Tylenol. Her hematocrit was trended and was noted to be stable at 32. On physical exam she was noted to be diffusely tender, right greater than left, without rebound or guarding. On POD 2, her pain was well controlled so her Dilaudid PCA was discontinued and she was transitioned to oral pain medications. Her hematocrit was stable at 34 although her a.m. labs were notable for a platelets of 104 which stabilized on p.m. repeat labs to 251. She was tolerating a regular diet without nausea or vomiting. She was ambulating independently. Her abdominal exam remained benign and was appropriately tender on day of discharge. Patient scheduled for outpatient follow up labs on ___. For her outpatient anticoagulation plan, her heme-onc team was consulted and agreed to bridge as an outpatient. The patient to go home on Lovenox 60 mg twice daily with plan to bridge to warfarin in 2 weeks. By POD2, she was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*100 Capsule Refills:*0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 4. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 60 mg/0.6 mL 1 twice a day Disp #*60 Syringe Refills:*1 Discharge Disposition: Home Discharge Diagnosis: grade ___ endometrial cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10196271-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Fibroid uterus, symptomatic <MAJOR SURGICAL OR INVASIVE PROCEDURE> Open Mymectomy, Abdominal Wound Closure <HISTORY OF PRESENT ILLNESS> ___ yo G7P2 with large, symptomatic fibroid uterus and desire for future fertility. her menses are heavy and long and she had used OCs on different occaions for cycle control. She has currently been using them for about 4 months, and finally this month ( period just started) has had decrease in flow and cramping. Denies postcoital or intermenstrual bleeding. Has "always " been anemic and feels lightheaded and weak during her periods. Admits to some pelvic pressure, but denies bowel or bladder problems. Pt had ultrasound and got the results at that time, but nothing was explained to her. Now she is very worried about this. <PAST MEDICAL HISTORY> 1. Anemia. 2. Diabetes: Type 2 diet controlled. Recently started back on metformin 3. Hypertension: On medication for years. 4. Obesity. PSHx 1. Breast reduction: ___. 2. Cesarean section: X 2, FTP for first, suspected macrosomia with ___ DM for second. 3. D&C: elective termination x 5. 4. Wisdom Teeth. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: DM. Living. Father: ___ cancer, died when pt was ___. Living. Children: ___, ___, good health. Other: Many relativess with DM. <PHYSICAL EXAM> On ___ by Dr. ___: Neuro/Psych: Oriented x3, Affect Normal, NAD, *Abnormal: Pt declines exam due to current menses. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy. Heart: Regular rate and rhythm, No edema or varicosities. Lungs: Clear, Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia, *Abnormal: Large pannus covering previous incision site, somewhat excoriated. Cx: parous, no CMT, no lesion or blood Ut: 12cm, retro, NT, mobile Adn: NE, NT Rectal: normal tone, no masses Extr: no edema, calf tenderness. 1+ DTR <PERTINENT RESULTS> ___ Creat-0.7 <MEDICATIONS ON ADMISSION> 1. LEVONORGESTREL-ETHINYL ESTRAD [AVIANE] - 0.1 mg-20 mcg Tablet - 1 Tablet(s) by mouth once a day 2. LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day 3. METFORMIN - 850 mg Tablet - 1 Tablet(s) by mouth twice a day 4. PHENTERMINE - (Prescribed by Other Provider) - 37.5 mg Capsule -1 Capsule(s) by mouth once a day 5. DOCUSATE SODIUM - 100 mg Capsule - one Capsule(s) by mouth twice a day as needed for constipation for post operative use 6. IRON - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth twice a day <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: do not exceed 4g acetaminophen in 24 hrs. Disp: *50 Tablet(s)* Refills: *0* 2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* 6. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for nausea. Disp: *16 Tablet(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus, frequent abdominal infections <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. * 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. **if no cervix p LSC hyst, nothing in vagina for 3 months * 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. ___ was admitted ___ to the GYN service. Her post-operative course was uncomplicated and her pain was controlled and she was ambulating and tolerating a regular diet. She was discharged home on post-operative day 2 with 2 JP drains with ___ follow-up.
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10196271-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> elevated blood sugars <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G8P2 with T2DM at 4w6d gestation presents for evaluation of elevated blood sugar. She was seen in clinic ___ for N/OB visit; her metformin (1000mg BID), glipizide (10mg BID), and lisinopril were discontinued at the time and she was started on insulin (NPH 15mg QHS). On ___, by the on call physician, she was started on a Humalog insulin sliding scale. Her fingersticks throughout the past 2 days have been as follows: ___ @ 0605: 278 -> 6u Humalin R ___ @ 0705: ate cinnamon raisin bagel/plain cream cheese ___ @ 0810: 441 ___ @ 0915: 435 ___ @ 1052: ___ @ 1430: 181 -> 2 units Humalin R ___ @ 1823: ___ @ 2107: 228 -> 4 units Humalin R --- ___ @ 0800: 257 (fasting) -> 6 units Humalin R ___ @ 1052: 346 (1 hour post-prandial) ___ @ 1200: ___ @ 1546: 297 -> 6 units Humalin R with lunch ___ @ 1839: 426 -> spoke to on call doctor, called into triage In triage, she reports feeling mild fatigue, feeling "warm" and having occasional RLQ tenderness to palpation only, none at rest. Otherwise, ROS is negative. Specifically, denies fevers, night sweats, chills, headache, sore throat, URI sx, CP, SOB, N, V, PO intolerance, dysuria, constipation, abdominal or pelvic pain. Denies vaginal bleeding, leakage of fluid. <PAST MEDICAL HISTORY> PNC: -___: ___ by LMP (___) - +UPT ___ in clinic - Prenatal labs: A+/Ab-/HIV-/R pending/RPRNR/HbsAg pending/ HCV Ab pending - Issues: 1. T2DM: on metformin, glipizide in early pregnancy -> started on insulin ___ A1c 8.0 (___). 2. cHTN: on lisinopril pre-/early pregnancy, discontinued ___. Booking BP: 130/84. Baseline PIH labs ___: Hct 33.9, Plt 363, BUN 12, Cre 0.9, ALT 16, AST 14, 24h urine collection in process. 3. Hemoglobin C trait 4. Hx C/S x2, abdominal myomectomy, plan for repeat cesarean for delivery. OB Hx: -G8P2 -TABx5, D&C -C/S x2: first for arrest of dilation, 8#14; second for GDMA2, potential macrosomia, 9#1 GYN Hx: 1. Fibroids, s/p abdominal myomectomy 2. History of menorrhagia and dysmenorrhea. 3. Hx HSV 3. Denies hx abnl paps or STIs PMH: 1. Type 2 diabetes: on metformin, glipizide in early pregnancy -> started on insulin ___. Dx ___. Reports history of intermittent periods of poor control requiring insulin. 2. cHTN: on lisinopril pre-/early pregnancy, discontinued ___. 3. Morbid obesity: BMI 37 4. Anemia PSH: 1. Breast reduction: ___. 2. Cesarean section: X 2, ___ FTP, ___ suspected macrosomia with ___ DM. 3. D&C: elective termination x 5. 4. Wisdom Teeth. Denies anesthestic complications. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: DM. Living. Father: ___ cancer, died when pt was ___. Living. Children: 10, 14, good health. Other: Many relativess with DM. <PHYSICAL EXAM> (on admission) VS: T 98.7, HR 107, BP 118/66, RR 20 Weight: 235 lbs Height: 66 inches Gen: NAD, AxO Abd: Soft, obese, NT, ND, no R/G Ext: no edema <PERTINENT RESULTS> ___ WBC-8.7 RBC-4.19 Hgb-10.8 Hct-32.2 MCV-77 Plt-366 ___ Neuts-67.7 ___ Monos-4.7 Eos-1.2 Baso-0.2 ___ Glu-386 BUN-11 Creat-0.8 Na-135 K-4.2 Cl-100 HCO3-25 ___ Calcium-8.9 Phos-2.9 Mg-1.9 ___ HCG-266 ___ HCG-743 ___ URINE Blood-TR Nitrite-NEG Protein-NEG Glucose->1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-5 ___ URINE pH-6 Hours-24 Volume-1700 Creat-111 TotProt-<6 ___ URINE 24Creat-1887 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> NPH 15u QHS, Humalin R sliding scale (BS 150-200: 2 units, 200-250: 4 units, 250-300, 6 units). [until ___, was on metformin, glipizide, lisinopril] <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY RX *PNV with ___ 27 mg iron-1 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills: *3 2. One Touch Ultra Test (blood sugar diagnostic) 1 test strip miscellaneous 7x/day RX *blood sugar diagnostic [One Touch Ultra Test] Use to check fingersticks as directed by endocrinologist 5x/day Disp #*120 Not Specified Refills: *6 3. One Touch UltraSoft Lancets (lancets) 1 lancet miscellaneous 7x/day RX *lancets [One Touch UltraSoft Lancets] Use to check fingersticks as directed by endocrinologist 5x/day Disp #*120 Not Specified Refills: *6 4. HumaLOG (insulin lispro) 100 unit/mL subcutaneous 3x/day RX *insulin lispro [Humalog] 100 unit/mL ___ units sc three times a day Disp #*1 Vial Refills: *3 RX *insulin lispro [Humalog] 100 unit/mL ___ units sc 3x/day Disp #*1 Vial Refills: *6 5. NPH insulin human recomb 100 unit/mL subcutaneous bid RX *NPH insulin human recomb [Humulin N] 100 unit/mL 54 units sc twice a day Disp #*1 Vial Refills: *6 6. NPH 54 Units Breakfast NPH 54 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *NPH insulin human recomb [Humulin N] 100 unit/mL 54 units sc 54 Units before BKFT; 54 Units before BED; Disp #*1 Vial Refills: *6 7. Insulin Syringe (insulin syringe-needle U-100) 1 mL 29 x ___ miscellaneous 5x/day RX *insulin syringe-needle U-100 [BD Insulin Syringe ___ 29 gauge x ___ use as directed to administer insulin 5x/day Disp #*120 Syringe Refills: *6 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> early pregnancy poorly controlled Type 2 diabetes <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the ___ service for glycemic control. While you were here, the doctors from ___ followed you and adjusted your insulin regimen. ___ from the ___ will call you with an appointment for tomorrow (___). Continue checking your fingersticks and taking insulin as instructed. Please call if you have any questions or concerns.
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Ms ___ was admitted at 4 weeks GA by ___ for inpatient diabetes control. She was seen by the ___ and ultimately titrated up to NPH 54 qam and 54qpm and an aggressive insulin sliding scale with adequate control. She was seen and counseled by nutrition. Her hcg rose appropriately suggesting viable IUP and plan made for viability US at ~7w GA. She was discharged in good condition with close follow-up.
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10204006-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> contact metal agent <ATTENDING> ___. <CHIEF COMPLAINT> ___ eval <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ yo G3P0 at 39 weeks and 5 days gestational age who presented for ___ evaluation after having mildly elevated blood pressures in clinic. She denied HA, visual changes, RUQ/epigastric pain. She denies contractions, vaginal bleeding, and loss of fluid. She had active fetal movement. <PAST MEDICAL HISTORY> PNC: -___: ___ by ___ -Labs: AB+(___ control NEG)/Ab-/HBsAg-/RPRNR/RI/HIV-/GBS- -Screening: LR ___! -FFS: placenta previa, marginal cord, otherwise WNL -GLT: elevated 1hr, passed 3hr -U/S: ___ previa resolved, 1707g, 31%ile OBHx: -TAB x2 GynHx: denies PMH: h/o hypogonadotropic hypogonadism with ___ brain MRI showing 3mm hyoenchancing focus withing pituitary gland suspicious for pituitary microadenoma PSH: D&C TAB x1, left breast biopsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Exam on discharge VS: Afebrile, Vital signs stable Neuro/Psych: no acute distress, Oriented x3, Affect Normal Heart: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 01: 50PM BLOOD WBC-8.2 RBC-3.90 Hgb-12.4 Hct-36.6 MCV-94 MCH-31.8 MCHC-33.9 RDW-12.7 RDWSD-43.8 Plt ___ ___ 01: 30AM BLOOD WBC-8.6 RBC-3.97 Hgb-12.5 Hct-37.7 MCV-95 MCH-31.5 MCHC-33.2 RDW-12.7 RDWSD-44.3 Plt ___ ___ 10: 55AM BLOOD Hct-33.2* ___ 01: 50PM BLOOD Plt ___ ___ 01: 30AM BLOOD Plt ___ ___ 01: 30PM BLOOD Plt ___ ___ 01: 50PM BLOOD Creat-0.6 ___ 01: 30AM BLOOD Creat-0.7 ___ 01: 30PM BLOOD Creat-0.6 ___ 01: 50PM BLOOD ALT-21 AST-19 ___ 01: 30AM BLOOD ALT-20 AST-20 ___ 01: 30PM BLOOD ALT-20 AST-23 ___ 01: 50PM BLOOD UricAcd-4.9 ___ 01: 30AM BLOOD UricAcd-4.9 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild/Fever NOT relieved by Ibuprofen 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Hydrocortisone (Rectal) 2.5% Cream ___ID: PRN hemorrhoid 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild/Fever RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *2 5. NIFEdipine (Extended Release) 30 mg PO BID RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p vaginal delivery s/p preeclampsia with severe features s/p varivax #1 ___ <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 take more than 4000mg acetaminophen (APAP) in 24 hrs Continue blood pressure medication as directed. Do not take more than 2400mg ibuprofen in 24 hrs Please call the ___ or Emergency Line if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting or any other concerns.
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Ms. ___ had a spontaneous vaginal delivery on ___ after induction of labor for preeclampsia with severe feature (BPs) and required fast-acting anti-hypertensives and 24 hours of magnesium postpartum and started on anti-HTN medications. The remainder of her postpartum course was uncomplicated except for elevated blood pressures. Her blood pressure medications were titrated to goal eventually. Her vaginal bleeding was within normal limits. She tolerated a regular diet, voided spontaneously without issue, and ambulated independently. By postpartum day 4 after vaginal delivery, she was deemed stable for discharge with a plan set for postpartum follow up.
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10205565-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet / sertraline <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingectomy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 3 para 2 with a history of increasing pelvic pressure, uterine pain, excessive vaginal bleeding in the face of a fibroid uterus and urinary incontinence. On ___ she underwent an endometrial biopsy that showed benign findings. On ___ she had an MR of her pelvis which showed an anteverted uterus that measured 8.8 x 9.2 x 13.9 cm. Post-surgical changes were seen from prior cesarean section. Multiple fibroids were seen throughout the uterus with heterogeneous enhancement, the largest of which was an intramural fibroid in the posterior right aspect of the fundus which measured 8.5 x 8.4 x 9.0 cm. This measured up to approximately 4 cm in ___. There was a submucosal fibroid in the anterior wall of the body of the uterus that measured 1.7 x 1.8 x 1.8 cm. The endometrium was normal in thickness for her age and measured 6 mm. The junctional zone was not thickened. The right ovary was visualized and appeared within normal limits the left ovary was visualized and appeared within normal limits. A corpus luteum cyst was seen in the left ovary. Trace pelvic free fluid was within physiologic limits. These findings were discussed with the patient and her questions were answered. <PAST MEDICAL HISTORY> PREVIOUS OB/GYN HISTORY: G3P2- hx c/s x 2 LAST PAP: ___ PLACE: ___ RESULT: neg Menarche 13 x 30 x 4 Medical history: BACK PAIN HX PPD POSITIVE KIDNEY STONES MILLIUM FIBROID UTERUS H/O GESTATIONAL DIABETES Surgical History: PRIOR CESAREAN SECTION x2 DILATION AND CURETTAGE MAB ARTHROSCOPY R knee <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, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 06: 45AM BLOOD WBC-8.4 RBC-3.38* Hgb-9.8* Hct-29.6* MCV-88 MCH-29.0 MCHC-33.1 RDW-15.5 RDWSD-49.4* Plt ___ ___ 10: 50AM BLOOD WBC-7.7 RBC-4.41 Hgb-12.7 Hct-37.6 MCV-85 MCH-28.8 MCHC-33.8 RDW-14.6 RDWSD-45.7 Plt ___ ___ 06: 45AM BLOOD Glucose-87 UreaN-9 Creat-0.5 Na-136 K-4.0 Cl-102 HCO3-26 AnGap-12 ___ 06: 45AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0 <MEDICATIONS ON ADMISSION> AMLODIPINE - amlodipine 10 mg tablet daily propranolol - 60 mg ER tablet daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 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. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO do not drive or drink alcohol while taking this medication RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 5. amLODIPine 10 mg PO DAILY 6. Ferrous Sulfate 325 mg PO DAILY 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. Propranolol LA 60 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY <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. * 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 a total abdominal hysterectomy and bilateral 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 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 dilaudid, acetaminophen, and ibuprofen. For her history of hypertension, she was continued on her home amlodipine and propranolol. 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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10207925-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> pelvic organ prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilation and curretage, lefort colpocleisis, perineorrhaphy, cystoscopy <HISTORY OF PRESENT ILLNESS> This is an ___ patient who presented with procidentia. She has had increasing pelvic discomfort, bleeding discharge and lower abdominal discomfort with advancing prolapse. She notes a large bulge in the vagina. She denies stress-type incontinence, but does have some urge incontinence. She does not go the bathroom much in the daytime, although she feels like she has to sometimes, but cannot get the urine out, however, at nighttime, she tends to void more. She denies history of recurrent bladder infections, hematuria, dysuria or kidney stones. She has no problems with constipation or fecal incontinence. She is not sexually active. Her husband has had prostate surgery. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Arthritis, asymptomatic gallstones, hypertension, low back pain, hyperparathyroidism, hypothyroidism, osteoporosis, spinal stenosis. Past Surgical History: 1. Parathyroidectomy 2. Cataract surgery. 3. Hip replacement and revision in ___ and ___ right knee replacement in ___. Past OB History: Three pregnancies, total three vaginal deliveries. Birth weight of largest baby delivered vaginally 8 pounds. No forceps or vacuum-assisted vaginal delivery. Past GYN History: Menopause at age ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father, brain tumor. Sister has some kind of cancer, unknown to the patient. <PHYSICAL EXAM> On exam, weight 203, height 5 feet 5 inches, blood pressure 131/69, pulse 63, temp 97.8. General: Well developed, well groomed, overweight. Psych: Oriented x 3, affect is normal. Skin: Warm and dry, no atypical lesions or rashes noted. Cardiovascular: Pulse normal rate and rhythm. Mild swelling in the lower extremities, ankles and feet. Pulmonary: Normal respiratory effort. No use of accessory muscles. Abdomen: Soft, nontender. No masses, guarding or rebound. No hepatosplenomegaly noted and no hernias. Neurologic: The bulbocavernosus reflex is positive. The anal wink is negative. Grossly normal sensation to light touch in the saddle region. Genitourinary: External genitalia is normal, no lesions or discharge. Urethral Meatus: No caruncle or prolapse. Urethra: Nontender, no masses or exudate. Bladder: Nonpalpable and nontender. Vagina is atrophic. There is procidentia. See POP-Q below. Cervix: Friable small ulceration, chronic irritation due to prolapse. The bimanual exam reveals no masses or tenderness of the adnexa or uterus. Anus and perineum also no masses or tenderness. Supine empty stress test was negative. Post-void residual volume obtained via catheterization was 270 mL. <PERTINENT RESULTS> ___ 07: 20AM BLOOD WBC-11.1*# RBC-3.95* Hgb-11.9* Hct-36.1 MCV-91 MCH-30.2 MCHC-33.1 RDW-14.8 Plt ___ ___ 07: 20AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-138 K-4.3 Cl-99 HCO3-27 AnGap-16 ___ Cystourethroscopy: Findings: 1. Urethra: Normal Atrophic 2. Bladder: No lesions, tumors, stones, foreign objects Mod trabeculations 3. Trigone: Normal 4. Ureteral orifices: Normal position bilaterally ___ Urodynamics Findings: 1. Complex Uroflow (performed using computerized uroflowmetry): Voided volume (ml): 521 Qmax (ml/sec): 24 Qave (ml/sec): 8 Flow time (min: sec): 67sec Flow pattern: Comments: Bell-shaped curve Continuous flow 2. Post void residual volume (ml): 150 3. There was a negative urinalysis. 4. Complex Cystometrogram: Performed using a 7 ___ dual lumen urethral catheter with simultaneous rectal catheter placement for abdominal pressure monitoring. Saline as instilled into the bladder at rate of 50 ml/min. First sensation (ml): 68 First desire (ml): 287 Normal desire (ml): Strong desire (ml): 486 Urgency (ml): Max Cystometric Capacity (ml): 601 Sensation: Normal Compliance: Normal Capacity: Normal Detrusor overactivity: some DO seen at capacity with movement of urethral catheter Leak Pressure Test: performed utilizing both urethral and rectal balloon catheters for simultaneous vesical and abdominal pressure monitoring. Straining maneuvers consisting of coughing and graded valsalva efforts were performed in an effort to induce leakage. Leakage was not seen. 5. Urethral pressure profiles: Performed using 7 ___ urethral catheter with a slow constant pull using a mechanical arm at a rate of 1mm/sec. MUCP average (cmH2O) with empty ___ MUCP average (cmH2O) with full bladder: 27 6. Pressure Flow Test: Performed using both bladder and rectal catheters for detrusor, vesical, and abdominal pressure monitoring. Infused volume (ml): 601 Attempt to void: yes Detrusor contraction: Present Qmax (ml/sec): 30 Qave (ml/sec): 10 Pdet at Qmax (cm H2O): 8.4 Max Pdet (cm H2O): 14 Voided volume (ml): 613 Catheterized PVR (cc): 50 Comments: no straining 7. EMG performed using perineal patch electrodes Recruitment: normal recruitment was seen corresponding with strain maneuvers. Activity during voiding: synergistic <MEDICATIONS ON ADMISSION> Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Patient. 1. Amitriptyline 10 mg PO HS 2. Amlodipine 5 mg PO DAILY 3. Carvedilol 12.5 mg PO qAM, 25 mg PO qPM 4. Hydrochlorothiazide 25 mg PO DAILY 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Pantoprazole Dose is Unknown PO Q24H <DISCHARGE MEDICATIONS> 1. Amitriptyline 10 mg PO HS 2. Amlodipine 5 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Carvedilol 12.5 mg qAM, 25 mg qPM 8. Acetaminophen 650 mg PO TID 9. Docusate Sodium 100 mg PO BID Patient may refuse. Hold if patient has loose stools. RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Tablet Refills: *0 10. TraMADOL (Ultram) 25 mg PO Q6H: PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills: *0 11. Nitrofurantoin (Macrodantin) 100 mg PO HS RX *Macrodantin 100 mg 1 capsule(s) by mouth HS Disp #*7 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse <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 You are going home with a foley catheter. Please take the antibiotic as prescribed while the catheter is in place in order to prevent urinary tract infection. 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 ___. 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. ___ underwent an uncomplicated D&C, ___ colpocleisis, perineorrhaphy, cystoscopy for prolapse; see operative report for details. She failed her voiding trial on postoperative day #1 with instillation of 300 cc and inability to void x2. She was discharged home with Foley in place and on macrodantin for prophylaxis. Dr. ___ will contact her with instructions regarding repeat voiding trial and catheter removal. She otherwise had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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10208304-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> short cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> Betamethasone for fetal lung maturity <HISTORY OF PRESENT ILLNESS> ___ G3P ___ with short cx referred from ATU for progressively shortening cx. On TV today, cx measures 4.4mm w/funelling. Prior eval on ___ was sig for CL 11mm. Pt denies ctx. +FM, no VB, no LOF. <PAST MEDICAL HISTORY> PMH: None All: NKDA PSH: None Gyn: ASCUS w/HR HPV ___ for Pap/colpo PP. OB: TAB x 1 SAB x 1 CS for fetal distress PNC: A+/RPR NR/Rub ___ neg/GLT nl/ FFS sig for echogenic cardiac focus and bilat choroid plexus cyst, pt declined quad and amnio <SOCIAL HISTORY> The pt emigrated from ___ in the setting of civil war and has successfully sought asylum here. She was accompanied by her husband. The remainder of her family remains in ___. Her daughter was born here. She is a ___ students. She depends on her husband's income who works at ___. She denies ___. <PHYSICAL EXAM> 76 107/67 18 NAD Clear RRR Gravid, NT SVE Deferred FHT 140, mod variability, no decel AGA Toco: no ctx BPP: ___, AFI 13.7, vtx <PERTINENT RESULTS> ___ 01: 49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD ___ 01: 49PM URINE COLOR-Yellow APPEAR-Hazy SP ___ Negative Urine Culture <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Short cervix <DISCHARGE CONDITION> Stable, without contractions but with shortened cervix!! <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> PLEASE MAINTAIN BEDREST!! Please call your doctor if you have contractions, leak of fluid, vaginal bleeding or if you don't feel your baby move.
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The patient was admitted for shortened cervix, which had been followed by ___ since her full fetal survey. She was started on 48h course of betamethazone, which she completed on day of discharge (HD#3). Fetal well being was evaluated by BPP and daily NSTs, which were all reassuring. Of note, the patient has b/l choroid plexus cyst & echogenic intercardiac focus, for which she has also seen MFM, and declined quad or an amnio. She was advised to stay hospitalized until 32wks GA, however, pt declined. Pt was offered to stay for at least a week by Dr. ___ pt declined. Pt reports difficult child care issues. Pt was thus advised by Dr. ___ to maintain complete bedrest and to have another cervical length check in one week (scheduled ___. Pt was seen by social work while inhouse, given her social history as well as her life stressors at present, including child care issues. Pt was discharged on HD#3, stable, per Dr. ___.
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10208304-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G3P2 at ___ WGA presents with vaginal bleeding. She has a known placenta previa diagnosed on routine full fetal survey. Today she felt like she had tightening like menstrual cramps for an hour and then had vaginal bleeding like a period for several hours soaking 2 pads in total. The bleeding has since resolved. The patient's first episode of vaginal bleeding was ___. She is currently reporting no contractions but felt some abdominal tightening earlier in the evening. She is feeling normal fetal movement and denies any other gushes of fluid. She denies dizziness, palpitations, shortness of breath, light headedness. <PAST MEDICAL HISTORY> PNC - Dating: by LMP: ___, ___: ___ tri u/s s=d - Labs: A+ / Ab- / Hg AA / HBV neg, RPR neg, Rub Immune/ HIV neg ___ / UCX neg / GC neg / CT neg - Screening: ERA/QUAD declined, FFS: normal, complete placenta previa - Issues: Complete placenta previa - h/o short cervix in previous pregnancy (4.1cm on FFS) - h/p LTCS x 2 with dense fundal adhesions on second c/s OBHx: LTCSx2, first for arrest of dilation. Both term. Second pregnancy c/b short cervix but delivered at term. GynHx: LSIL pap, HR HPV, no cervical surgery PMH: denies PSH: LTCS x2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 97.9, HR 64, RR 18, BP 100/63 GENERAL: NAD LUNGS: CTA bilaterally HEART: RRR ABDOMEN: soft, gravid, NT SSE: plum sized clot evacuated from vaginal vault consistent with previous bleeding. No active bleeding from the os. Os is closed. TAUS: good fluid and movement. Breech. EFW 654g 55% FHT: 140 TOCO: irritable <PERTINENT RESULTS> ___ WBC-6.7 RBC-4.60 Hgb-12.1 Hct-38.0 MCV-83 Plt-184 ___ WBC-7.4 RBC-3.51 Hgb-9.7 Hct-28.7 MCV-82 Plt-169 ___ WBC-5.3 RBC-3.53 Hgb-9.6 Hct-28.9 MCV-82 Plt-170 ___ ___ PTT-29.0 ___ ___ ___ PTT-28.7 ___ ___ Creat-0.5 Glucose-127 ___ URINE RBC-0 WBC-4 Bacteri-MANY Yeast-NONE Epi-31 ___ URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> placenta previa ___ bleed <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Bed rest with bathroom privileges
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___ yo G3P2 with known placenta previa admitted at 23w4d with vaginal bleeding. On arrival to labor and delivery, she was hemodynamically stable with no active bleeding. CBC and coagulation studies were stable and she is Rh positive. She had some irritability on toco, however, her cervix appeared closed visually and the irritability resolved. Fetal testing was reassuring. She was admitted for hospitalized bedrest and close observation. At 24 weeks gestation, she received a course of betamethasone for fetal lung maturity and the NICU was consulted. On hospital day #3, she had a small episode of spotting. Following this episode, she had no further bleeding for seven days. She had no contractions on toco and fetal testing remained reassuring. She was discharged home at that time in stable condition and will continue bedrest at home. Of note, social services met with her during this admission given her difficult social stressors.
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10208304-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> -term pregnancy w/ known complete placenta previa, 2 prior c/s -hypotension, diffuse bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> -classical c/section -supracervical hysterectomy -cystoscopy -fascial closure <HISTORY OF PRESENT ILLNESS> Pre-op: ___ G5P2 w/ history of prior c/s x 2 w/ known complete placenta previa and dense fundal adhesions noted at prior c/s for elective repeat cesarean section @ 37weeks via midline incision. Feels well, denies LOF, further vaginal bleeding, ctx. +AFM. On Admission to ICU: HPI: ___ F with vaginal bleeding beginning approximately 20 weeks into her pregnancy with known placenta previa diagnosed on routine full fetal survey who is s/p planned classical (midline) c-section at 37 weeks at noon today ___. EBL for the case was 1000cc. Inititally upon arrival to PACU the patient was stable, with a Hct of 36. She became hypotensive to the ___, but pressures improved with neo and volume. However, her abdomen began to become distended, so she was brought back to the OR for ex lap given concern for intra-abdominal bleed. Only about 100-200cc were present in the abdomen, but soon after entering the OR, she began to have extensive vaginal bleeding. She had a supracervical hysterectomy. Given adhesion of the uterus to the bladder, urology was called during the case. Cystoscopy revealed bladder edema, no obvious perforation, but poor visulalization of ureters so can't completely rule out. Labs began to reflect DIC: Plts 115, fibrinogen 150s (<300 is low in pregnancy), INR 1.5. Hct nadir 16. Massive transfusion initiated, recieved: 16 FFP, 13 pRBCs, 5 plts, 4 cyro, 10L IVF. Total EBL 4L, outs 5150. Trauma surgery unable to pack her abdomen ___ bowel edema. Abdomen packed with surgical towels, covered with Ioban with NG tube in place acting as a wound vac. Got 3 doses of vancomycin and 1 dose of gent. Continunes to be intubated post-op, had acidemia to pH 7.02. pH 7.19 prior to arrival to ___. Anesthesia noted that the patient was a difficult intubation. Had a-line and 3 PIVs (2 18G and 1 18G) in place. Labs prior to transfer: Hct 34.9. Fibro 277, plts 167. <PAST MEDICAL HISTORY> PNC - Dating: by LMP: ___, ___: ___ tri u/s s=d - Labs: A+ / Ab- / Hg AA / HBV neg, RPR neg, Rub Immune/ HIV neg ___ / UCX neg / GC neg / CT neg - Screening: ERA/QUAD declined, FFS: normal, complete placenta previa - Issues: Complete placenta previa - h/o short cervix in previous pregnancy (4.1cm on FFS) - h/p LTCS x 2 with dense fundal adhesions on second c/s OBHx: TAB x1, SAB x1 LTCSx2, first for arrest of dilation. Both term. Second pregnancy c/b short cervix but delivered at term. GynHx: LSIL pap, HR HPV, no cervical surgery PMH: denies PSH: LTCS x2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Pre-op: NAD CTA RRR Abd soft, gravid, NT Ext w/ no C/E On Admission to ICU: <PHYSICAL EXAM> VS: Temp: 93.1F BP: 164/98 HR: 59 RR: 16 O2sat 100% GEN: intubated, sedated HEENT: pupils round and equal, sclera and conjunctiva clear B/L, edematous tongue RESP: diffuse weezes throughout lung fields CV: RR, S1 and S2 wnl, no m/r/g ABD: distended, +BS, midline incision packed, iodoform and NG tubing in place EXT: no c/c/e Back: epidural catheter in place <PERTINENT RESULTS> ECHO ___: Normal global and regional biventricular systolic function. Cystogram ___: Normal cystogram. Specifically, no leak ___ 11: 21AM BLOOD WBC-6.2 RBC-4.38 Hgb-10.2* Hct-33.0* MCV-75* MCH-23.4* MCHC-31.1 RDW-19.3* Plt ___ ___ 10: 50AM BLOOD WBC-6.8 RBC-4.67 Hgb-10.7* Hct-36.0 MCV-77* MCH-22.9* MCHC-29.7* RDW-19.8* Plt ___ ___ 03: 20PM BLOOD WBC-6.0 RBC-3.28*# Hgb-7.8*# Hct-25.0*# MCV-76* MCH-23.7* MCHC-31.0 RDW-19.6* Plt ___ ___ 06: 41PM BLOOD WBC-7.4 RBC-2.31*# Hgb-6.2* Hct-19.1* MCV-83# MCH-26.9*# MCHC-32.6 RDW-18.0* Plt ___ ___ 08: 09PM BLOOD WBC-6.0 RBC-3.41*# Hgb-10.0*# Hct-30.4*# MCV-89 MCH-29.4 MCHC-33.0 RDW-15.1 Plt ___ ___ 08: 46PM BLOOD WBC-6.0 RBC-3.93* Hgb-11.6* Hct-34.9* MCV-89 MCH-29.7 MCHC-33.4 RDW-14.7 Plt ___ ___ 11: 41PM BLOOD WBC-5.5 RBC-5.29# Hgb-15.4# Hct-44.8# MCV-85 MCH-29.1 MCHC-34.3 RDW-15.2 Plt ___ ___ 03: 01AM BLOOD WBC-4.6 RBC-5.23 Hgb-15.4 Hct-43.4 MCV-83 MCH-29.5 MCHC-35.6* RDW-14.3 Plt ___ ___ 10: 05AM BLOOD WBC-6.2 RBC-4.69 Hgb-14.0 Hct-39.1 MCV-83 MCH-29.8 MCHC-35.8* RDW-14.7 Plt ___ ___ 04: 13AM BLOOD WBC-8.1 RBC-4.55 Hgb-13.6 Hct-38.4 MCV-84 MCH-30.0 MCHC-35.5* RDW-15.7* Plt ___ ___ 07: 30PM BLOOD WBC-9.3 RBC-4.88 Hgb-14.3 Hct-41.7 MCV-85 MCH-29.3 MCHC-34.3 RDW-15.7* Plt ___ ___ 04: 09AM BLOOD WBC-8.8 RBC-4.95 Hgb-14.9 Hct-42.2 MCV-85 MCH-30.1 MCHC-35.3* RDW-15.6* Plt ___ ___ 03: 47AM BLOOD WBC-7.3 RBC-4.71 Hgb-13.7 Hct-40.0 MCV-85 MCH-29.2 MCHC-34.4 RDW-14.9 Plt ___ ___ 10: 50AM BLOOD ___ PTT-28.2 ___ ___ 03: 20PM BLOOD ___ PTT-39.6* ___ ___ 06: 41PM BLOOD ___ PTT-61.2* ___ ___ 08: 09PM BLOOD ___ PTT-45.6* ___ ___ 08: 46PM BLOOD ___ PTT-36.0* ___ ___ 11: 41PM BLOOD ___ PTT-34.3 ___ ___ 11: 41PM BLOOD Plt ___ ___ 10: 05AM BLOOD ___ PTT-28.1 ___ ___ 03: 04PM BLOOD ___ PTT-28.5 ___ ___ 07: 46PM BLOOD ___ PTT-31.0 ___ ___ 02: 48PM BLOOD ___ PTT-29.3 ___ ___ 07: 30PM BLOOD ___ PTT-29.2 ___ ___ 02: 17AM BLOOD ___ PTT-31.7 ___ ___ 04: 09AM BLOOD ___ PTT-23.9 ___ ___ 10: 50AM BLOOD ___ ___ 03: 20PM BLOOD ___ ___ 06: 41PM BLOOD ___ ___ 08: 09PM BLOOD ___ ___ 08: 46PM BLOOD ___ 11: 41PM BLOOD ___ ___ 03: 01AM BLOOD ___ ___ 07: 46PM BLOOD ___ ___ 04: 13AM BLOOD ___ ___ 02: 48PM BLOOD ___ ___ 02: 17AM BLOOD ___ ___ 04: 09AM BLOOD ___ ___ 11: 41PM BLOOD Glucose-154* UreaN-4* Creat-0.6 Na-144 K-3.8 Cl-106 HCO3-20* AnGap-22* ___ 03: 01AM BLOOD Glucose-94 UreaN-5* Creat-0.6 Na-146* K-3.0* Cl-108 HCO3-24 AnGap-17 ___ 10: 05AM BLOOD Glucose-74 UreaN-7 Creat-0.7 Na-145 K-3.8 Cl-109* HCO3-30 AnGap-10 ___ 02: 44PM BLOOD Glucose-62* UreaN-10 Creat-0.7 Na-142 K-3.6 Cl-113* HCO3-24 AnGap-9 ___ 07: 30PM BLOOD Glucose-91 UreaN-9 Creat-0.7 Na-141 K-3.9 Cl-113* HCO3-21* AnGap-11 ___ 04: 09AM BLOOD Glucose-105* UreaN-12 Creat-0.8 Na-142 K-4.3 Cl-107 HCO3-25 AnGap-14 ___ 04: 58PM BLOOD Glucose-105* UreaN-22* Creat-0.7 Na-143 K-3.8 Cl-105 HCO3-28 AnGap-14 ___ 03: 47AM BLOOD Glucose-124* UreaN-25* Creat-0.7 Na-145 K-4.0 Cl-108 HCO3-29 AnGap-12 ___ 11: 41PM BLOOD ALT-20 AST-28 LD(LDH)-326* AlkPhos-89 TotBili-5.6* ___ 10: 05AM BLOOD ALT-14 AST-26 LD(LDH)-275* AlkPhos-66 TotBili-9.7* DirBili-1.9* IndBili-7.8 ___ 04: 13AM BLOOD ALT-49* AST-119* LD(___)-357* AlkPhos-70 TotBili-5.8* DirBili-1.7* IndBili-4.1 ___ 03: 12AM BLOOD ALT-28 AST-33 LD(LDH)-355* AlkPhos-100 TotBili-6.2* DirBili-4.2* IndBili-2.0 ___ 03: 47AM BLOOD ALT-35 AST-35 LD(LDH)-350* AlkPhos-92 TotBili-3.7* ___ 11: 41PM BLOOD Calcium-12.9* Phos-4.7* Mg-1.1* UricAcd-2.9 ___ 03: 01AM BLOOD Calcium-11.8* Phos-3.8 Mg-2.2 ___ 10: 05AM BLOOD Calcium-10.0 Phos-5.3* Mg-1.7 ___ 04: 13AM BLOOD Albumin-2.5* Calcium-8.2* Phos-5.0* Mg-1.5* ___ 07: 30PM BLOOD Calcium-7.8* Phos-5.1* Mg-2.0 ___ 04: 09AM BLOOD Calcium-8.7 Phos-4.8* Mg-1.8 ___ 03: 12AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.7 ___ 04: 58PM BLOOD Calcium-8.6 Phos-3.7 Mg-2.3 ___ 11: 41PM BLOOD Hapto-105 ___ 03: 01AM BLOOD Hapto-70 ___ 03: 04PM BLOOD Hapto-35 ___ 03: 12AM BLOOD Hapto-223* ___ 04: 45PM BLOOD Type-ART pO2-193* pCO2-36 pH-7.36 calTCO2-21 Base XS--4 ___ 06: 58PM BLOOD Type-ART FiO2-60 pO2-185* pCO2-39 pH-7.27* calTCO2-19* Base XS--8 Intubat-INTUBATED Vent-CONTROLLED ___ 07: 40PM BLOOD Type-ART pO2-162* pCO2-39 pH-7.25* calTCO2-18* Base XS--9 ___ 08: 22PM BLOOD Type-ART FiO2-50 pO2-106* pCO2-67* pH-7.02* calTCO2-19* Base XS--15 Intubat-INTUBATED Vent-CONTROLLED ___ 09: 01PM BLOOD Type-ART pO2-101 pCO2-62* pH-7.06* calTCO2-19* Base XS--13 ___ 09: 18PM BLOOD Type-ART pO2-193* pCO2-45 pH-7.19* calTCO2-18* Base XS--10 ___ 11: 46PM BLOOD Type-ART pO2-259* pCO2-32* pH-7.41 calTCO2-21 Base XS--2 ___ 03: 15AM BLOOD Type-ART Temp-35.7 pO2-138* pCO2-29* pH-7.54* calTCO2-26 Base XS-3 ___ 06: 24AM BLOOD Type-ART pO2-208* pCO2-40 pH-7.44 calTCO2-28 Base XS-3 ___ 10: 30AM BLOOD Type-ART pO2-189* pCO2-39 pH-7.47* calTCO2-29 Base XS-5 ___ 08: 41AM BLOOD Type-ART Temp-37.7 PEEP-0 pO2-161* pCO2-42 pH-7.33* calTCO2-23 Base XS--3 Intubat-INTUBATED Vent-SPONTANEOU ___ 06: 57PM BLOOD Type-ART pO2-115* pCO2-41 pH-7.43 calTCO2-28 Base XS-3 ___ 12: 05AM BLOOD Type-ART Temp-37.7 FiO2-40 pO2-110* pCO2-42 pH-7.41 calTCO2-28 Base XS-1 Intubat-NOT INTUBA ___ 03: 18AM BLOOD Type-ART Temp-37.2 Rates-/___ FiO2-40 pO2-140* pCO2-39 pH-7.46* calTCO2-29 Base XS-4 Intubat-NOT INTUBA Comment-SIMPLE FAC ___ 10: 50AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR ___ 09: 37AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-4* pH-5.5 Leuks-SM <MEDICATIONS ON ADMISSION> PNV, iron <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp: *20 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 4. 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 With Service Facility: ___ <DISCHARGE DIAGNOSIS> classical c/section for previa supracervical hysterectomy DIC <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per instruction sheet wound vac to continue at home
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L&D Course: The patient is a ___ gravida 5, para 2 who presented to Labor & Delivery for a planned cesarean delivery at term given a history of a posterior placenta previa in this pregnancy. Her c-section on ___ was uncomplicated. For full details please see the operative report. In the PACU, the patient was found to have persistent hypothermia and hypotension. She was initially treated with pharmacologic pressure support and transfusion, however, she developed a tense abdomen and abdominal pain concerning for an intra-abdominal bleed and was taken back to the OR where she underwent exploratory laparotomy, supracervical hysterectomy, cystoscopy, bladder oversew, and temporary abdominal closure with intra-abdominal packing for postpartum hemorrhage from the uterus and surgical incision with disseminated intravascular coagulation (DIC). MFM, Gyn/Onc, Urology and Trauma Surgery were all consulted intraoperatively. For full details please see the operative report. The patient was transferred to the SICU post-operatively. ICU Course: A/P: ___ F with known placenta previa with vaginal bleeding after midline c-section, now s/p hysterectomy. Massive transfusion protocol initiated for DIC. . # Vaginal bleeding/DIC: Hct stable and coagulopathy greatly improved after massive transfusion. Hct on arrival to unit 44.8. Hct remained stable during her ICU stay. Fibrinogen trended upwards, haptoglobin was stable. Hyperbilirubinemia persisted, which when first fractionated was mainly indirect and thought to be evidence of some hemolysis in the setting of massive transfusion. . # Acidemia: CXR showed diffuse, fluffy infiltrates, likely edema but could be consistent with ARDS. ABG on arrival to floor 7.41/32/259/21. Pt was diuresed intermittently with small doses of Lasix while in the ICU. She remained on CMV until after abdominal closure. She was able to be weaned to pressure support. She was extubated on ___. She initially had some stridor and required steroids and inhaled racemic epinephrine. Her respiratory status improved. At the time of transfer to OB/Gyn floor, pt was saturating mid-90s on 2L nasal cannula without complaints of SOB. . # hypertension: Not accompanied by tachycardia. LFTs and urine protein:Cr were not evident of pre-ecclampsia/HEELP syndrome. CBC and uric acid (3.7) already checked. Resolved without any intervention. . # Bladder edema: Repeat cystoscopy at time of abdominal closure was able to visualize ureters. The patient had an echocardiogram on ___ which showed normal LVEF at 55%. On ___, the patient underwent exploratory laparotomy, takedown of a temporary abdominal closure, fascial closure, and cystoscopy. For full details please see the operative report. Course on the post-partum floor: Pt transferred from the ICU to the post-partum floor on ___. On the post-partum floor she was hemodynamically stable and was weaned off of oxygen. The patient was seen by the wound care team on ___. She underwent dressing changes twice a day until a wound vacuum was approved and placed on the day of discharge. She was discharged home with the wound vac and ___ services. On ___ the patient's NGT was discontinued and her diet was advanced as tolerated. She was discharged home on a regular diet. Pain initially controlled w/ IV pain medication and she was transitioned to oral pain medication which she was discharged home on. On ___ she underwent a cystogram per urology which was normal with no leak. Her foley was then removed and she was able to void spontaneously. The patient was followed by social work during her stay and was evaluated by psychiatry on ___ and diagnosed with adjustment disorder/difficulty coping. The patient was also evaluated and followed by physical therapy who signed off prior to discharge as the patient was functioning independently. The patient was discharged home on post-operative day ___ in stable condition with ___ services for wound care.
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10208740-DS-21
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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> EUA, TOTAL ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGECTOMIES <HISTORY OF PRESENT ILLNESS> Cc: ___ fibroid uterus LMP ___ HPI: Ms. ___ is a ___ gravida 0 with worsening symptomatic fibroid uterus. She has heavy vaginal bleeding during menses only. She denies intermenstrual bleeding or postcoital bleeding however, she endorses significant dysmenorrhea and dyspareunia. Patient states that she does not desire future childbearing. She is a lesbian woman and is not interested in IUI or IVF to achieve pregnancy. Patient would entertain multiple myomectomy if I could guarantee that she would not have recurrence of uterine fibroids requiring treatment. Of course I let her know that I could not guarantee that. On ___ at the ___ she had a pelvic ultrasound which showed an enlarged uterus measuring 18.2 x 7.5 x 18.4 cm. The endometrial stripe measured 8 mm. There was a 13.7 x 7.0 x 14.8 cm subserosal fibroid in the uterine body and fundus causing a mass-effect on the superior aspect of the uterus and extending up into the abdomen. Small intramural fibroids also noted. The right ovary measured 3.9 x 3.2 x 3.8 cm. The left ovary was less clearly visualized but appeared to measure 4.9 x 4.8 x 3.6 cm. There was small amount of free fluid in the cul-de-sac. Labs in ___ were reviewed which included normal CBC, Chem-7 and TSH, etc. Labs performed at ___ included normal liver function tests <PAST MEDICAL HISTORY> OB/GYN history: Menarche at 11, cycles monthly, bleeds heavily for 4 days Lesbian and is currently sexually active She has been exposed to sperm in the past and in ___ had gonorrhea and chlamydia She denies pelvic inflammatory disease She has never had a pregnancy Medical history: ASTHMA BIPOLAR AFFECTIVE DISORDER HEMOGLOBIN C TRAIT HIDRADENITIS IRON DEFICIENCY CONSTIPATION FIBROIDS ANXIETY Surgical History: None Medications (Last Review: ___ by ___, MD): Active Medication list as of ___: Medications - Prescription CLINDAMYCIN PHOSPHATE - clindamycin phosphate 1 % topical solution. apply to affected area twice a day CYCLOBENZAPRINE - cyclobenzaprine 10 mg tablet. 1 tablet(s) by mouth Daily - (Prescribed by Other Provider) LINACLOTIDE [LINZESS] - Linzess 145 mcg capsule. 1 capsule(s) by mouth Once daily with meals NAPROXEN - naproxen 500 mg tablet. 1 tablet(s) by mouth Daily, as needed - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth once a day on an empty stomach, half hour before eating SERTRALINE - sertraline 50 mg tablet. 1 tablet(s) by mouth Daily - (Prescribed by Other Provider) <ALLERGIES> No known drug allergies <SOCIAL HISTORY> <SOCIAL HISTORY> Country of Origin: ___ Marital status: Single Children: No Lives with: Alone Lives in: Rented room Work: ___ Multiple partners: ___ ___ activity: Present Sexual orientation: Female Sexual Abuse: Past Domestic violence: Denies Contraception: None Tobacco use: Former smoker Year Quit: ___ months without smoking Years Since 0 Quit: Alcohol use: Present, during holidays only drinks per week: <1 Recreational drugs smokes MJ every day to help with pain <FAMILY HISTORY> Family History (Last Verified ___ by ___ ___, MD): Father ___ ___ DIABETES MELLITUS HYPERTENSION MILD HEART ATTACK Mother Living KNEE SURGERY Sister Living Brother Living Comments: Grandmother had lung cancer. One aunt with bone cancer or breast cancer. No heart disease. <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, appropriately tender, no rebound/guarding; incision clean, dry, intact Ext: no tenderness to palpation <PERTINENT RESULTS> N/A <MEDICATIONS ON ADMISSION> flexeril prn, linzess, naproxen, omeprazole 20mg daily, sertraline 50mh daily All: NKDA <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever 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: *1 3. 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 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Do not drive or drink alcohol while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 5. Omeprazole 20 mg PO DAILY 6. Sertraline 50 mg PO DAILY <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. * 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 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 total abdominal hysterectomy and 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 a Dilaudid PCA and scheduled IV toradol/Tylenol . On post-opeative day 1, she spiked a temperature to 100.4 in the setting of likely atelectasis. She defervesced spontaneously with coughing, and remained afebrile for the remainder of her admission. On post-operative day 2, 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/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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10208867-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Adhesive Tape <ATTENDING> ___. <CHIEF COMPLAINT> Fever, wound infection <MAJOR SURGICAL OR INVASIVE PROCEDURE> Wound opened and debrided <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old G1P1 POD# ___ s/p Primary LTCS after failed VAVD who presents to Gyn Triage with a concern for a wound infection. Patient seen in the office today by Dr. ___ prescribed ___ for which she received 1 dose thus far. She comes in to Triage after developing a fever to 101.3 this evening. Patient reports worsening skin erythema, swelling and serosanguinous discharge from her incision. Patient tolerating PO and reports minimal abdominal pain. No changes in bowel or bladder function. Of note, patient and infant's initial MRSA screen negative <PAST MEDICAL HISTORY> OBHx: G1P1 Primary LTCS after failed VAVD PMH: Denies PSH: Breast Bx <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PERTINENT RESULTS> ___ 07: 16PM WBC-9.1 RBC-3.24* HGB-9.4* HCT-27.6* MCV-85 MCH-29.1 MCHC-34.2 RDW-13.4 ___ 07: 16PM NEUTS-78.2* LYMPHS-15.5* MONOS-5.3 EOS-0.7 BASOS-0.3 ___ 07: 16PM PLT COUNT-376# Wound culture ___: GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. WOUND 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.. ANAEROBIC CULTURE (Preliminary): ANAEROBIC GRAM NEGATIVE ROD(S). MODERATE GROWTH. BETA LACTAMASE NEGATIVE. BCX ___: NGTD <MEDICATIONS ON ADMISSION> Motrin, Tylenol, Percocet, Colace, PNV, Fish Oil <DISCHARGE MEDICATIONS> 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp: *20 Tablet(s)* Refills: *2* 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for prior to dressing change. Disp: *20 Tablet(s)* Refills: *0* 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> wound infection <DISCHARGE CONDITION> improved <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Given
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Ms. ___ was admitted from GYN triage with a wound infection. The wound was opened, cultures were obtained, and then it was debrided. She was started on IV vancomycin, clindamycin, and ciprofloxacin. She had BID dressing changes with debridement when necessary. An infectious disease consult was obtained to help guide antibiotic therapy. Given blood cultures remained negative, patient defervesced, and wound culture with mixed bacteria but no MRSA, she was transitioned to oral ciprofloxacin and clindamycin. She was discharged on HD #5 with ___ services to complete dressing changes twice daily with plan for wound vac to be placed as an outpatient.
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10210966-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain and fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> -CT guided drainage of tuboovarian abscess -repair of right carotid artery and right internal jugular vein -exploratory laparotomy, lysis of adhesions, bilateral salpingo-oophorectomy, repair of cecal enterotomy, rigid proctoscopy, dilation and currettage <HISTORY OF PRESENT ILLNESS> ___ year old G0 with history of endometriosis who originally presented to ___ ___ with a two day history of left lower back pain, LLQ pain, fevers and vomiting. An ultrasound showed bilateral endometriomas and she was started on Amp/Gent/Clinda. WBC count on admission 15.4 and Tmax was 103.2 on ___. On HD#5 she was transferred to ___ for further management. Upon transfer she continued to have sharp/crampy left back pain and LLQ pain, nausea and fevers. Review of imaging was felt consistent with either an infected cyst vs tubo-ovarian abscess in her pelvis. <PAST MEDICAL HISTORY> PSH: LSC right ovarian cystectomy (endometrioma) GynHx: G0, regular menses, +h/o abnormal Pap s/p LEEP ___ years ago. Denies h/o STI's. +severe endometriosis. +infertility <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother deceased of uterine CA Denies any other family members with breast, ovarian, uterine cancers. <PHYSICAL EXAM> Admission exam: VS on admission: T 100.9 BP 103/69 HR 98 RR 18 sat 98%RA A&O, NARD, lying comfortably on bed Lungs CTAB Heart RRR Abd soft, mildly distended, TTP LLQ>RLQ, no rebound, +BS SSE normal mucosa, moderate discharge from os, no bleeding, GC/CT collected BME no CMT, uterus AV, normal sized, no fundal tenderness, bilateral adnexal fullness and TTP with vol guarding of adnexae, L>R Discharge exam: afebrile, VSS NAD, A/O x 3 RRR CTAB abdomen soft, ND, appropriately tender, incision closed using already in place prolene and staples, no erythema/induration ext NT, ND <PERTINENT RESULTS> Admission labs: ___ 03: 47PM BLOOD WBC-11.2* RBC-3.59* Hgb-9.5* Hct-28.6* MCV-80* MCH-26.5* MCHC-33.3 RDW-13.5 Plt ___ ___ 03: 47PM BLOOD Neuts-79.9* Lymphs-12.7* Monos-6.2 Eos-1.0 Baso-0.2 ___ 03: 47PM BLOOD ___ PTT-35.2* ___ ___ 03: 47PM BLOOD Glucose-101* UreaN-4* Creat-0.7 Na-139 K-3.8 Cl-101 HCO3-31 AnGap-11 ___ 03: 47PM BLOOD Calcium-8.5 Phos-4.2 Mg-2.1 . Other labs: ___ 07: 15AM BLOOD HCG-<5 ___ 10: 37AM BLOOD CRP-296.8* ___ 08: 34PM BLOOD ESR-95* ___ 03: 47PM BLOOD ALT-15 AST-22. . Microbiology: GC/CT negative UCx ___ negative BCx ___ negative Abscess cx: _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>___BDOMEN/PELVIS W/CONTRAST ___: 1. Bilateral adnexal cystic masses. Given prior stated history, right solitary adnexal mass appears most consistent with endometrioma. 2. The more complex left-sided mass is indeterminate in origin. This may represent tubo-ovarian abscess though the absence of surrounding inflammatory change is unusual but might be due to the recent antibiotic treatment. Differential also includes complex endometriotic cysts. 3. The abnormal appearance of the left fallopian tube is difficult to interpret, given the known prior history of left hydrosalpinx. . CT GUIDANCE DRAINAGE ___: Status post CT-guided drainage/aspiration of left ovarian complex fluid collection, with aspiration of approximately 20 cc of purulent material, concerning for tubo-ovarian abscess. Drainage catheter was removed, as it appeared to have become clotted, and would not flush. . CHEST PORT. LINE PLACEMENT ___: No previous images. Right IJ catheter extends to the upper portion of the SVC. No evidence of pneumothorax. There is prominence of somewhat indistinct pulmonary vessels, suggesting overhydration related to the large amount of fluid given to this patient with sepsis. . ABDOMEN (SUPINE ONLY) IN O.R. ___: Two views of the abdomen were obtained. The distal aspect of a nasogastric tube is seen extending into the expected location of the stomach. The patient's known JP drain is seen extending into the left pelvis, crossing midline into the right lower quadrant. The very distal tip of a central venous catheter is seen projecting over the mid SVC, not optimally evaluated. No additional radiopaque foreign body is seen. <MEDICATIONS ON ADMISSION> Tylenol PRN <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp: *10 Tablet(s)* Refills: *0* 5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp: *10 Tablet(s)* Refills: *0* 6. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> -tubo-ovarian abscess -sepsis -vascular injury in the neck <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. * Your stitches and staples will be removed at your follow-up visit.
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Ms. ___ was transferred from an OSH to ___ secondary to concern for tubo-ovarian abscess. Once transferred she was started on ampicillin, gentamicin, and clindamycin. Her imaging was reviewed and thought consistent with infected endometrioma or tubo-ovarian abscess. She subsequently had CT guided percutaneous drainage of 20 cc purulent fluid on her left side. Despite ___ drainage and triple antibiotic therapy she continued to be febrile. Blood and cultures continued to be negative. On hospital day 3 she became hypotensive and tachycardic consistent with sepsis. She was aggressively fluid resuscitated and transferred to the medical ICU. A central line was placed. The decision was then made to proceed to the OR for exlap given failed medical management. In the operating room, her central line was found to be in the carotid artery. Vascular surgery was called and prior to proceeding with the exploratory laparotomy, her IJ and carotid artery were repaired. On entry into the abdomen there was no frank pus. She was found to have enlarged multicystic ovaries with endometriomas and purulent cavities bilaterally which were densely adherent to uterus and bowel. A bilateral salpingo-oophorectomy was performed and the pelvis was irrigated. She also had repair of a cecal enterotomy. The fascia was closed however the skin was left open. During the case she received 3 units of PRBC's as well as 2.5L crystalloid. Her blood pressure and tachycardia improved significantly. Postoperatively, Ms. ___ recovery was uncomplicated. She was monitored in the ICU postop briefly before being transferred to the floor. Given likely gram negative sepsis,her antibiotics were switched to vanc/meropenem. She remained afebrile and eventually her regimen was tailored to ctx/flagyl based on the culture results. She was discharged with a 10 day course of PO cipro/flagyl. Ms. ___ NG tube was removed on POD 1 and her diet was advanced slowly. By discharge on POD 5, she was tolerating a regular diet, pain was controlled with PO medications, she was voiding spontaneously, and ambulating. Her wound was closed prior to discharge. Discussed briefly need for hormone replacement therapy given bilateral salpingo-oophorectomy.
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10212003-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 @ 25w6d re-presents after discharge earlier today with right sided abdominal pain. Pt had been admitted with the same pain, had MRI that ruled out acute emergent causes of pain but revealed a 3mm renal calculi, which was felt to be the etiology of this pain. She was tolerating PO dilaudid on discharge, but represents tonight because she is unable to tolerate PO meds due to nausea. Severity and quality of pain is unchanged. Received SC dilaudid with improved relief. No current nausea or vomiting. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ reports nl ERA, FFS, labs having GLT in 2wks GYNECOLOGIC HISTORY - denies abnl pap or STI - denies endometriosis, fibroids, or infertility PAST MEDICAL HISTORY - interstitial cystitis in the past but no recent flares SURGICAL HISTORY - wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 99.4, HR 80, RR 20, BP 94/50 GENERAL: appears comfortable ABDOMEN: soft, tender to palpation in RLQ, right flank. No LLQ pain. No rebound/guarding. EXTREMITIES: no C/C/E SVE deferred TOCO: no ctx FHT: 150/mod var/+accels/no decels (some areas of discontinuity), AGA <PERTINENT RESULTS> ___ WBC-7.8 RBC-3.66 Hgb-10.3 Hct-31.3 MCV-85 Plt-309 ___ WBC-10.8 RBC-3.36 Hgb-9.5 Hct-28.6 MCV-85 Plt-278 ___ WBC-6.0 RBC-2.82 Hgb-7.9 Hct-24.1 MCV-85 Plt-227 ___ Glucose-89 UreaN-10 Creat-0.6 Na-137 K-4.0 Cl-105 HCO3-22 ___ ALT-7 AST-13 AlkPhos-70 TotBili-0.2 Lipase-37 Albumin-3.6 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE CULTURE (Final ___: NO GROWTH <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Disp: *30 Tablet, Rapid Dissolve(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 26+1 weeks gestation nephrolithiasis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> stay well hydrated. Take pain medication and anti-nausea medication as needed. call your doctor with worsening of pain not relieved by medication, fevers >100.4, persistent nausea/vomiting, leaking of fluid, vaginal bleeding, regular or painful contractions, or decreased fetal movement. Continue to strain all urine. Save any stones passed.
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___ y/o G1 readmitted at 25+5 weeks with right sided abdominal/flank pain; recently diagnosed with right nephrolithiasis. . Ms ___ was readmitted for pain control and antiemetics. She was afebrile and with minimal tenderness, mostly in right upper quadrant/flank. She had no signs or symptoms of preterm labor. She was continued on IV fluids and strained her urine. She was tolerating a regular diet. By hospital day #3, her nausea and pain was well controlled with po medication and she was discharged home. Fetal testing was reassuring during this admission. She will have close outpatient followup.
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10212003-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 @ ___ re-presents for third time with right upper quadrant abdominal pain and right flank pain after discharge on ___ from antepartum service where she was being treated with narcotics for pain control for nephrolithiasis measuring 3mm in right ureter. Patient is tolerating PO dilaudid but this is not controlling her pain adequately. Pt has received 2mg IV dilaudid which has helped her pain significantly. Of note patient reports that she has 2 kidneys and 2 ureters on her right side although there is no mention of this on her MRI imaging from ___. MRI at the time demonstrated nl R ovary and nl appearing appendix. Patient reports that she has been able to tolerate POs. She reports no problems with urination. She has been constipated with no BM since last ___ but has been passing flatus. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ reports nl ERA, FFS, labs having GLT in ___ GYNhx: - denies abnl pap or STI - denies endometriosis, fibroids, or infertility MedHx: - interstitial cystitis in the past but no recent flares SurgHx: - wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 99, HR 75, BP 115/69 GENERAL: appears comfortable ABDOMEN: soft, tender to palpation in RLQ, right flank. No LLQ pain. No rebound/guarding. No fundal tenderness EXTREMITIES: no C/C/E SVE no bleeding, os visually closed TOCO CTX Q ___ FHT 150/mod var/+accels/no decels AGA TAUS: VTX, FHR 137, anterior placenta, AFI 14.3, BPP ___ TVUS: CL 3.5cm <PERTINENT RESULTS> ___ WBC-8.0 RBC-3.42 Hgb-9.7 Hct-28.8 MCV-84 Plt-344 ___ Neuts-81.7 ___ Monos-7.4 Eos-0.8 Baso-0.1 ___ WBC-6.6 RBC-3.23 Hgb-9.2 Hct-27.2 MCV-84 Plt-325 ___ ___ PTT-33.8 ___ ___ BLOOD Glucose-78 UreaN-6 Creat-0.7 Na-135 K-3.2* Cl-100 HCO3-22 AnGap-16 ___ ALT-10 AST-12 Amylase-38 TotBili-0.2 Lipase-16 ___ Calcium-8.5 Phos-3.3 Mg-1.8 ___ BLOOD HBsAg-NEGATIVE IgM HAV-NEGATIVE ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> prenatal vitamins colace 100mg bid <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 27+1 weeks gestation abdominal pain <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> stay well hydrated. continue colace daily, eat high-fiber diet. If constipated, you may use Miralax. Call your doctor with any leaking of fluid, vaginal bleeding, regular or painful contractions, fevers >100.4, persistent pain, nausea/vomiting, decreased fetal movement, or anything that concerns you.
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___ G1P0 readmitted at 26w5d RLQ/flank pain. . Ms ___ was readmitted for persistent right sided abdominal pain and constipation. She remained afebrile and without evidence of infection. Since she was recently diagnosed with a small renal stone and subsequently was readmitted twice with persistent pain, urology was consulted. Urology recommended repeating an ultrasound, which revealed no evidence of distal ureteral stone, mild right hydronephrosis, no jets visible bilaterally but bladder noted to be increasing in size by end of exam. They felt that her presentation did not appear consistent with renal calculi, including her pain, no red blood cells in urine, and only physiologic hydronephrosis on ultrasound. Therefore, they did not feel that a stent was warranted. She contined to receive IV fluids and Dilaudid for pain control. She was on a bowel regimen due to her recent history of constipation, likely due to narcotic use. By hospital day 3, she continued to report intermittent right sided abdominal pain. She had a couple small bowel movements. GI was consulted at that time and they did not feel the etiology of her pain was GI related. For her constipation, they recommended avoiding narcotics and miralax as needed. On hospital day #4, Ms ___ pain had completely resolved. The etiology of her pain remained unclear, however, she was afebrile, tolerating a regular diet, and was painfree. She was discharged home and will have close outpatient followup. . Fetal testing remained reassuring. Ultrasound on ___ revealed a vertex fetus, BPP ___, AFI 15.5, and EFW 991g(48%).
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10215754-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / codeine <ATTENDING> ___. <CHIEF COMPLAINT> back pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 at 28+4 with sudden, new stabbing and constant L low back pain wrapping around her side since this AM. Had BM this AM loose. Pain feels better when bearing down. Seems to worsen at times but never completely resolves. Has not tried any pain meds. Decreased appetite but would like to drink fluids. Of note, pt evaluated in triage ___ for brown spotting and DFM, reassuring fetal testing and brown spotting attributed to postcoital. No further spotting/VB since then. ROS: No urinary sxs or diarrhea, no bloody urine or stools. +Nausea without emesis, no f/c. +flatus. No abd pain, no VB/LOF. +AFM without pain. <PAST MEDICAL HISTORY> PNC: -___: ___ by ultrasound -Labs: O+/Ab-/RPRNR/RI/VI/HbsAg-/HIV- -Screening: Low risk CF, LR ERA, nl Hg electrophoresis -FFS: wnl, girl -GLT: 88 -Issues: teen pregnancy, spontaneous OB Hx: G1 current, spontaneous GYN Hx: LMP ___ PMH: denies PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Afebrile, VS wnl Appears uncomfortable, not moving in bed RRR, CTAB No CVAT Abd ND non-tender throughout, no r/g, fundus soft NT Ext NT NE Reproducible TTP in left lower back and left flank FHT AGA with mod var, occ sm variables Toco flat SVE LCP, ffn discarded TAUS AFI 19.0, grossly appropriate AFM, cephalic ___ ULTRASOUND IMPRESSION: 1. Bilateral hydronephrosis, greater on the left. 2. Single live intrauterine pregnancy. 3. Diffuse echogenicities within the liver, spleen, most likely due to prior granulomatous infection. ___ IMPRESSION: - Mild cardiac enlargement is physiologic for pregnancy. Lungs are clear and there is no pleural effusion. <PERTINENT RESULTS> ___ WBC-14.8 RBC-3.32 Hgb-10.4 Hct-31.0 MCV-93 Plt-233 ___ Neuts-87.3 ___ Monos-2.4 Eos-0.1 Baso-0.2 ___ WBC-11.3 RBC-2.92 Hgb-9.1 Hct-27.1 MCV-93 Plt-196 ___ Neuts-84.0 ___ Monos-4.2 Eos-0.2 Baso-0.2 ___ Glu-123 BUN-7 Cre-0.5 Na-137 K-4.0 Cl-104 HCO3-22 ___ Glu-100 BUN-6 Cre-0.5 Na-140 K-3.6 Cl-106 HCO3-23 ___ ALT-16 AST-17 ___ ALT-14 AST-14 ___ Calcium-8.3 Phos-4.1 Mg-1.5 ___ Calcium-8.6 Phos-3.0 Mg-1.8 BARTONELLA (ROCHALIMEA) HENSELAE ANTIBODIES, IGG AND IGM Results Pending ___ URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG ___ URINE RBC-10 WBC-5 Bacteri-FEW Yeast-NONE Epi-25 ___ URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE RBC-34 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 HISTOPLASMA ANTIGEN Results Pending STONE ANALYSIS Results Pending URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. YEAST VAGINITIS CULTURE (Final ___: YEAST. SPARSE GROWTH. Blood Culture, Routine (Pending): TOXOPLASMA IgG ANTIBODY (Final ___: NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA TOXOPLASMA IgM ANTIBODY (Final ___: NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA <MEDICATIONS ON ADMISSION> 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Nephrolithiasis Granulomas (unclear etiology), further work up 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 into the antepartum service for symptomatic treatment of nephrolithiasis. You passed a stone and your pain has subsided. You were able to tolerate food and water by mouth and we feel you can be discharged home. Upon evaluation, you were found to have granulomas in your kidneys, liver and spleen. You were seen by the infectious disease doctors and are ___ undergoing further work up. You also have an appointment scheduled with rheumatology upon discharge.
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___ yo G1 admitted at 28w4d with left lower flank pain and nausea; suspected nephrolithiasis. . Ms ___ was admitted for pain control and conservative management of her suspected nephrolithiasis. She had no evidence of infection and fetal testing was reassuring. Renal ultrasound revealed bilateral hydronephrosis, otherwise, no obvious kidney stone. In addition, there was an incidental finding of granulomas in her liver, spleen, and kidney. She had a PPD test, which was negative. She was seen by ID and they recommended some blood work for infectious etiologies, which are all negative to date. She was scheduled for a rheumatology appointment for possible autoimmune etiology of the granulomas. She was discharged home after adequate pain control was accomplished and she had adequate follow up in place.
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10215754-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / codeine <ATTENDING> ___. <CHIEF COMPLAINT> back pain, deceleration on NST <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1 at ___ sent from ___ after she had a decel to ___ on NST. She went to the ___ with c/o decreased FM. Had a BPP ___, had decel on NST after US after having a contraction on the monitoring. Here, feeling +AFM. No vaginal bleeding. No LOF. No abnormal discharge. Feeling some discomfort, back pain with urination. No burning with urination. No fevers/chills. No abdominal pain. Feeling intermittent contractions, unchanged from the last several weeks. <PAST MEDICAL HISTORY> PNC: - ___ ___ by 12 wk u/s - Opos/Abneg/HCVneg/HIVneg/HBsAgneg/RPRNR/RI/GBS negative - Nl Hg electrophoresis - CF low risk - LR ERA - FFS: girl, normal - GLT normal - Issues: *) hospitalization for nephrolithiasis on ___, passed a stone - *) Granulomas: found during renal ultrasound during admission. ID work-up negative to date including bartonella, histoplamsosis, toxo. Did not keep appointment with rheumatology. - US: ___: EFW 3240 g , 76%ile, vertex, BPP ___, AFI 11.6 OB Hx: G1 current, spontaneous GYN Hx: LMP ___, denies STIs/fibroids/ov cysts/endometriosis PMH: nephrolithiasis PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Admission Exam VS: T 98 BP 130/68 HR 85 RR 18 Gen: NAD, appears comfortable, mother at bedside CV: RRR Lungs: CTAB Back: +CVAT on right Abd: soft, gravid, nontender Ext: trace edema bilaterally FHT: 135/mod var/+accels/late decel to 70 x 4 min at 1834 Toco: Rare contractions Discharge Exam: VSS Abdomen: soft, non-tender, gravid Back: mild tenderness of palpation of R lower back and flank <PERTINENT RESULTS> ___ 07: 00PM BLOOD WBC-9.1 RBC-3.24* Hgb-9.5* Hct-28.7* MCV-88 MCH-29.2 MCHC-33.1 RDW-13.9 Plt ___ ___ 07: 00PM BLOOD Neuts-74.9* ___ Monos-5.5 Eos-0.7 Baso-0.3 ___ 05: 30PM URINE Color-Straw Appear-Hazy Sp ___ ___ 05: 30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM ___ 05: 30PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-3 ___ 5: 26 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> PNV, Fe, omeprazole, ranitidine <DISCHARGE MEDICATIONS> 1. Ferrous Sulfate 325 mg PO DAILY 2. Omeprazole 20 mg PO BID 3. Prenatal Vitamins 1 TAB PO DAILY 4. Ranitidine 150 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregancy at 36 weeks gestation back pain <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for back pain and concern for kidney stones, however, your pain improved significantly while you were here. It was felt it was safe for discharge.
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Ms. ___ is a ___ year old G1P0 who was admitted to the hospital on ___ with back pain, nephrolithiasis vs. musculoskeletal pain. She initiall presented for decreased fetal movement with a deceleration seen on NST. She received prolonged monitoring for 4 hours on L&D with reassuring tracing. She was admitted given her back pain. She received IV fluids. She received one dose of percocet, but pain was otherwise well-controlled with acetaminophen. She did not pass any stones during her admission. Her pain improved and she was discharged to home with appropriate follow-up scheduled.
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10215754-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> contractions, physical assault <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ y/o G3P1 at 27+4 who presents with contractions after a physical assault at 2am this morning. She reports that her mother kicked and scratched her. There was trauma to her abdomen. Since the incident, she has been painfully contracting every ___ minutes. She has had no vaginal bleeding or leaking fluid. Endorses decreased fetal movement since the incident as well. Currently does not feel pain other than in her abdomen with contractions. Of note, per patient report, she was seen at ___ ___ yesterday for abdominal and back pain and was found to have a closed os. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP - Labs ___ unknown - Screening: normal quad screen - FFS limited by fetal position - GLT passed - Issues: Zika exposure, declined follow up OBHx: G3P1 - TAB x1 - C/S ___, term, for NRFHT GynHx: denies history of STIs or abnormal pap smears PMH: kidney stones PSH: L ureteral stent placement (___), C/S ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Vitals: ___ 06: 00Resp.: 20 / min ___ 06: 00Temp.: 97.0°F ___ ___: 80 ___ 05: 53BP: 106/63 (73) Gen: A&O, comfortable Pulm: breathing comfortably on RA Abd: soft, gravid, nontender SSE: cervical os appears closed SVE: 1 cm dilated, soft, long, mid U/S: vertex, BPP ___, MVP 5 cm Toco: Q2min FHT 120/moderate varability/+accels/-decels <PERTINENT RESULTS> ___ WBC-8.0 RBC-3.25 Hgb-9.6 Hct-28.7 MCV-88 Plt-170 ___ ___ PTT-25.5 ___ ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-3 TransE-<1 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis NEISSERIA GONORRHOEAE, NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> PNV, vitamin B6, vitamin D <DISCHARGE MEDICATIONS> PNV, vitamin B6, vitamin D <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 27w5d preterm contractions s/p abdominal trauma <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for observation due to preterm contractions following abdominal trauma. Fetal testing was reassuring while you were here and you had no evidence of preterm labor or abruption. You received a course of betamethasone for fetal lung maturity. Please avoid strenuous activity and maintain pelvic rest (nothing in the vagina) until you are re-evaluated in the office.
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___ y/o G3P1 admitted at ___ with threated preterm labor and rule out abruption after physical assault. On arrival, she was contracting every two minutes and her cervix was 1cm dilated. She was started on Magnesium for neuroprotection and closely monitored on labor and delivery. She received betamethasone for fetal lung maturity (complete ___. Fetal testing was reassuring. Her contractions spaced out significantly and her cervix remained unchanged. The Magnesium was discontinued and she was transferred to the antepartum floor where she remained stable without any evidence of preterm labor. She reported intermittent cramping. Her monitored showed occasional irritability with reassuring fetal testing. Given the assault, she was seen by social services who assisted her in finding safe housing. She was discharged on ___ and will have close follow up in 1 week.
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10215754-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> CC: right back pain, cramping, ?SROM, VB <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cystoscopy, right ureteral stent placement <HISTORY OF PRESENT ILLNESS> HPI: ___ G3P2 at 34w5d with right sided back pain that started at 0430 this AM that radiates down flank to lower pelvis. Back pain is constant but radiating pain comes and goes. Endorses fevers and chills, fever to 102 at home. Associated with N/V with 4 episodes of emesis today. Took Tylenol 6 hours ago without relief. Denies any urinary symptoms. Regular BM, last 1 day ago. Gush of fluid soaking pants on arrival to hospital. She reports she has continued to leak on pad underneath her currently. Endorses some pink when wiping. No bright red bleeding. Endorses cramping and contractions. +FM. PNC: - ___ ___ by LMP c/w 8w6d US - Labs Rh+/Abs-/Rub I/RPR NR/HBsAg /HIV-/GBS+ - Screening: - FFS: wnl - GLT: wnl - U/S (___): 1663g, 17% - Issues: *) Late presentation to care (18 weeks) *) H/o PP depression <PAST MEDICAL HISTORY> POBHx: G4P2 - G1: TAB - G2: pLTCS for arrest of dilation (___) c/b chorio - G3: rLTCS, ___ IUD (___) - G4: current PMH: kidney stones w/ L ureteral stent placement in ___ PSH: cesarean x2, L ureteral stent Meds: none All: penicillin (anaphylaxis) <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On day of discharge: Vitals: ___ ___ Temp: 98.4 PO BP: 106/65 HR: 88 RR: 18 O2 sat: 100% O2 delivery: ra Pain Score: ___ Fetal Monitoring: FHR: 120-130 FM: Present ___ Temp: 98.2 PO BP: 133/79 HR: 77 RR: 18 O2 sat: 98% O2 delivery: ra Pain Score: ___ Fetal Monitoring: FHR: 130-140 FM: Present Gen: NAD, lying in bed Resp: no evidence of respiratory distress Back: mod R flank pain Abd: soft, gravid, non-tender uterus Ext: no edema, non-tender Date: ___ Time: 0400 FHT: 120/mod var/+accels/few quick variables Toco: flat Date: ___ Time: 0400 FHT: 125/mod var/+accels/-decels Toco: irritable <PERTINENT RESULTS> ___ 09: 39PM BLOOD WBC-7.5 RBC-3.00* Hgb-9.2* Hct-27.7* MCV-92 MCH-30.7 MCHC-33.2 RDW-12.9 RDWSD-43.1 Plt ___ ___ 09: 54PM BLOOD Glucose-96 UreaN-6 Creat-0.6 Na-135 K-3.6 Cl-102 HCO3-21* AnGap-12 ___ 09: 54PM BLOOD Calcium-8.4 Phos-3.4 Mg-1.8 ___ 12: 51AM URINE Color-DkAmb* Appear-Cloudy* Sp ___ ___ 09: 41PM URINE Color-Amber* Appear-Cloudy* Sp ___ ___ 12: 51AM URINE Blood-SM* Nitrite-NEG Protein-200* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG* ___ 09: 41PM URINE Blood-SM* Nitrite-NEG Protein-100* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG* ___ 12: 51AM URINE RBC-16* WBC->182* Bacteri-NONE Yeast-NONE Epi-10 ___ 09: 41PM URINE RBC-32* WBC->182* Bacteri-MOD* Yeast-NONE Epi-0 ___ 12: 51AM URINE WBC Clm-MANY* Mucous-MANY* ___ 09: 41PM URINE WBC Clm-MANY* Mucous-OCC* ___ 10: 21PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG ___ 12: 51 am URINE Source: ___. URINE CULTURE (Preliminary): BETA STREPTOCOCCUS GROUP B. >100,000 CFU/mL. CLINDAMYCIN SUSCEPTIBILITIES REQUESTED PER ___. ___ (___) ON ___. ___ 6: 00 pm URINE Site: CYSTOSCOPY RIGHT RENAL PELVIC URINE. **FINAL REPORT ___ URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. >10,000 CFU/ML. ___ 5: 58 pm URINE Site: CYSTOSCOPY BLADDER URINE. **FINAL REPORT ___ URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. >10,000 CFU/ML. Renal Ultrasound ___ Final Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with left side back pain radiating to lower pelvic c/f kidney stone // r/o kidney stone TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Ultrasound abdomen from ___ FINDINGS: There is severe hydronephrosis of the right kidney, which has worsened from the prior study on ___. Dilation of the proximal right ureter is seen, though technically difficult to evaluate this more distally. No renal stones are visualized. Punctate cortical calcifications are noted in the left kidney, nonspecific, but also present on prior CT from ___. There is no hydronephrosis, stones, or masses in the left kidney. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 13.4 cm Left kidney: 13.1 cm The bladder is moderately well distended and normal in appearance. There is a single live intrauterine pregnancy with heart rate of 120 BPM. IMPRESSION: 1. Severe right hydroureteronephrosis, worsened from prior, without visualized renal or ureteral stones. 2. Single live intrauterine pregnancy. ___ ___ Ultrasound EFW 2,392 g 35% , BPP ___, MVP 8.7cm COMPLETE GU U.S. (BLADDER & RENAL) ___ Final Report EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL) INDICATION: ___ year old woman with right ureterolithiasis s/p right stent placement // evaluate proximal and distal stent coil positions TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and bladder were obtained. COMPARISON: Ultrasound performed ___ FINDINGS: Interval improvement in now mild right hydronephrosis. A echogenic tubular structure is seen in the right renal pelvis consistent with the superior stent coil. The inferior stent coil is seen in the bladder. There is interval development of mild right renal collecting system fullness. No renal stones are visualized. A punctate cortical calcification in the left kidney is again noted and is nonspecific. There is normal corticomedullary differentiation and cortical echogenicity bilaterally. Right kidney: 12.0 cm Left kidney: 12.3 cm The bladder is normal in appearance.Ureteral jets are demonstrated bilaterally. Prevoid volume of the bladder is 105.3 cm3. Postvoid volume of the bladder is 7.7 cm3. There is a single live intrauterine pregnancy with a heart rate of 126 beats per minute. IMPRESSION: 1. interval improvement in mild right hydroureteronephrosis, with a right ureteral stent in overall appropriate position within the limits of modality. 2. New left renal pelvic fullness without evidence of obstructing stone or lesion. 3. Preserved bilateral ureteral jets. 4. Post void residual of 7.7 cm3. <MEDICATIONS ON ADMISSION> prenatal vitamin <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H Do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *2 2. Cefpodoxime Proxetil 200 mg PO Q12H RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 4. Ferrous Sulfate 325 mg PO DAILY ___ cause constipation. Take with a stool softener daily. RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth once daily Disp #*60 Tablet Refills: *6 5. GuaiFENesin ___ mL PO Q6H: PRN cough RX *guaifenesin 200 mg 1 tablet by mouth every six (6) hours Disp #*30 Tablet Refills: *1 6. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN Pain - Moderate ___ cause sedation. Do not drink or drive while taking. RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 5 hours Disp #*5 Tablet Refills: *0 7. Oxybutynin 5 mg PO TID RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills: *1 8. Phenazopyridine 100 mg PO TID Duration: 3 Days Do not take for more than 3 days continuously. Will turn your urine orange. RX *phenazopyridine 100 mg 1 tablet(s) by mouth every eight (8) hours Disp #*10 Tablet Refills: *0 9. Tamsulosin 0.4 mg PO QHS Take daily until your stent is removed. RX *tamsulosin 0.4 mg 1 capsule(s) by mouth Every night before bed Disp #*50 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Nephrolithiasis with R ureteral stent placement, urinary tract infection <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 antepartum service with pain likely due to a kidney stone and bladder infection. You were seen by the Urologists and they placed a stent in the tube that carries urine from your kidneys to your bladder. You were started on medications for the pain and antibiotics to treat the infection in your urine. It is important you take the full course of these antibiotics as prescribed. We think it is now safe for you to go home. Please attend all appointments with your obstetrician and all fetal scans. You will have follow-up with the urologists to have your stent removed after your C-section. Please monitor for the following danger signs: - headache that is not responsive to tylenol - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns - Difficulty urinating - Blood in urine - Foul smelling urine - Heavy vaginal bleeding - Fever greater than 101 - Chills - Any other symptoms that concern you
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Ms. ___ is a ___ G4P2 at ~ 35w GA with h/o nephrolithiasis admitted for R flank pain. Her pain was initially controlled with IV dilaudid and tylenol. She was given aggressive IVF hydration. A Renal US on ___ showed severe Right hydroureteronephrosis. Her UA was equivocal and her WBC and Creatinine were normal. She was started on Macrobid. Urology was consulted and recommended a right ureteral stent placement which was done under spinal anesthesia on ___. A repeat Renal US on POD#1 showed improved mild Right hydronephrosis with the stent in the correct spot. After the procedure she had continued flank pain that improved with tamsulosin, oxybutynin, pyridium and PO dilaudid. Her urine cultures grew >10k CFUs of Groub B streptococcus. Infectious disease was consulted and recommended discharge on cefpodoxime for 10 days. She had reassuring fetal testing during the duration of her stay. She was started on PO iron for a baseline hct of 27. By hospital day 3 she was meeting all of her miletones, her pain was well-controlled with PO medications and she was discharged with close Obstetric and Urology follow-up.
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10215754-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> back pain, contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G3P2 at 36w4d with h/o LTCS x 2 and severe R hydronephrosis s/p antepartum admission (___) for R flank pain s/p R ureteral stent placement by Urology ___ presented with contractions that increased in frequency and intensity over the course of the day. She denies LOF, VB. She endorses good fetal movement. She denies nausea, vomiting, fevers, chills, chest pain, sob. Denies urinary or bowel symptoms. During her triage visit her contractions eventually resolved but patient felt that her back pain ___ ureteral stent placement returned with the pain radiating to her lower pelvis. She is taking tamsulosin, pyridium, oxybutynin prescribed by Urology for stent pain relief. Patient expresses that her stent pain is very frustrating as she is able to get limited rest at home and has taking care of her children. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w 8w6d US - Labs Rh+/Abs-/Rub I/RPR NR/HBsAg /HIV-/GBS+ - Screening: not done - FFS: wnl - GLT: wnl - U/S (___): 1663g, 17% - Issues: *) Late presentation to care (18 weeks) *) H/o PP depression POBHx: G4P2 - G1: TAB - G2: pLTCS for arrest of dilation (___) c/b chorio - G3: rLTCS, ___ IUD (___) - G4: current PMH: kidney stones w/ L ureteral stent placement in ___, now with R ureteral stent placement (___) PSH: cesarean x2, L ureteral stent, R ureteral stent placement <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: ___ 22: 03BP: 120/78 (88) ___ ___: 79 ___ 22: 07Temp.: 98.6°F ___ 22: 07Resp.: 16 / min Gen: A&O, lying uncomfortably in pain Resp: breathing comfortably on RA Abd: soft, gravid. non-tender to palpation GU: No CVA tenderness Ext: no lower extremity edema SVE: ___, stable over 3 exams FHT: 130/moderate variability/+accels/-decels Toco: q2-4mins, spaced ------------------- On discharge: Vitals: ___ 0300 Temp: 97.9 PO BP: 116/76 HR: 75 RR: 18 O2 sat: 98% O2 delivery: ra Pain Score: ___ Gen: NAD Resp: No evidence of respiratory distress Abd: soft [x] non-tender Ext: [x] no edema [x] non-tender Date: ___ Time: 2200 FHT: 130/moderate variability/+accels/-decels Toco: q2-4mins, spaced <PERTINENT RESULTS> ___ WBC-10.4 RBC-3.41 Hgb-10.5 Hct-32.2 MCV-94 Plt-178 ___ Neuts-72.1 ___ Monos-6.2 Eos-1.6 Baso-0.4 AbsNeut-7.60* AbsLymp-1.97 AbsMono-0.65 AbsEos-0.17 AbsBaso-0.04 ___ BLOOD Glucose-75 UreaN-10 Creat-0.5 Na-138 K-4.1 Cl-106 HCO3-19* AnGap-13 ___ BLOOD Calcium-8.8 ___ URINE Blood-LG* Nitrite-NEG Protein-100* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NORMAL pH-7.0 Leuks-SM* ___ URINE RBC->182* WBC-36* Bacteri-NONE Yeast-NONE Epi-6 URINE CULTURE (Pending): Renal US ___ IMPRESSION: 1. Interval worsening of now severe right hydroureteronephrosis. Right ureteral stent is overall in stable position. 2. Nonspecific debris within the right renal collecting system. Exclusion of urinary tract infection is recommended. 3. Single live intrauterine pregnancy. <MEDICATIONS ON ADMISSION> FERROUS SULFATE HYDROMORPHONE OXYBUTYNIN CHLORIDE PHENAZOPYRIDINE PNV ___ FUMARATE-FA ACETAMINOPHEN GUAIFENESIN <DISCHARGE MEDICATIONS> 1. Cyclobenzaprine 10 mg PO TID: PRN pain RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID: PRN Disp #*30 Tablet Refills: *0 2. Fosfomycin Tromethamine 3 g PO ONCE Duration: 1 Dose Dissolve in ___ oz (90-120 mL) water and take immediately RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by mouth once Disp #*1 Packet Refills: *0 3. Phenazopyridine 200 mg PO TID Duration: 3 Days RX *phenazopyridine 200 mg 1 tablet(s) by mouth three times a day Disp #*20 Tablet Refills: *0 4. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild/Fever 5. DiphenhydrAMINE 25 mg PO QHS: PRN insomnia 6. Oxybutynin 5 mg PO TID 7. Tamsulosin 0.4 mg PO QHS <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right flank pain <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 antepartum service for evaluation of right sided pain. We determined that you were not in preterm labor and that the pain is likely due to your right stent placement. For evaluation of this pain, we obtained a renal (kidney) ultrasound. This showed that the right stent is in the correct place. It also showed moderate-severe hydronephrosis, which is expected. We spoke with urology about these findings and at this time, they determined that your stent should be kept in place until delivery, after which it will be removed. They recommended continuing your current regimen for pain and increased the pyridium dosing to 200mg three times daily. We also obtained a urinalysis and concluded that your pain may also be due to a urinary tract infection. We think it is now safe for you to go home. Please attend all appointments with your obstetrician and all fetal scans. Please follow the instructions below: Urinary tract infection: - Please take fosfomycin 3g once for your urinary tract infection Right flank pain: - Please continue your home regimen for the stent. You may increase your pyridium dose to 200mg three times daily. Please continue your flexeril 10mg three times daily as needed for muscle spasms. Please monitor for the following danger signs: - headache that is not responsive to tylenol - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ is a ___ G3P2 with a history of recurrent nephrolithiasis, s/p R sided nephroureteral stent placement on ___, re-admitted on ___ with abdominal and flank pain likely secondary to R sided nephroureteral stent. Her UA showed 32 WBCs and neg nitrites on ___. Urology was consulted and recommended increasing her pyridium and evalauting stent placement by US. Renal US was performed on ___ which showed Right ureteral stent is overall in stable position. Per urology she was continue on flomax, oxybutynin, pyridium, Tylenol, flexeril, Benadryl for stent colic. They also added cyclobenzaprine and fosfomycin. She had multiple vaginal exams to rule out preterm labor as a cause of her discomfort and she was unchanged at 1cm/50% effaced/-3 station. By the evening of ___ her pain had improved, she was tolerating PO, ambulating, voiding without issue and she was discharged home with follow-up with her primary OB scheduled.
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10216336-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo history of stage IV endometriosis s/p surgical management ___ who presents for worsening pelvic pain. In ___ she underwent extensive surgical resection of endometriosis with Dr. ___ (stage IV via laparoscopy findings). Intra-operative findings: "The patient had stage IV endometriosis with an obliterated pelvis. There was no normal pelvic anatomy that was able to be appreciated. The adhesions involved the entire posterior uterus, bilateral adnexa and the entire length of the rectosigmoid bowel. It was difficult to differentiate bowel from the tube, from either ovary, from the uterus. It was also difficult to separate the right and left adnexa as everything was fused at the midline. Neither pelvic sidewall was visible given the extensive adhesions." Her surgery included: Extensive laparoscopic lysis of adhesions (enterolysis, uterine lysis, bilateral adnexal lysis, Bilateral ovarian drainage and biopsy, Excision of endometriosis (right abdominal wall). Post-operatively she was started on OCPs. Her pain improved with OCPs around mid-___ and was relatively well controlled with motrin, midol. However, in ___ her pain began to worsen. She followed up at ___ where she was found to have recurrent endometriomas. She was also seen by IVF specialists there and pain team via anesthesia who provided her a nerve block (via superficial supra-pubic injection per patient - minimal improvement). She saw Dr. ___ for a second opinion, who also recommended Lupron and progestin prior to IVF treatment if that continued to be patient's goal primary goal. Both consultants counseled patient that surgical management would potentially result in oophorectomy given extensive disease. Patient elected for medical management. Due to insurance reasons, Lupron not covered. She therefore had her brother (who is a physician in ___ obtain for her and administer this past ___ (he gave her 3 month dosing). The following day she had small VB and onset of pelvic pain which has worsened since then. It is similar to prior episodes (dull, achy), but now more intense. She tried treating at home with motrin, celexra, midol, hydrocodone with no improvement. Went home took Celebrex, motrin, hydrocodone, nexium, Mylanta, lorazepam and then went to bed. Awoke this morning from the pain. Since arriving to the ED she has received 3 mg IV dilaudid since arrival at 0520, 15 mg of IV toradol. Felt better after second dose of dilaudid. Reports no menses since ___ when she began to take OCPs which she discontinue on ___ after getting Lupron on ___. Pain dull ache, more prominent on the left side and to buttock and feels. <PAST MEDICAL HISTORY> OB: G1P1 - ___, C-section 41 weeks gestation male infant 7 pounds. GYN: - Menarche age ___, LMP ___ - Sexually active with partner - ___: None ___ years, withdrawal method prior to that. - STD History: Chlamydia ×2 (___). PMH: - Umb hernia --> s/p umbilical hernia repair ×2 (___) - Umbilical endometriosis, dx'd with last umb hernia surg ___ - Fibroid uterus - Chlamydia ×2 (___), outpatient management - Infertility (no BC but SA with same partner x ___ ___ - Severe dysmenorrhea/pelvic pain (L > R), (r/o endometriosis)7. 8 cm pelvic cyst (suspect endometrioma on MRI/PUS) PSH: - ___, cesarean delivery - ___, right shoulder arthroscopy - ___,? Hysteroscopic myomectomy, ___ - ___, umbilical hernia repair #1 with mesh at OSH - ___, umbilical hernia repair #2 with excision of umbilical endometriosis, at OSH by a diff general surgeon Note: Neither operative report or pathology report available for my review today. <SOCIAL HISTORY> ___ <FAMILY HISTORY> ___: Denies family h/o GYN cancers such as breast or ovarian cancer. <PHYSICAL EXAM> General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, nontender to palpation without rebound or guarding Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 05: 19AM BLOOD WBC-4.5 RBC-3.97 Hgb-11.5 Hct-35.8 MCV-90 MCH-29.0 MCHC-32.1 RDW-13.1 RDWSD-42.9 Plt ___ ___ 05: 19AM BLOOD Neuts-33.6* Lymphs-53.9* Monos-10.1 Eos-2.0 Baso-0.2 Im ___ AbsNeut-1.49* AbsLymp-2.40 AbsMono-0.45 AbsEos-0.09 AbsBaso-0.01 ___ 05: 19AM BLOOD ___ PTT-29.4 ___ ___ 05: 19AM BLOOD Glucose-101* UreaN-5* Creat-0.7 Na-140 K-3.4* Cl-104 HCO3-25 AnGap-11 ___ 05: 19AM BLOOD ALT-8 AST-15 AlkPhos-42 TotBili-0.3 ___ 05: 19AM BLOOD Lipase-29 ___ 05: 19AM BLOOD Albumin-4.4 ___ 05: 19AM BLOOD HCG-<5 ___ 12: 10PM URINE Blood-MOD* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12: 10 pm URINE CLEAN CATC. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. <MEDICATIONS ON ADMISSION> Meds: - Lupron - Motrin - Lorazepam - Tylenol - Celebrex - Baclofen vaginal tablet, after intercourse and nightly <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 2. Baclofen 10 mg PO BID RX *baclofen 10 mg 1 tablet(s) in vagina every 12 hours Disp #*14 Tablet Refills: *0 3. Diazepam 5 mg PO Q12H pain RX *diazepam 5 mg 1 tablet in vagina every 12 hours Disp #*14 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth every 12 hours Disp #*60 Capsule Refills: *1 5. HYDROmorphone (Dilaudid) ___ mg PO Q3H: PRN Pain - Moderate RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 6. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 7. Senna 8.6 mg PO BID: PRN Constipation - First Line RX *sennosides [senna] 8.6 mg 1 tablet by mouth every 12 hours Disp #*60 Tablet Refills: *1 8. Aygestin (norethindrone acetate) 5 mg oral daily 9. Aygestin (norethindrone acetate) 5 mg oral daily 10. Aygestin (norethindrone acetate) 5 mg oral daily 11. LORazepam 0.5 mg PO ONCE MR1 insomnia Duration: 1 Dose <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometriosis flare <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 control of your pain. 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. * 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 for pain control after an endometriosis flare. She was initially given IV pain meds and transitioned to oral pain meds. By ___, 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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10217041-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim / Demerol / Percocet <ATTENDING> ___. <CHIEF COMPLAINT> pelvic pain/expanding hematoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ s/p car vs pedestrian accident in ___ in ___. She had an open pelvic fracture with a bladder perforation and vaginal lacerations. She was treated with an SI screw and external fixation. Course complicated by pelvic hematoma, UTI, and superficial RLE DVT found on routine screening and she was placed on coumadin. She was sent to ___ on ___. On ___ there appeared to be increased drainage coming from the pin site and she was admitted to ___ for removal external hardware and antibiotics. CX data showed MRSA. She underwent on ___ removal of pelvic hardware except SI screw. She has been followed by ortho and noted to have a stable L perineal hematoma. Over the past few days she has been a bit more active on crutches at home. She noted some increased discomfort last night, and then at 5AM noted sudden increase in pain to ___ and feeling the swelling increase to the perirectal area. She and her husband called an ambulance and she was taken to ___. There, VSS and labs were OSH labs: WBC 9, hct 33.9, plts 222, INR 1.9. She was transferred to ___. <PAST MEDICAL HISTORY> PMH: - mild asthma, exercise induced - eczema - cervical and lumbar herniated discs (treated with injections and stable, no h/o spine surgery) - intermittent reflux (PRN zantac) - migraines - h/o community acquired PNA - herpes simplex involving eye (maintenance acyclovir) PSH: - appendectomy - pelvis ORIF on ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On Admission PE: 98.3 76 120/67 16 97% RA Abdomen: soft, flat, NT External anatomy: labial swelling noted on L at 5 o'clock. Approximately 7 x 4 cm. No overlying erythema suggestive of cellulitis. exquisitely TTP. On digital examination, swelling approximately 5cm up L vaginal sidewall, just distal to palpable vaginal sutures. Ext: NE, NT On day of discharge PE NAD CTAB RRR abd s nt, nd GU: 8cm perineal hematoma, no e/o infection ext: NE, NT <PERTINENT RESULTS> ___ 09: 30PM WBC-7.2 RBC-3.66* HGB-10.6* HCT-32.7* MCV-93 MCH-29.1 MCHC-31.3 RDW-13.3 ___ 09: 30PM PLT COUNT-203 ___ 09: 30PM ___ PTT-35.1 ___ ___ 04: 55PM WBC-7.7 RBC-3.85* HGB-11.3* HCT-34.8* MCV-90 MCH-29.3 MCHC-32.5 RDW-13.2 ___ 04: 55PM NEUTS-71.2* LYMPHS-17.1* MONOS-6.2 EOS-5.3* BASOS-0.4 ___ 04: 55PM PLT COUNT-233 ___ 04: 55PM ___ PTT-39.5* ___ ___ 03: 14PM HGB-12.3 calcHCT-37 ___ 11: 57AM LACTATE-0.8 ___ 11: 50AM GLUCOSE-91 UREA N-8 CREAT-0.6 SODIUM-142 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14 ___ 11: 50AM estGFR-Using this ___ 11: 50AM WBC-9.1 RBC-3.99*# HGB-11.7* HCT-36.5# MCV-91 MCH-29.3 MCHC-32.0 RDW-13.1 ___ 11: 50AM NEUTS-77.2* LYMPHS-14.1* MONOS-5.1 EOS-3.0 BASOS-0.5 ___ 11: 50AM PLT COUNT-231 ___ 11: 50AM ___ PTT-44.8* ___ <DISCHARGE INSTRUCTIONS> Mrs. ___, ___ was a pleasure caring for you here at ___. You were admitted for a hematoma in your pelvis which was expanding while you were on anti-coagulation. Once your anti-coagulation was stopped, your bleeding stopped and you hematoma has not grown in size. Your pain is controlled with oral medication and you are urinating, eating a regular diet and ambulating. Thus you were felt to be safe to go home. 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 * No strenuous activity until cleared by your doctor ___ your doctor for: * fever > 100.4 * worsening 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 *shortness of breath, chest pain, dizziness/lightheadedness To reach medical records to get the records from this hospitalization sent to your doctor at home, ___ ___.
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Mrs. ___ is a ___ who was being anticoagulated for a DVT s/p severe pelvic fracture 2 mos ago admitted with left labial hematoma and initially active extravasation from branch of L internal pudendal artery. This then stabilized after reversal of anti-coagulation, followed by expectant management with serial exams and hematocrits performed. Her anticoagulation, initial INR 2.0, was reveresed with vitamin K and FFP. Of note pt received one unit of FFP without issue but on initiation of her second unit had an allergic reaction with eye swelling requiring benadryl and an albuerol neb for resolution. By hospital day 2 her INR was 1.2, hematocrit stabilized, and the hematoma stabilized at 8cm. With expectant management and ice packs to area, pain in labia significantly decreased. On discharge day, pain was well controlled on po medications and the patient was able to tolerate ADLs and void without foley catheter. During her admission the gyn-oncology service was consulted regarding possibility of evacuation of the clot for symptomatic relief. This was thought to be unexceptable risk of infection and thus expectant management was continued. Given that active bleeding in area had clinically stopped, ___ intervention was not thought to be necessary. Orthopedics was also consulted who recommended discontinuation of her anti-coaguation at this time. 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. Gabapentin 600 mg PO QAM RX *gabapentin 600 mg 1 tablet(s) by mouth daily Disp #*40 Capsule Refills:*0 3. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain RX *oxycodone 10 mg 1 tablet(s) by mouth no more frequently than every 8 hours Disp #*45 Tablet Refills:*0 4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H RX *oxycodone [OxyContin] 30 mg 1 tablet extended release 12 hr(s) by mouth every 12 hours Disp #*30 Tablet Refills:*0 5. Lactulose 30 mL PO DAILY PRN constipation RX *lactulose 10 gram/15 mL 30 ml by mouth daily Disp #*1 Bottle Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left perineal hematoma s/p pelvic fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10218052-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> short cervix, discordant growth of twins <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> HPI: ___ yo G1P0 at 26'1 wks with di-di twins who was admitted after an ultrasound showed a short cervix of 1.5cm with funneling, and discordant growth of 20%, with twin A (female) measuring greater than twin B (male). She reports that she had been having mild intermittent cramping in the 3 days prior to admission yesterday but that she was overall feeling well. She was not feeling the contractions she was having yesterday in Triage. She has not had any tightening or cramping today. No fluid leaking, no bleeding, no back pain. She reports normal fetal movement. PNC: - ___ ___ by LMP - Labs Rh neg/Abs neg/Rub I/RPR neg/HBsAg neg/HIV neg/GBS unknown - Screening: low risk ERA x 2 - FFS: normal x 2 - U/S: ___ -> A: 819g, 41%, maternal left, female, breech. B: 699g, 19%, maternal right, male, transverse. Short cervix, 1.5cm with funneling. OBHx: - G1: current GynHx: - denies abnormal Pap or cervical procedures - denies fibroids, endometriosis, ovarian cysts - denies STIs, including HSV PMH: denies PSH: right breast lumpectomy Meds: PNV All: NKDA SocHx: works at a ___ as a caregiver lives ___/ mother and younger brother; boyfriend is involved no T/E/D, although mother and boyfriend smoke <PHYSICAL EXAM> Physical Exam on Admission Vitals: BP 110s/70s, hr 90-100, sat 97-99% on RA Gen: NAD Abd: soft, gravid, nontender SVE per Dr. ___ on ___: FT/50/-3/mid position/medium consistency FHT A- AGA B- AGA Toco: on ___, q2-3 min ctx on ___, rare ctx Discharge Physical Exam Vitals: 98.3, 107/65, 93, 18, Oo2 99% RA Gen: [x] NAD Resp: [x] No evidence of respiratory distress Abd: [x] soft [x] non-tender Ext: [x] no edema [x] non-tender <PERTINENT RESULTS> ___ 04: 40PM BLOOD WBC-11.8* RBC-3.29* Hgb-10.0* Hct-29.5* MCV-90 MCH-30.4 MCHC-33.9 RDW-13.0 RDWSD-42.2 Plt ___ ___ 04: 40PM BLOOD Neuts-67.9 ___ Monos-6.2 Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.01* AbsLymp-2.94 AbsMono-0.73 AbsEos-0.02* AbsBaso-0.02 ___ 04: 40PM BLOOD Plt ___ ___ 04: 37PM URINE Color-Straw Appear-Clear Sp ___ ___ 04: 37PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 04: 37PM URINE RBC-0 WBC-1 Bacteri-FEW* Yeast-NONE Epi-1 ___ 04: 37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 03: 15PM OTHER BODY FLUID CT-NEG NG-NEG ___ 3: 15 pm ANORECTAL/VAGINAL Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: Negative for Group B beta streptococci. ___ 3: 15 pm SWAB Source: Vaginal. **FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. ___ 4: 37 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for observation due to a shortened cervix and preterm contractions. You were observed in the hospital and had no evidence of ongoing preterm labor. You received a course of betamethasone for fetal lung maturity. Fetal testing was reassuring while you were here. Since Twin B has been measuring smaller than A, you will have another growth scan in 2 weeks. Please maintain pelvic rest (nothing in vagina, no sex) and avoid strenuous activity at home.
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___ yo G1P0 who was admitted to the Antepartum Service on ___ at 26w1d with discordant di-di twins and short cervix. She underwent an ultrasound on ___ which demonstrated lagging biometry for twin B with weight discordance of 20%, with cervix 1.5cm in length with funneling. On admission, she was having regular contractions and her cervix was FT/50/-3. Her admission labs were notable WBC 11.8, negative UTox, and her UA was negative for UTI. She was started on indomethacin and started on a course of betamethasone (betamethasone complete on ___. She continued to have mild occasional cramps during her admission and on ___, she reported a small amount of leaking fluid with sneezing, which prompted a sterile speculum exam (visually closed, long, negative nitrazine/ferning/pooling). She remained stable for the remainder of her admission and was discharged home on ___ with outpatient follow-up scheduled. Discharge Medications: 1. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: twin pregnancy short cervix preterm contractions Discharge Condition: stable Followup Instructions: ___
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10218444-DS-13
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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> Exploratory laparotomy, right salpingo-oophorectomy, end colostomy, and rigid proctoscopy <HISTORY OF PRESENT ILLNESS> ___ was referred to Gyn Oncology for a pelvic mass, hydronephrosis and h/o urinary retention. She was seen in the ED ___ and was found to have urinary retention. A foley catheter was placed and drained for 750ml. She continues to have a foley catheter and reports adequate drainage of C-Y-U. She has undergone a pelvic ultrasound ___ which revealed Within the pelvis is a large cystic mass measuring 11.4 x 15.2 x 12.5 cm, with internal layering echogenic material consistent with blood products. Soft tissue component/nodules do not demonstrate internal vascularity, but there is increased vascularity peripherally. No normal ovarian tissue or the uterus could be visualized. CT Scan was done and revealed large complex cystic pelvic mass with thick wall measures 12 cm .Suspect mesenteric and lesser sac masses and lymph node enlargement, likely metastasis. Unopacified bowel is less likely. Highly enhancing 2 cm mass in the fundus of the uterus .Bilateral hydronephrosis and hydroureter caused by the pelvic mass. CT Scan Chest: Small 2 mm nodule seen within the right lower lobe. No other nodules concerning for malignancy identified.LABS: CEA 1.4,CA 125: 145, CA ___: <3, Cr 0.9 Today she reports some bloody stool but occasionally strains to have a BM and has hemorrhoids. She reports occasional abdominal pain but no bloating. She has had weight loss ( unknown amount), decreased appetite x ___ weeks and early satiety. She denies any BLE edema or pain. No VB or D/C. <PAST MEDICAL HISTORY> PMH: ANEMIA, DYSPHAGIA, HYPERCHOLESTEROLEMIA, OSTEOPOROSIS PSH: sinus surgery, hsc with polypectomy, hsc with endometrial ablation OBGYNHx: G5P3 - SVD x 3, Denies abnormal paps, or postmenopausal bleeding <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father had heart problems and died from sudden death at the age of ___. Brother died at the age of ___ from a myocardial infarction. Per OMR, maternal aunt with stomach cancer, maternal aunt with breast cancer and two cousins with breast cancer, younger sister with type 2 diabetes. <PHYSICAL EXAM> ADMISSION to FICU: Vitals: T: 98.5 BP: 100/44 P: 78 R: 18 O2: 100%RA GENERAL: Alert, oriented, no acute distress 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, colostomy in place RLQ with clean pink borders, midline abdominal scar, mild ttp in rlq, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: MAE LINES: 2 22g PIV, R arterial line LABS: see below DISCHARGE: 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, ostomy pink ___: nontender, nonedematous <PERTINENT RESULTS> ADMISSION: ___ 07: 30PM BLOOD WBC-11.2*# RBC-3.33* Hgb-10.3* Hct-28.8* MCV-86 MCH-30.9 MCHC-35.7* RDW-13.8 Plt ___ ___ 07: 30PM BLOOD ___ PTT-29.2 ___ ___ 07: 30PM BLOOD Plt ___ ___ 07: 30PM BLOOD ___ 08: 50PM BLOOD Glucose-187* UreaN-14 Creat-0.7 Na-140 K-3.1* Cl-109* HCO3-21* AnGap-13 ___ 08: 50PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.4* ___ 06: 53PM BLOOD Type-ART pO2-311* pCO2-36 pH-7.38 calTCO2-22 Base XS--2 Intubat-INTUBATED ___ 06: 53PM BLOOD Glucose-175* Lactate-2.2* Na-138 K-3.6 Cl-109* ___ 06: 53PM BLOOD Hgb-10.3* calcHCT-31 O2 Sat-99 ___ 06: 53PM BLOOD freeCa-1.05* ___ 12: 33AM BLOOD WBC-11.7* RBC-3.32* Hgb-10.1* Hct-28.7* MCV-87 MCH-30.3 MCHC-35.0 RDW-14.3 Plt ___ ___ 06: 06AM BLOOD WBC-13.1* RBC-3.28* Hgb-9.9* Hct-28.2* MCV-86 MCH-30.2 MCHC-35.2* RDW-14.6 Plt ___ ___ 04: 40PM BLOOD WBC-15.8* RBC-3.19* Hgb-9.4* Hct-27.2* MCV-85 MCH-29.6 MCHC-34.7 RDW-14.8 Plt ___ ___ 07: 40AM BLOOD WBC-14.8* RBC-2.90* Hgb-8.6* Hct-25.0* MCV-86 MCH-29.8 MCHC-34.4 RDW-14.4 Plt ___ ___ 06: 00AM BLOOD WBC-13.8* RBC-2.88* Hgb-8.5* Hct-25.2* MCV-88 MCH-29.7 MCHC-33.9 RDW-14.3 Plt ___ ___ 06: 00AM BLOOD WBC-12.1* RBC-2.91* Hgb-8.7* Hct-25.4* MCV-87 MCH-29.7 MCHC-34.1 RDW-13.8 Plt ___ ___ 05: 44AM BLOOD WBC-6.9 RBC-2.85* Hgb-8.6* Hct-25.3* MCV-89 MCH-30.1 MCHC-34.0 RDW-13.6 Plt ___ <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain 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 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. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Pelvic 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> 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. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. * If you have staples, they will be removed at your follow-up visit. . Ostomy care: For your ostomy a visiting nurse will be coming to your home for teaching and ostomy care. . 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 ___ previously healthy female who underwent Exploratory laparotomy, right salpingo-oophorectomy, end colostomy, and rigid proctoscopy for a large adherent deep pelvic side wall tumor of unclear etiology on ___ whose procedure was complicated by a large EBL of 1700cc and subseqent hypotension. and Immediately post-op she was transfered to the FICU for post-operative hypotension requiring phenylephrine in the setting of surgical blood loss and sedation. Post-operative course is as follows: # Hypotension: post-operative pressures in ___. Likely secondary to epidural, and significant 1700cc blood loss in the OR. Receuved 250cc albumin, 2.5L crystalloid, and 2 units PRBCs intraop. BP supported with phenylephrine, weaned as tolerated. A-line used for monitoring wherein her blood pressures remained stable. CBCs serially monitored which remained stable, not requiring additional transfusion. Her pain was controlled with dilaudid bolus PRN via access with two large bore IVs. She remained hemodynamically stable through her night in the ICU and was called out to the floor on post-operative day 1. Immediately prior to being transferred to the regular floor her epidural was restarted however was found to be hypotensive to the ___ upon arrival. Her epidural was turned off with resultant increase in her blood pressure to ___. She received a fluid bolus and her hematocrit was rechecked which continued to be stable. Upon cessation of her epidural she remained normotensive throughout the remainder of her post-operative course. Immediately postoperatively, her pain was controlled with an epidural however this was discontinued due to hypotension. Her pain was then controlled with dilaudid PCA and tylenol. Her diet was slowly advanced without difficulty and she was transitioned to oxcodone and tylenol for pain. On post-operative day #3, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She was also followed by an ostomy nurse for ostomy care and teaching during her admission. She was seen by social work as well. 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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10227305-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> wound infection <MAJOR SURGICAL OR INVASIVE PROCEDURE> Excisional debridement of abdominal wall wound <HISTORY OF PRESENT ILLNESS> This is a ___ y/o P1 ___ s/p pLTCS who was sent over from clinic today for wound eval. Two days ago she began noticing slight clear leakage from her vertical midline incision. Since then, the leakage has increased and become malodorous today. Also reports increasing abdominal pain since today. Has been placing pads over the incision and changing them every few hours; denies any topical therapies. She is using ___ tabs percocet q3-4h, as well a ibuprofen 600mg q6h and colace. Reports occasional sweats, but denies fevers, chills, nausea, vomiting, PO intolerance. Per her operative note, her vertical midline skin incision was closed as follows: fascia closed using 0 PDS ___ mass closure fashion, subcutaneous tissue closed ___ three layers using ___ Vicryl sutures ___ running fashion, and skin closed with staples. <PAST MEDICAL HISTORY> OB History: LTCS x 1, SAB x 1. pLTCS after second stage arrest. GBS negative. GYN History: remote hx of chlamydia. Negative during pregnancy. PMH: Obesity (BMI 53.5); asthma; sciatica PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On the day of admission: VS: T 98.3 HR 106 BP 144/86 RR 18 O2 100% RA Gen: A&O, NAD, FOB/baby present Resp: nl respiratory effort Abd: morbidly obese, soft, diffusely minimally tender to palpation over incision/pannus, non-distended, no rebound or guarding Incision: vertical midline incision with staples intact, malodorous yellow-green exudate diffusely along incision most notably at dependent inferior aspect of incision. Erythema extending laterally to patient's right, 3cm focal area of skin necrosis to right of incision debrided at bedside after prepping with Chloraprep and injection with 1% lidocaine. Area of necrosis extends through dermis ___ approx 1.5cm wide aspect; gray foul smelling fluid exudating; wound cx collected. On the day of discharge: VS: Afebrile, vital signs within normal limits Gen: well-appearing, comfortable, no acute distress Resp: normal respiratory effort Abd: morbidly obese, soft, non-tender, non-distended, wound vac ___ place over vertical midline incision with overlying abdominal binder, no surrounding erythema, induration or drainage Ext: no edema <PERTINENT RESULTS> ___ 05: 25PM BLOOD WBC-12.4* RBC-3.70*# Hgb-9.7*# Hct-30.7* MCV-83 MCH-26.3* MCHC-31.7 RDW-14.6 Plt ___ ___ 05: 25PM BLOOD Neuts-84.2* Lymphs-11.3* Monos-3.2 Eos-1.1 Baso-0.2 ___ 11: 20AM BLOOD WBC-10.0 RBC-3.57* Hgb-9.2* Hct-29.6* MCV-83 MCH-25.7* MCHC-31.0 RDW-14.5 Plt ___ ___ 11: 20AM BLOOD Neuts-84.6* Lymphs-11.6* Monos-2.6 Eos-1.0 Baso-0.1 ___ 03: 20PM BLOOD WBC-10.6 RBC-3.75* Hgb-9.7* Hct-30.9* MCV-83 MCH-26.0* MCHC-31.5 RDW-14.7 Plt ___ ___ 03: 20PM BLOOD Neuts-81.0* Lymphs-14.3* Monos-2.9 Eos-1.6 Baso-0.2 ___ 07: 55AM BLOOD WBC-8.9 RBC-3.37* Hgb-8.9* Hct-28.3* MCV-84 MCH-26.4* MCHC-31.4 RDW-14.3 Plt ___ ___ 07: 55AM BLOOD Neuts-75.4* ___ Monos-3.9 Eos-2.0 Baso-0.3 ___ 11: 20AM BLOOD Glucose-144* UreaN-8 Creat-0.6 Na-139 K-3.9 Cl-106 HCO3-25 AnGap-12 ___ 11: 20AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.7 ----- ___ 8: 30 pm SWAB Source: wound - superficial. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. WOUND CULTURE (Final ___: This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture.. ----- ___ 10: 14 pm SWAB Source: wound - deep. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture.. FURTHER WORK UP REQUESTED PER ___. ___ ___. ENTEROCOCCUS SP.. MODERATE GROWTH. STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE GROWTH. Sensitivity testing performed by Sensititre. CLINDAMYCIN MIC <= 0.12 MCG/ML. GRAM POSITIVE RODS. CORYNEFORM BACILLI . UNABLE TO FURTHER IDENTIFY. PRESUMPTIVE STREPTOCOCCUS BOVIS. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. HAEMOPHILUS SPECIES NOT INFLUENZAE. SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | STREPTOCOCCUS ANGINOSUS (___) GROU | | AMPICILLIN------------ <=2 S CLINDAMYCIN----------- S ERYTHROMYCIN---------- =>8 R PENICILLIN G---------- 2 S <=0.06 S VANCOMYCIN------------ 1 S <=1 S ANAEROBIC CULTURE (Final ___: MIXED BACTERIAL FLORA. Mixed bacteria are present, which may include anaerobes and/or facultative anaerobes. The presence of B.fragilis, C.perfringens, and C.septicum is being ruled out. BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH. BETA LACTAMASE POSITIVE. PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE POSITIVE. ----- ___ 11: 50 pm TISSUE ABDOMINAL WOUND TISSUE. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). Reported to and read back by ___ (___) 3: 25AM ___. SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final ___: MIXED BACTERIAL FLORA. Due to mixed bacterial types [>=3] an abbreviated workup is performed; all organisms will be identified and reported but only select isolates will have sensitivities performed. ENTEROCOCCUS FAECALIS. SPARSE GROWTH. GRAM POSITIVE RODS. SPARSE GROWTH. CORYNEFORM. UNABLE TO FURTHER IDENTIFY. STREPTOCOCCUS ANGINOSUS (___) GROUP. RARE GROWTH. Sensitivity testing performed by Sensititre. CLINDAMYCIN MIC <= 0.12 MCG/ML. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | STREPTOCOCCUS ANGINOSUS (___) GROU | | AMPICILLIN------------ <=2 S CLINDAMYCIN----------- S ERYTHROMYCIN---------- =>8 R PENICILLIN G---------- 4 S <=0.06 S VANCOMYCIN------------ 1 S <=1 S ANAEROBIC CULTURE (Final ___: MIXED BACTERIAL FLORA. Mixed bacteria are present, which may include anaerobes and/or facultative anaerobes. The presence of B.fragilis, C.perfringens, and C.septicum is being ruled out. BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ----- DERMATOPATHOLOGY REPORT - Final PATHOLOGIC DIAGNOSIS: Skin and soft tissue, abdomen (1A-B): Skin and subcutis with ulceration, acute inflammation, and florid necrosis with bacterial overgrowth. ----- <MEDICATIONS ON ADMISSION> 1. percocet 2. motrin 3. colace <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain Take with food to avoid GI upset. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not drive or combine with alcohol. Do not take >4000mg acetaminophen ___ 24hrs. RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID Hold for loose stools. RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 4. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 10 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills: *0 5. Ciprofloxacin HCl 750 mg PO Q12H Duration: 10 Days RX *ciprofloxacin 750 mg 1 tablet(s) by mouth every 12 hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Abdominal wound infection <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 postpartum service after presenting with an abdominal wound infection after your cesarean section. You were treated with debridement of your wound ___ the operating room and antibiotic treatment. You have recovered well and the teams feels that you are now ready to be discharged. Please follow the instructions below: * Take your medications as prescribed. You must finish all the antibiotics as prescribed. If infection symptoms increase, call ___ immediately. * You should not breastfeed while taking the current antibiotics. If you want to breastfeed, please contact us and the antibiotic regimen needs to be changed before you resume breastfeeding. * Follow the instructions for the wound vac as reviewed by the wound representative. * 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) ___ 24 hrs * No strenuous activity until your post-op appointment * Nothing ___ 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 Incision care: * You will have a visiting nurse to assist you with taking care of the wound vac at home. * Change the wound vac and evaluate wound every ___, ___, and ___ until wound is healed. * If any concern regarding the wound, please call ___ ___ and arrange for follow up. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ presented to gyn triage for evaluation of a possible wound infection after having been seen ___ clinic earlier that day. She was afebrile upon presentation with a borderline leukocytosis. Inspection of her wound ___ triage revealed diffuse erythema surrounding her vertical incision and a gray necrotic area of tissue slightly lateral to the incision, which was debrided under local anesthesia. Given the concern for extensive infection and pain control, the decision was made to proceed with a exploration and debridement of her wound ___ the operating room. General surgery was consulted and performed the surgery ___ conjunction with gynecology. Intra-op findings were notable for diffuse fat necrosis and infected tissue, requiring extensive debridement of the approximately 10x15x15cm wound area. Fascia was intact. The wound was packed with wet-to-dry dressings and she was admitted to the postpartum service for wound management. Her wound and tissue were cultured and ultimately grew out polymycrobial infections. Pre-operatively, she was started on Gentamicin and Clindamycin and received 1 dose each. Post-operatively, she was started on IV Vancomycin, Clindamycin and Cefipime. After consultation with ID on hospital day 3, she was transitioned to IV Zosyn alone, and then on hospital day 7, she was transitioned to PO Augmentin and Ciprofloxacin for a planned ___s an outpatient. For her wound management, the Wound Care team was consulted and actively involved ___ her care. She was treated with twice daily then daily wet-to-dry dressings with Aquacel Ag, and then on hospital day 5, she had a wound vac placed. ___ was set up for management of the wound vac and wound evaluation at home. For her pain, she was initially treated with a Dilaudid PCA and then transitioned to PO percocet and motrin, with well controlled pain. For prophylaxis, she received subcutaneous heparin TID throughout her hospitalization. She was discharged home on hospital day 6 ___ improved condition with close outpatient follow-up scheduled.
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: Sciatica pain Elevated blood pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> - repeat low transverse cesarean section - ___ IUD <HISTORY OF PRESENT ILLNESS> ___ G3P1011 @ ___ with morbid obesity and hx of prior C-section after IOL for gHTN presents with worsening sciatic pain. She has been followed for ___ horse pain" since ___ and ___ was recommended. She went to her initial apt but missed the next four. She has been taking 4000mg Tylenol daily since ___. She reports worsening in her sciatic pain with difficulty ambulating today so was brought to the ED via ambulance. Her pain originates in the right buttock and travels down past her knee. She denies any calf pain, chest pain, or SOB. She denies contractions, LOF, VB. +FM Given her hx of gHTN in last pregnancy, she has been followed closely with blood pressure monitoring and had normal baseline labs and a negative 24hr urine (112) on ___. Her booking blood pressure was 104/72 and her only elevated BP in review of records is 140/100 with rpt 128/82 on ___. She denies headache, visual changes, or RUQ pain. <PAST MEDICAL HISTORY> PNC: *) Dating: ___: ___ by 7wk US (not c/w LMP ___ - ___ ___ *) Labs: O+/Ab-/RPRNR/RI/HbsAg-/HCV-/HIV-/GBS neg *) Routine: - Genetics: - U/S: nl full fetal survey; EFW ___ (41%) - GLT: Normal early 1hr (124), elevated 1hr rpt (152), normal 3hr (76/181/151/90 on ___ - s/p TDaP and flu vaccines *) Issues - hx of prior low transverse c-section for arrest of descent (OP, asynclintic infant per op report) via vertical skin incision c/b wound infection c/f necrotizing faciitis s/p excisional debridement of abdominal wall wound in OR and wound vac for 6 months; signed consent for both repeat C-section and TOLAC; quoted 11% chance of VBAC success and rpt csx recommended in clinic and scheduled for ___. - hx of gHTN in prior preg: normal baseline labs (ALT 9/AST 14/CR 0.5/PLT 291/UP: C 0.1), neg 24hr urine (112) on ___ - Morbid obesity: BMI 58, HgA1C 5.8%, missed anesthesia consult- rescheduled to ___ - Positive Utox for marijuana ___ AND ___, rpt utox neg - UTI in preg s/p macrobid, neg TOC POBHx: G1 SAB G2 pLTCS for arrest of descent c/f CPD. Per Op Report, infant OP and asynclitic, no mention of narrow pelvis or recommendation for repeat csx in future G3 current PGynHx: Remote hx of abnl Pap with normal f/u; no colposcopy; denies hx of STI PMH: mild intermittent asthma - no hospitalizations or intubations PSH: C-section, tonsillectomy, ear and nose surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On arrival: BP 138/58 -> 152/93 (___) -> 140/102 -> 125/73 (3 min later after cuff adjusted) -> 128/82 -> 157/78 -> 132/74 (13 min later after cuff adjusted) -> 128/76 (2304) Gen: NAD, comfortable, eating doritos in triage Abd: soft, gravid, NT, unable to determine EFW by ___ due to habitus SVE: closed/long/posterior Ext: NT ___, positive straight leg raise test on right only On discharge: BP: xxxxxxxxx Gen: NAD, comfortable Abd: soft, NT, uterus at approximately xx, firm Ext: xxxxx[NT ___, positive straight leg raise test on right only] <PERTINENT RESULTS> ___ 08: 45PM BLOOD WBC-12.1* RBC-4.37 Hgb-11.0* Hct-34.4 MCV-79* MCH-25.2* MCHC-32.0 RDW-15.2 RDWSD-43.0 Plt ___ ___ 05: 55AM BLOOD WBC-11.5* RBC-4.51 Hgb-11.3 Hct-35.5 MCV-79* MCH-25.1* MCHC-31.8* RDW-15.4 RDWSD-43.0 Plt ___ ___ 10: 46PM BLOOD WBC-11.3* RBC-4.67 Hgb-11.8 Hct-36.4 MCV-78* MCH-25.3* MCHC-32.4 RDW-15.6* RDWSD-42.8 Plt ___ ___ 09: 05AM BLOOD Hct-28.9* ___ 08: 45PM BLOOD Plt ___ ___ 05: 55AM BLOOD Plt ___ ___ 10: 46PM BLOOD Plt ___ ___ 08: 45PM BLOOD Creat-0.4 ___ 05: 55AM BLOOD Creat-0.4 ___ 08: 45PM BLOOD ALT-6 AST-20 ___ 05: 55AM BLOOD ALT-6 AST-11 ___ 08: 45PM BLOOD UricAcd-2.9 ___ 05: 55AM BLOOD UricAcd-2.7 ___ 07: 51PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 07: 57PM URINE Color-Yellow Appear-Clear Sp ___ ___ 07: 51PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 07: 57PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 07: 51PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-17 TransE-<1 ___ 07: 57PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-12 ___ 07: 51PM URINE Mucous-RARE ___ 07: 57PM URINE Mucous-RARE ___ 07: 51PM URINE Hours-RANDOM ___ 07: 51PM URINE Hours-RANDOM Creat-151 TotProt-32 Prot/Cr-0.2 ___ 07: 51PM URINE Hours-RANDOM ___ 01: 13AM URINE pH-6 Hours-24 Volume-1000 Creat-132 TotProt-24 Prot/Cr-0.2 ___ 01: 13AM URINE pH-6 Hours-24 Volume-1000 ___ 01: 13AM URINE 24Creat-1320 24Prot-240 ___ 07: 51PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG marijua-NEGATIVE <MEDICATIONS ON ADMISSION> PNV, Tylenol daily, inhaler prn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN Pain Do not exceed greater than 4g in 24 hours RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN Constipation Please take this medication while you are on narcotics RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain Please take this medication with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive or operate heavy machinery while on this medication RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - gestational hypertension - repeat low transverse cesarean section of a live born baby boy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, ___ on the birth of your baby. Please find the discharge instructions below: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks 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 the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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Ms. ___ was admitted to the antepartum service for evaluation of her labile blood pressures and severe sciatic pain limiting her mobility. HELLP labs were normal on admission. A 24 hour urine protein collection was 240 mg. She had no symptoms of pre-eclampsia. Initially, there was concern about whether her elevated blood pressures were due to incorrect cuff size. However, with careful monitoring, she did have several mild range blood pressures and this was consistent with a diagnosis of gestational hypertension. Plan was made for delivery between 37 and 38 weeks of gestation per ACOG guidelines. Fetal testing with a growth scan, BPP and daily NSTs were reassuring. ___ was consulted for assistance with her sciatica and pain and met with her for several sessions to assist in improving her mobility. She was counseled about mode of delivery (TOLAC vs repeat C-section) and after thorough counseling opted for a scheduled repeat C-section. She had an uncomplicated low transverse cesarean section on ___ with delivery of a live born baby boy. A ___ IUD was placed during delivery. Her postpartum course was significant for well controlled blood pressures not requiring anti-hypertensives. Her back and leg pain improved postpartum and she was able to ambulate without difficulty. She was discharged home on PPD # with a 2 week and 6 week follow-up appointment scheduled.
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10227447-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim / Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___ <CHIEF COMPLAINT> elevated BP, HA <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery <HISTORY OF PRESENT ILLNESS> ___ G3P2 at 36+0 with cHTN (BPs 140's over 90's documented as far back as ___ and mild range BP4/2. Outptatient labs WNL. Yesterday developed frontal headache, took BP at ___ and was 160/103. Called office today and was told to come in. In office, BPs 130's over 80's x2 but pt reports HA, "fuzzy vision" for a few seconds and RUQ "sharp" pain that comes/goes occasionally. <PAST MEDICAL HISTORY> NC: - Rh neg (s/p rhogam ___ @ 28wks) - ERA low risk - FFS echogenic bowel - GLT neg - Issues *) elevated BMI 37 OBHx: G3P2 (CS x2 for breech and repeat) GynHx: hx abnl pap s/p colpo PMH: asthma, carpal tunnel PSH: C/S <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Admission: -VS: ___ 17: 45BP: 141/85 (98) ___ ___: 114 ___ 18: 00Temp.: 98.5°F ___ 18: 15BP: 110/73 (78) ___ 18: 21BP: 108/81 (86) ___ 18: 30BP: 90/47 (55) ___ ___: 110 ___ 19: 00BP: 126/81 (91) ___ 19: 15BP: 134/81 (94) -Gen: NAD -Abd: gravid, soft, NT, including RUQ area -NST: 130's, mod var, +accels, no decels -Toco: rare ctx Discharge: Vitals: 24 HR Data (last updated ___ @ 2241) Temp: 98.4 (Tm 98.4), BP: 120/64 (112-134/64-81), HR: 58 (58-84), RR: 18, O2 sat: 96% (96-98) Gen: NAD, A&Ox3 Cardiopulm: No respiratory distress Abd: soft, NTND, fundus firm below umbilicus Incision: c/d/I, no erythema or purulent drainage Ext: no calf tenderness <PERTINENT RESULTS> ___ 12: 20PM BLOOD WBC-10.5* RBC-4.05 Hgb-11.6 Hct-36.0 MCV-89 MCH-28.6 MCHC-32.2 RDW-13.6 RDWSD-44.2 Plt ___ ___ 11: 05AM BLOOD WBC-UNABLE TO RBC-UNABLE TO Hgb-UNABLE TO Hct-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO RDWSD-UNABLE TO Plt Ct-UNABLE TO ___ 05: 40AM BLOOD WBC-9.2 RBC-3.70* Hgb-10.6* Hct-32.3* MCV-87 MCH-28.6 MCHC-32.8 RDW-13.7 RDWSD-43.2 Plt ___ ___ 06: 13PM BLOOD WBC-9.3 RBC-3.79* Hgb-11.0* Hct-32.7* MCV-86 MCH-29.0 MCHC-33.6 RDW-13.7 RDWSD-42.5 Plt ___ ___ 11: 05AM BLOOD Creat-0.4 ___ 05: 40AM BLOOD Creat-0.5 ___ 06: 13PM BLOOD Creat-0.5 ___ 11: 05AM BLOOD ALT-19 AST-33 ___ 05: 40AM BLOOD ALT-21 AST-38 ___ 06: 13PM BLOOD ALT-21 AST-45* ___ 11: 05AM BLOOD UricAcd-3.9 ___ 05: 40AM BLOOD UricAcd-3.9 ___ 06: 13PM BLOOD UricAcd-3.4 ___ 08: 30PM URINE pH-6 Hours-24 Volume-4775 Creat-52 TotProt-17 Prot/Cr-0.3* <MEDICATIONS ON ADMISSION> albuterol, clobetasol, PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H 2. Ibuprofen 600 mg PO Q6H RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Preeclampsia Repeat cesarean delivery <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 ___ G3P2 (now P3) who presented at 36+1 weeks with elevated blood pressures and HA in the setting of chronic HTN. She was admitted to the antepartum service for observation, but due to inpatient acuity, so she was managed on labor and delivery. Her serum pre-eclampsia labs were normal, but she ruled in with a P/C 0.3. Her 24 hour urine protein returned at 812 mg. She declined betamethasone. She initially reported a headache that subsequently improved and then returned persistently. Her blood pressures worsened, became severe and the patient was started on magnesium for seizure prophylaxis now that the patient had met criteria for severe preeclampsia, severe blood pressures and headache. The patient had history of a prior primary C-section, initially for breech, second repeat and her most current pregnancy would be for a third repeat. The patient was counseled on delivery via repeat cesarean section given severe preeclampsia. The patient expressed understanding. She underwent an uncomplicated cesarean section on ___. She remained on magnesium for 24 hours post partum. Her blood pressures were normal to mild range post partum. Her foley catheter was removed, and she voided without difficulty. She tolerated a regular diet and was able to ambulate. She was discharged on post operative day #4 with instructions for follow up.
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10229390-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> pain s/p hemorrhoid excision <MAJOR SURGICAL OR INVASIVE PROCEDURE> Hemorrhoidectomy (performed in the office prior to admission) <HISTORY OF PRESENT ILLNESS> ___ G2P0 at 36w5d referred by colorectal surgery for direct admission to antepartum service. Per report and discussion with colorectal: Patient had office excision of thrombosed hemorrhoid today. Immediately following procedure, patient noted to have bleeding from excision site. Rectal pack and stitch placed. Patient with increased pain in area. Currently, patient reports rectal pain and "stinging" sensation. No vaginal bleeding. Intermittent abdominal tightening, no painful ctxns. No LOF, no vaginal bleeding. Reports active fetal movement. <PAST MEDICAL HISTORY> Prenatal Care: PNC: - ___ ___ by LMP - Labs A+/Abs-/RI/RPRNR/HBsAg-/HIV-/GBS unk - Screening: LR ERA, neg AFP - FFS: normal, boy - GTT: normal - Issues: *) Hx of cervical cone, nl CL at FFS . Obstetric History: TAB x 1 Medical/Surgical History: - Hx of HSV - Hx of abnormal paps -> s/p cone - Denies fibroids, Gyn surgery, STIs - Hx of ovarian cysts PMH: as above PSH: D+C <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Admission: VS- 98.0, 73, 18, 118/78 Gen: NAD, appears uncomfortable Abd: soft, NT, ND, no R/G Rectal packing in place, small amt of blood, not soaked. FHT: 140, mod var, +accels, no decels (Reactive) Toco: q ___ mins (not felt by pt) BPP: ___, vtx, AFI 13.2cm <PERTINENT RESULTS> ___ 08: 15PM BLOOD WBC-10.4 RBC-4.22 Hgb-13.6 Hct-38.3 MCV-91 MCH-32.3* MCHC-35.6* RDW-13.9 Plt ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth q6 hours Disp #*30 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: *2 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Thrombosed hemorrhoids <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 after your hemorrhoidectomy in the office becuase you experienced some post-procedural bleeding. You received antibiotics afterwards. The bleeding has stopped and you are now being discharged home. Following your hemorrhoidectomy, you may experience some discomfort in your rectal area. You may also experience constipation, difficulty urinating, and possibly some rectal bleeding. The following are some general guidelines for proper care after your procedure. - A certain amount of bleeding is not uncommon following rectal surgery. A sanitary napkin may be helpful in the first several days after surgery. - Continue your regular diet as soon as you can tolerate it. - Take a stool softener (colace) for 10 days to prevent hard stools - ___ baths- This is sitting in a tub of warm water for five minutes at least twice a day will help your discomfort. Remove dressings and do not reapply them unless directed by your doctor. - To avoid upset stomach, take your pain medication as prescribed with food in your stomach. - Your nurse ___ instruct you on how to use ___ bath. Start these the day after your surgery in the morning. You are to do three per day and one after each bowel movement to cleanse the area. Continue these until you return for your next doctors appointment. - If your stools become too loose while using the stool softeners, stop them CALL YOUR PHYSICIAN IF YOU EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS: 1. Pain not controlled by your pain medication 2. Constipation not relieved by your stool softener medication 3. Worsening bleeding
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Ms. ___ was admitted for pain control and observation due to bleeding after office hemorrhoidectomy. Overnight she remained on IV pain medication and antibiotics, and her bleeding subsided. Colorectal Surgery consult was obtained, and her management and disposition were made on their recommendations. On Hospital Day 2, bleeding had stopped, antibiotics and foley were discontinued, and she was advanced to oral pain medications. She was discharged on HD #2 in stable condition, voiding, tolerating a regular diet, and her pain well controlled on oral medications. She was given rectal care and follow up instructions per Colorectal Surgery.
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10229579-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> erythromycin / Penicillins / Lexapro / Levaquin / ciprofloxacin / doxycycline <ATTENDING> ___. <CHIEF COMPLAINT> abdominal and fevers <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G1P1 with a h/o drug induced lupus, depression, and menorrhagia ___ to fibroids and endometrial polyps who is 2 days s/p a ___ transferred from ___ w/ abdominal pain, n/v, and fevers, OB/GYN was consulted for evaluation of post-operative complications. On ___, she underwent an operative hysteroscopy w/ submucosal myoma resection and D&C for menorrhagia, submucosal fibroids, and endometrial polyps. Over 50% of the fibroid was protruding into the uterine cavity. The procedure was uncomplicated. The patient reported overall feeling well after the procedure until yesterday on ___ when she developed nausea, 2 episodes of small volume (1 cup full), non-bilious emesis, dizziness, and fevers with a T-max of 101.4. She reported that the episodes of emesis were small volume approximately 1 cupful. Her last emesis was noon on ___. Given these symptoms, the patient called her primary surgeon and was instructed to present to the emergency room at ___ for further evaluation. Exam at ___ notable for fever of 100.5, tachycardia with a heart rate of 118, BP 121/76, RR 18, satting 100% on room air. Abdomen was noted to be tender. Pelvic exam deferred. PUS was performed at ___, which has been unread. Labs performed were notable for a white count of 6.9 with no bandemia and a slight left shift of 74. She had a normal lactate of 1.1. Her labs were only notable for a mild hypokalemia of 3.4. At ___, she was treated w/ the following: Flagyl ___, Toradol ___, morphine and ___, and ceftriaxone at 2238. Given the patients pain and fever, there was concern for postprocedural endometritis. The patient was transferred to ___ for further management. Upon arrival to the ED, the patient reports feeling the same. She denies any further episodes of emesis. She reports some mild to moderate lower abdominal pelvic pain. She denies any heavy vaginal bleeding. She reports only spotting after the surgery. She denies any unusual vaginal discharge. She denies any urinary or bowel symptoms such as constipation or diarrhea. ROS: 10 point review of systems is otherwise negative except as mentioned above PMH: - anxiety/depression - Lupus SLE vs drug-induced - GERD - sickle cell trait - migraine HA - asthma, exercise induced - SVT - Anemia PSH: - ___ hsc mmy, D&C - eye surgery OBHx: G1P1 GYNHx: h/o fibroids, denies h/o STIs, abnormal pap smears - LMP ___ - no contraception - sexually active w/ female partner - no h/o STIs - last STI screening per pt report ___, declines further testing SH: denies T/D/E MEDS: - Effexor 37.5 - iron 325 - meloxicam 7.5mg Allergies (Last Verified ___ by ___: *Penicillins ciprofloxacin doxycycline erythromycin Levaquin Lexapro <PHYSICAL EXAM> General: NAD, comfortable CV: RRR, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, minimal fundal tenderness with deep palpation. no rebound or guarding. Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 11: 15AM GLUCOSE-81 UREA N-6 CREAT-0.6 SODIUM-139 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-21* ANION GAP-15 ___ 11: 15AM CALCIUM-8.0* PHOSPHATE-2.0* MAGNESIUM-1.5* ___ 11: 15AM NEUTS-51.3 ___ MONOS-12.9 EOS-6.7 BASOS-0.8 IM ___ AbsNeut-2.59 AbsLymp-1.41 AbsMono-0.65 AbsEos-0.34 AbsBaso-0.04 ___ 11: 15AM PLT COUNT-184 ___ 06: 20AM URINE HOURS-RANDOM ___ 06: 20AM URINE UCG-NEG ___ 06: 20AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06: 20AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-80* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR* ___ 06: 20AM URINE RBC-3* WBC-9* BACTERIA-FEW* YEAST-NONE EPI-2 ___ 06: 20AM URINE MUCOUS-FEW* ___ 06: 00AM WBC-6.4 RBC-3.26* HGB-7.3* HCT-24.7* MCV-76* MCH-22.4* MCHC-29.6* RDW-15.9* RDWSD-43.7 ___ 06: 00AM PLT COUNT-158 ___ 03: 56AM GLUCOSE-85 UREA N-7 CREAT-0.7 SODIUM-138 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-20* ANION GAP-13 ___ 03: 56AM estGFR-Using this ___ 03: 56AM WBC-6.6 RBC-3.50* HGB-7.6* HCT-25.9* MCV-74* MCH-21.7* MCHC-29.3* RDW-16.0* RDWSD-42.6 ___ 03: 56AM NEUTS-56.1 ___ MONOS-9.6 EOS-5.5 BASOS-0.6 IM ___ AbsNeut-3.67 AbsLymp-1.83 AbsMono-0.63 AbsEos-0.36 AbsBaso-0.04 ___ 03: 56AM PLT COUNT-173 ___ 03: 56AM ___ PTT-24.9* ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for management of your post-operative endometritis. 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. Endometritis: Infection of your uterus. * Take your antibiotics as prescribed. Please complete the full course of antibiotic. * You may eat a regular diet. * You may walk up and down stairs **** It is important to call your doctor if you develop any abdominal pain, fever, chills, abnormal vaginal discharge. **** 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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*) Postprocedural endometritis - ___ hsc mmy & D&C, uncomplicated - Tmax (home) 101.4 w/ abd pain, nausea (resolving), and 2 episodes of small volume emesis - bimanual exam notable for fundal tenderness - continue IV gent/clinda x 72hrs (___) - pain: Tylenol, ibuprofen | Zofran prn nausea - ADAT - Final CT Abd/Pelvis ___: no e/o bowel injury. No air or fluid. Heterogeneity of endo cavity. Fibroid uterus. - transition to PO clindamycin ___ AM *) h/o drug induced lupus: multiple antibiotic drug allergies, s/p plaquenil, holding meloxicam in the setting of ibuprofen administration *) depression: continue Effexor 37.5mg 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:*0 2. Clindamycin 600 mg PO Q8H RX *clindamycin HCl 300 mg 2 capsule(s) by mouth every 8 hours. Disp #*72 Capsule Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours. Disp #*50 Tablet Refills:*0 4. Venlafaxine XR 37.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: post-operative endometritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10230141-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / latex / Reglan / indomethacin / Compazine <ATTENDING> ___. <CHIEF COMPLAINT> syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ 5d with h/o POTS, idiopathic intracranial HTN presenting with syncope x 2 today. Reports that the initial episode was at around 0800. She initially felt dizzy and then fainted hitting her cheek bone. The second episode occurred at around 1000 and this time her brother caught her before she fell. Denies jerking movements, tongue biting, altered mental status or urinary incontinence with both episodes. Reports episodes similar to POTS episodes. Reports palpitations with change in position which eventually become CP. Patient presented to the ED where she had EKG which showed anterior lead ST depression. Trop, lytes, CBC and UA were negative. She was then transferred to OB triage for further management. Denies SOB, ctx, VB, LOF, N/V, F/C. +FM. <PAST MEDICAL HISTORY> PNC: - ___ ___ by early U/S - Labs Rh /Abs /Rub /RPR /HBsAg /HIV /GBS - Screening: low risk ERA - FFS: normal FFS - U/S: ___, 95%ile - Issues: 1) Bipolar: Predominantly depressive sx. Followed by psych at ___ (Dr. ___, mood improved. On Ativan 1mg BID, Zoloft 50mg daily 2) S/p Gastric sleeve in ___ - ___: HCT 33, normocytic, normal B12 level. Pt still unable to take iron, B12 and Folate. Cont PNV. 3) Migraines - receiving botox injections with neurologist at ___- last ___ - previously used Tylenol 3, currently on Fioricet 4) POTS vs vasovagal syncope: Seen by cardiology at both ___ and ___. - Per cardiology at ___, most c/w vasovagal syncope; recommend postpartum tilt table testing. Holter monitor at ___ with sinus tach correlating with some episodes. - reports that Cardiology advised she f/u postpartum, has not met with them since ___ done - had normal echo 5) H/o DVT: provoked (in setting of PICC line) -recommend ppx anticoagulation for 6 weeks postpartum with prophylactic lovenox 6) Idiopathic Intracranial HTN-> likely resolved per neuro notes Followed by neurology at ___. Had previously been on acetazolamide, discontinued due to parasthesias. On review of records neurology feels intracranial hypertension no longer an issue following weight loss. OBHx: G1 GynHx: denies abnormal Pap, fibroids, Gyn surgery, STIs PMHx: POTS, endometriosis, bipolar, migraines, idiopathic intracranial HTN PSHx: LSO, gastric sleeve, T&A, breast reduction, breast lumpectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On admission: T 98.7 BP 90/59 HR 79 (lying down) BP 100/62 HR 98 (sitting) BP 117/71 HR 94 (standing) Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Neuro: grossly intact Ext: no calf tenderness SVE: deferred On discharge: AF VSS Gen: NARD, comfortable CV: RRR Lungs: CTAB Abd: Soft, nontender, gravid SVE: Deferred Ext: nontender, no edema <PERTINENT RESULTS> ___ 01: 10PM BLOOD WBC-7.4 RBC-3.63* Hgb-11.0* Hct-33.5* MCV-92 MCH-30.3 MCHC-32.8 RDW-13.4 RDWSD-45.2 Plt ___ ___ 01: 10PM BLOOD Neuts-60.4 ___ Monos-7.0 Eos-0.8* Baso-0.1 Im ___ AbsNeut-4.46 AbsLymp-2.29 AbsMono-0.52 AbsEos-0.06 AbsBaso-0.01 ___ 01: 10PM BLOOD Glucose-74 UreaN-6 Creat-0.4 Na-138 K-3.7 Cl-104 HCO3-26 AnGap-12 ___ 07: 07AM BLOOD Glucose-83 UreaN-4* Creat-0.5 Na-138 K-3.6 Cl-107 HCO3-24 AnGap-11 ___ 06: 38AM BLOOD Glucose-65* UreaN-5* Creat-0.5 Na-137 K-3.6 Cl-105 HCO3-28 AnGap-8 ___ 06: 27AM BLOOD Glucose-69* UreaN-4* Creat-0.5 Na-137 K-3.6 Cl-104 HCO3-25 AnGap-12 ___ 06: 27AM BLOOD Glucose-66* UreaN-4* Creat-0.4 Na-137 K-3.7 Cl-105 HCO3-24 AnGap-12 ___ 01: 10PM BLOOD cTropnT-<0.01 ___ 05: 39PM BLOOD cTropnT-<0.01 ___ 01: 10PM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7 ___ 07: 07AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.6 ___ 06: 38AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.3* ___ 06: 27AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.3* ___ 06: 27AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.3* ___ 01: 10PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 01: 10PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-___ ___ 01: 10PM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-2 ___ 1: 10 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. <MEDICATIONS ON ADMISSION> Fioricet PRN, Ativan BID, sertraline 50 mg daily, Colace, miralax, PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation 2. LORazepam 1 mg PO BID 3. Prenatal Vitamins 1 TAB PO DAILY 4. Sertraline 50 mg PO DAILY 5. Midodrine 5 mg PO TID Please take at 8am, 1pm and 6pm. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vasovagal syncope <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 overnight to the high risk OB service for 2 episodes of syncope (passing out). You were seen by Cardiology who agreed this was consistent with your vasovagal episode (passing out) likely also with dehydration. You were also seen by Neurology who started you on a medication (midodrine) that you should take three times daily (at 8am, 1pm, 6pm). You should not take this right before going to sleep. We recommend the following: - Please stop using miralax. - Please drink 2 liters of oral fluid daily; please have at least ___ be fluids with electolytes (Gatorade). - Please increase the amount of salt in your diet. - Please wear compression stockings. - We recommend you STOP driving until evaluated by Neurology given your recurrent episodes of fainting. - Follow up with Cardiology as scheduled. - Follow up with Neurology as scheduled - Start midodrine as prescribed by Neurology; please take at 8am, 1pm and 6pm.
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Ms. ___ was admitted to the antepartum service given recurrent syncope. She has a long standing history of syncope thought to be possible postural orthostatic tachycardia syndrome, although has never undergone tilt table testing. During her admission, she was hydrated with IV fluids. She was seen by Cardiology who thought these episodes were likely secondary to vasovagal syncope compounded by hypovolemia. They recommended 2L of PO fluid intake per day with ___ electrolytes, as well as compression stockings. The Autonomic Neurology service was contacted and recommended outpatient followup. On hospital day #3, she experienced an episode of syncope followed by shaking movements upon returning to bed. She was alert and oriented throughout her shaking episode, which lasted approximately 10 minutes. She was seen by Neurology who concluded that this was not consistent with seizure activity, and that she did not meet the criteria for POTS. They agreed with Cardiology's recommendations. They recommended she start on midodrine 5mg three times daily and undergone postpartum autonomic testing. Orthostatic vital signs were objectively negative, but the patient would feel symptomatic (dizziness) with standing. She received daily labs with repletion of electrolytes. She had daily reactive NSTs. By hospital day #5, her symptoms were improved and she was discharged home in stable condition with outpatient followup in 1 week with OB and a recommendation to followup with her primary Neurologist at ___. We recommended that she not drive given her recurrent episodes of syncope.
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10230141-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / latex / Reglan / indomethacin / Compazine <ATTENDING> ___. <CHIEF COMPLAINT> syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at ___ with h/o POTS, idiopathic intracranial HTN, and recent admission for syncope (___) presents after syncopal episodes x3 today. The first two episodes occurred at home while getting up to go to the bathroom. She fell into her husband's arms each time after losing consciousness. She reports urinary incontinence during one of the episodes which has never happened before. She denies tongue biting and her husband denies witnessing any convulsions or seizure activity. The third episode occurred while in the elevator up to Ob triage. Before this episode only she felt dizzy as if "on a roller coaster." She also reports chest pressure but denies CP or SOB. Also reports mild headache today c/w with her usual migraines. She reports blurry vision in her left eye this morning that has since resolved. She denies ctx, VB, LOF. +FM <PAST MEDICAL HISTORY> PNC: - ___ ___ by early U/S - Labs Rh /Abs /Rub /RPR /HBsAg /HIV /GBS - Screening: low risk ERA - FFS: normal FFS - U/S: ___, 95%ile - Issues: 1) Bipolar: Predominantly depressive sx. Followed by psych at CHA (Dr. ___, mood improved. On Ativan 1mg BID, Zoloft 50mg daily 2) S/p Gastric sleeve in ___ - ___: HCT 33, normocytic, normal B12 level. Pt still unable to take iron, B12 and Folate. Cont PNV. 3) Migraines - receiving botox injections with neurologist at ___- last ___ - previously used Tylenol 3, currently on Fioricet 4) POTS vs vasovagal syncope: Seen by cardiology at both ___ and ___. - Per cardiology at ___, most c/w vasovagal syncope; recommend postpartum tilt table testing. Holter monitor at ___ with sinus tach correlating with some episodes. - reports that Cardiology advised she f/u postpartum, has not met with them since Holter done - had normal echo 5) H/o DVT: provoked (in setting of PICC line) -recommend ppx anticoagulation for 6 weeks postpartum with prophylactic lovenox 6) Idiopathic Intracranial HTN-> likely resolved per neuro notes Followed by neurology at ___. Had previously been on acetazolamide, discontinued due to parasthesias. On review of records neurology feels intracranial hypertension no longer an issue following weight loss. OBHx: G1 GynHx: denies abnormal Pap, fibroids, Gyn surgery, STIs PMHx: POTS, endometriosis, bipolar, migraines, idiopathic intracranial HTN PSHx: LSO, gastric sleeve, T&A, breast reduction, breast lumpectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On admission: BP 96/51 HR 85 (lying down) BP 100/59 (sitting) BP 98/51 HR 80 (standing) Gen: A&O, comfortable Neuro: CNII-XII intact, strength ___, and sensation symmetric Abd: soft, gravid, nontender SVE: deferred Ext: no calf tenderness On discharge: AF VSS Gen: A&O, comfortable CV: RRR Lungs: CTAB Abdomen: Soft, gravid, nontender SVE: Deferred Ext: no calf tenderness <PERTINENT RESULTS> ___ 05: 17PM BLOOD WBC-7.8 RBC-3.56* Hgb-10.7* Hct-32.3* MCV-91 MCH-30.1 MCHC-33.1 RDW-13.2 RDWSD-43.7 Plt ___ ___ 05: 17PM BLOOD Glucose-74 UreaN-5* Creat-0.4 Na-136 K-3.8 Cl-103 HCO3-24 AnGap-13 ___ 05: 17PM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7 <MEDICATIONS ON ADMISSION> Ativan BID, sertraline 50 mg daily, PNV, midodrine 5mg TID <DISCHARGE MEDICATIONS> 1. LORazepam 1 mg PO BID 2. Midodrine 5 mg PO Q0800,Q1300,Q1800 3. Sertraline 50 mg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vasovagal syncope <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 antepartum service with an episode of syncope. This was consistent with your prior episodes. You received IV fluid hydration and your symptoms improved. You are safe to be discharged home. Please continue your midodrine three times daily, at 8am, 1pm and 6pm. 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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Ms. ___ was admitted to the antepartum service with an episode of syncope in the setting of decreased oral intake. She was started on IV fluids. Electrolytes were checked and were within normal limits. She was continued on her recently started medication midodrine. She had a reactive NST daily. On hospital day #2, her dizziness had improved and she had increased oral intake. Her IV fluids were discontinued and she was discharged home with a plan for followup in 2 days in ___ clinic. We recommended she schedule followup with Neurology at ___ for further evaluation of her syncope. A consult was deferred during this admission given that Neurology had consulted the week prior.
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10230141-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / latex / Reglan / indomethacin / Compazine <ATTENDING> ___. <CHIEF COMPLAINT> convulsions <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G1P0 @ ___ with hx of DVT and frequent syncopal episodes due to POTS vs vasovagal syncope brought to ED via EMS with concern for seizure activity. Patient reports feeling lightheaded and nauseous then while in the bathroom preparing to vomit she lost consciousness. Per her mother who witnessed the event, while in the bathroom, her eyes rolled back, arms began to tremor, fists slowly became clenched, and both legs became stiff. These events lasted fifteen minutes and she was responsive throughout. Her mother reports that this episode was different from her past syncopal episodes. The patient denies tongue biting, head trauma, and urinary incontinence. She denies F/C, CP/SOB and abd pain. She denies VB or LOF. She had two contractions all day. She has had a headache and photophobia all day c/w with her usual migraines. She reports seeing floaters earlier today, but not currently. She denies a diagnosis of seizures but had an EEG and MRI done prior to pregnancy at ___ for possible seizure. She does report a history of upper extremity tremors in the past. In the ED, she received a 4gm bolus of magnesium prior to transfer to Ob Triage. <PAST MEDICAL HISTORY> PNC: - ___ ___ by early U/S - O pos/ab neg/RI/HIV neg/HBsag neg/Hep C neg/RPR NR/GC neg/CT negative/GBS unk - Screening: low risk ERA - FFS: normal FFS - GLT: not done, risk of dumping syndrome s/p gastric sleeve, random FSBS always <100 - U/S ___: BPP ___, EFW 1590g, 41% - Issues: 1) Bipolar: Predominantly depressive sx. Followed by psych at CHA (Dr. ___, mood improved. On Ativan 1mg BID, Zoloft 50mg daily 2) S/p Gastric sleeve in ___: HCT 33, normocytic, normal B12 level. Pt still unable to take iron, B12 and Folate. 3) Migraines: receiving botox injections with neurologist at ___, last ___. previously used Tylenol 3 and Fioricet. 4) POTS vs vasovagal syncope: Seen by cardiology at both ___ and ___. Per cardiology at ___, most c/w vasovagal syncope, recommend postpartum tilt table testing. Holter monitor at ___ with sinus tach correlating with some episodes. s/p ___ neuro consult and started on midodrine ___. Had normal echo. Has weekly pheresis appts for IVF. 5) H/O DVT: provoked (in setting of PICC line): recommend ppx anticoagulation for 6 weeks postpartum with prophylactic lovenox 6) Idiopathic Intracranial HTN: likely resolved per neuro notes. Followed by neurology at ___. Had previously been on acetazolamide, discontinued due to parasthesias. On review of records neurology feels intracranial hypertension no longer an issue following weight loss. 7) Antepartum admission ___ & ___ following syncopal episode. OBHx: G1 current GynHx: denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: POTS vs vasovagal syncope, endometriosis, bipolar, migraines, hx idiopathic intracranial HTN now resolved, hx DVT PSH: LSO, gastric sleeve, knee surgery, T&A, breast reduction, breast lumpectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On admission: Initial VS in ED 99.0 101 117/70 -> 96/60 14 100% RA Gen: NAD, resting comfortably in stretcher, A&Ox3, conversant CV: RRR Pulm: CTAB Abd: soft, gravid, NT GU: no wetness on pants or underwear Ext: +3 DTR b/l brachioradialis and patellar reflexes, +1 ankle clonus b/l, no tremors noted On discharge: AF VSS orthostats lying down 97/53 HR 87 sitting 107/44 HR 82 standing 105/73 HR 85 General: NARD, comfortable, pleasant CV: RRR Lungs: CTB Abdomen: Soft, gravid, nontender SVE: Deferred Extremities: nontender, no edema <PERTINENT RESULTS> ___ 09: 25PM BLOOD WBC-9.8 RBC-3.33* Hgb-9.8* Hct-30.6* MCV-92 MCH-29.4 MCHC-32.0 RDW-12.6 RDWSD-41.7 Plt ___ ___ 09: 25PM BLOOD Neuts-58.4 ___ Monos-8.3 Eos-0.8* Baso-0.2 Im ___ AbsNeut-5.72 AbsLymp-3.09 AbsMono-0.81* AbsEos-0.08 AbsBaso-0.02 ___ 09: 25PM BLOOD ___ PTT-23.7* ___ ___ 09: 25PM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-139 K-3.7 Cl-106 HCO3-23 AnGap-14 ___ 09: 25PM BLOOD ALT-12 AST-20 AlkPhos-118* TotBili-0.1 ___ 09: 25PM BLOOD Albumin-2.9* Calcium-8.3* Phos-2.5* Mg-1.6 UricAcd-3.4 ___ 09: 25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09: 45PM BLOOD Lactate-2.0 ___ 03: 43AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG marijua-NEGATIVE EEG ___ normal continuous ICU EEG monitoring study in wakefulness and sleep. There were no areas of prominent focal slowing, and there were no epileptiform discharges or electrographic seizures. There were no pushbutton activations. EEG ___ Normal continuous ICU EEG monitoring study in wakefulness and sleep. There were no areas of prominent focal slowing, and there were no epileptiform discharges or electrographic seizures. There were no pushbutton activations. Compared to the prior day's recording, the record was unchanged. EEG ___ This telemetry captured no pushbutton activations. It showed a normal background, usually in drowsiness. There were no focal abnormalities or epileptiform features. <MEDICATIONS ON ADMISSION> PNV Zoloft Ativan Midodrine 5 TID Colace Miralax <DISCHARGE MEDICATIONS> 1. Midodrine 5 mg PO 3X/DAY 2. Prenatal Vitamins 1 TAB PO DAILY 3. Sertraline 50 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 33w1d recurrent syncope <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 hospital for a vasovagal event with characteristics that were concerning for a seizure. You were observed on the antepartum service while an electroencephalogram (EEG) was performed to monitor seizure activity. The neurology team was following you while you were admitted. While in the hospital, your midodrine was continued, and you received IV fluids. You will continue to get IV fluids in the pheresis unit twice weekly. You recovered well, and there was no evidence of seizure like activity on work up. The team feels as though you are now safe to be discharged home.
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Ms. ___ is a ___ year old G1P0 well known to the ___ service with a history of POTS vs vasovagal syncope as well as PICC-associated DVT who presented at 33w0d who presented with possible seizure activity. However, per report she was responsive throughout the episode without a postictal state, but the was thought to be different from her prior episodes of syncope and tremors. On arrival to the ED, she was given a 4gm magnesium bolus due to initial concern for eclampsia. However, after she was seen and evaluated by OB, this was thought to be much lower on the differential given normal BP and normal labs. Neurology was consulted who had a low suspicion for seizure, but recommended admission. She was admitted to the antepartum service for further neurologic evaluation. She underwent continuous EEG and Neurology followed along during her admission. She was without further evidence of convulsive activity. She received IV fluids and her vasovagal symptoms improved. Head MRI was recommended and declined by the patient after full counseling. Suspicion for eclampsia remained low. She had normal BP throughout her admission. Social Work was consulted given multiple admission and followed along throughout her admission. Ultimately, her evaluation was negative and symptoms were thought to be secondary to vasovagal syncope. Her orthostatic vital signs were negative throughout her admission. She was continued on midodrine. She had reassuring fetal status with a reactive NST daily. She received a betamethasone course for fetal lung maturity. She was betamethasone complete on ___. She was ultimately discharged home on hospital day #2 in stable condition with twice weekly IV fluid infusions scheduled and a prenatal visit scheduled the following week.
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10230141-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / latex / Reglan / indomethacin / Compazine <ATTENDING> ___. <CHIEF COMPLAINT> syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ w 2 d who has h/o multiple syncope, bipolar affective disorder, h/o DVT, who gets weekly IVF infusions at the ___ center who was in her USOH until today she had 2 witnessed LOC. No headstrike or abdominal trauma per witnesses. No VB, LOF, CTX, Abdominal pain. After patient arrived to L&D unit she started to have shaking movements bilaterally. She responded to verbal commands and was able to speak, stating her name and yes or no to questions. She would sometimes close her eyes. Given some concern for seizure like activity she was given 0.5 mg Ativan IV. Neurology was consulted. history was initially obtained primarily from patients RN from the pheresis unit and her mother. Her mother states that ___ has episodes like this at times with LOC. She also occasionally has LOC with shaking movements after. <PAST MEDICAL HISTORY> PNC: - ___ ___ by early U/S - O pos/ab neg/RI/HIV neg/HBsag neg/Hep C neg/RPR NR/GC neg/CT negative/GBS unk - Screening: low risk ERA - FFS: normal FFS - GLT: not done, risk of dumping syndrome s/p gastric sleeve, random FSBS always <100 - U/S ___: BPP ___, EFW 1590g, 41% - Issues: 1) Bipolar: Predominantly depressive sx. Followed by psych at CHA (Dr. ___, mood improved. On Ativan 1mg BID, Zoloft 50mg daily 2) S/p Gastric sleeve in ___: HCT 33, normocytic, normal B12 level. Pt still unable to take iron, B12 and Folate. 3) Migraines: receiving botox injections with neurologist at ___, last ___. previously used Tylenol 3 and Fioricet. 4) POTS vs vasovagal syncope: Seen by cardiology at both ___ and ___. Per cardiology at ___, most c/w vasovagal syncope, recommend postpartum tilt table testing. Holter monitor at ___ with sinus tach correlating with some episodes. s/p ___ neuro consult and started on midodrine ___. Had normal echo. Has weekly pheresis appts for IVF. 5) H/O DVT: provoked (in setting of PICC line): recommend ppx anticoagulation for 6 weeks postpartum with prophylactic lovenox 6) Idiopathic Intracranial HTN: likely resolved per neuro notes. Followed by neurology at ___. Had previously been on acetazolamide, discontinued due to parasthesias. On review of records neurology feels intracranial hypertension no longer an issue following weight loss. 7) Antepartum admission ___ & ___ following syncopal episode. OBHx: G1 current GynHx: denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: POTS vs vasovagal syncope, endometriosis, bipolar, migraines, hx idiopathic intracranial HTN now resolved, hx DVT PSH: LSO, gastric sleeve, knee surgery, T&A, breast reduction, breast lumpectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On admission: Vitals remained normal during entire episode Afebrile HR ___ O2 sat 99-100% ra BP 129/74 Reactive NST with no decelerations Toco flat GEN - well appearing, well developed HEENT - normal, mmm RESP - normal WOB ABD - soft, NT, ND. Gravid. Fundus nontender. No contractions palpated EXTR - atraumatic Pelvic - NEFG. No VB. On discharge: AFVSS General NARD, comfortable Lungs easy work of breathing Abdomen soft nontender gravid SVE deferred Extremities nontender, no edema <PERTINENT RESULTS> ___ 12: 12PM BLOOD WBC-8.5 RBC-3.41* Hgb-9.8* Hct-30.3* MCV-89 MCH-28.7 MCHC-32.3 RDW-12.1 RDWSD-39.0 Plt ___ ___ 12: 12PM BLOOD Glucose-85 UreaN-6 Creat-0.5 Na-136 K-3.8 Cl-104 HCO3-24 AnGap-12 ___ 12: 12PM BLOOD CK(CPK)-28* ___ 12: 12PM BLOOD Calcium-8.5 Phos-3.1 Mg-1.5* <MEDICATIONS ON ADMISSION> lorazepam 1mg BID, midodrine 5mg TID, prenatal vitamin, sertraline 100 mg daily <DISCHARGE MEDICATIONS> 1. LORazepam 1 mg PO BID 2. Midodrine 5 mg PO TID 3. Prenatal Vitamins 1 TAB PO DAILY 4. Sertraline 100 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> recurrent vasovagal syncope pregnancy at 36 weeks <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 hospital for a vasovagal event with characteristics that were concerning for a seizure. The neurology team was following you while you were admitted and on evaluation felt these episodes were likely related to your vasovagal syncope episodes and not a new seizure. While in the hospital, your midodrine was continued, and you received IV fluids. You will continue to get IV fluids at L&D Triage twice weekly. You also had contractions while admitted, which resolved spontaneously. Your cervix did not dilate and there was no evidence of preterm labor. At home, please continue your medications and focus on staying hydrated. Try using compression stockings to prevent pooling of fluid/edema in your legs. You recovered well, and there was no evidence of seizure like activity on work up. The team feels as though you are now safe to be discharged home.
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Ms. ___ is a ___ G1 @ 36w2d with frequent syncopal episodes secondary to vasovagal syncope followed by convulsions who presented to OB triage from Pheresis Unit with an epsisode of syncope followed by convulsions. In triage, her episode resolved spontaneously. Neurology was urgently consulted who had a low suspicion for seizure activity. They concluded that her episode was consistent with vasovagal syncope compounded by hypovolemia with possible functional overlay and postsyncopal tremor. They recommended supportive care. She had normal electrolytes; magnesium was repleted for mild hypomagnesemia. EKG was normal sinus rhythm. She received IV fluids in triage. She was admitted to the antepartum service for observation given recurrent episodes. She was given IV fluids, placed on telemetry. She was able to get out of bed with assistance. She had reassuring fetal status throughout her admission. She had previously been made betamethasone complete on ___. Regarding her depression, she was continued on her home medications of Zoloft and Ativan. She was monitored x 48 hours with improvement in her symptoms. She received a 1L IV fluid bolus prior to discharge. She was discharged home in stable condition on hospital day #3 with a plan for twice weekly IV fluids and a prenatal visit this upcoming week.
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10230141-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / latex / Reglan / indomethacin / Compazine / narcotics <ATTENDING> ___. <CHIEF COMPLAINT> recurrent syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ who has h/o frequent syncope, bipolar affective disorder, h/o DVT, who gets weekly IVF infusions at the ___, was sent in via EMS for convulsive episodes at home. She states that this is consistent with her prior episodes. Per the patient, she had prodromal symptoms of a syncope, and then had a convulsive episode. It was witnessed by her husband, who quickly called EMS. When EMS arrived, they saw her having a convulsive episode with her eyes closed and her clenched fists shaking. They describe that she was briefly post-ictal, but was able to answer questions shortly after. Ms. ___ herself denies urinary or fecal incontinence. She has amnesia of what happened between her first episode and the arrival of the EMS team. She was recently discharged from the hospital on ___, after having a similar episode of convulsion on ___. This is her ___ convulsive episode in 4 days. No VB, LOF, CTX, Abdominal pain. <PAST MEDICAL HISTORY> PNC: - ___ ___ by early U/S - O pos/ab neg/RI/HIV neg/HBsag neg/Hep C neg/RPR NR/GC neg/CT negative/GBS unk - Screening: low risk ERA - FFS: normal FFS - GLT: not done, risk of dumping syndrome s/p gastric sleeve, random FSBS always <100 - Issues: 1) Bipolar: Predominantly depressive sx. Followed by psych at CHA (Dr. ___, mood improved. On Ativan 1mg BID, Zoloft 100mg daily 2) S/p Gastric sleeve in ___: HCT 33, normocytic, normal B12 level. Pt still unable to take iron, B12 and Folate. 3) Migraines: receiving botox injections with neurologist at ___, last ___. previously used Tylenol 3 and Fioricet. 4) POTS vs vasovagal syncope: Seen by cardiology at both ___ and ___. Per cardiology at ___, most c/w vasovagal syncope, recommend postpartum tilt table testing. Holter monitor at ___ with sinus tach correlating with some episodes. s/p ___ neuro consult and started on midodrine ___. Had normal echo. Has weekly pheresis appts for IVF. 5) H/O DVT: provoked (in setting of PICC line): recommend ppx anticoagulation for 6 weeks postpartum with prophylactic lovenox 6) Idiopathic Intracranial HTN: likely resolved per neuro notes. Followed by neurology at ___. Had previously been on acetazolamide, discontinued due to parasthesias. On review of records neurology feels intracranial hypertension no longer an issue following weight loss. 7) Multiple admissions for syncopal episodes, s/p reassuring evaluations by Neurology and Cardiology OBHx: G1 current GynHx: denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: POTS vs vasovagal syncope, endometriosis, bipolar, migraines, hx idiopathic intracranial HTN now resolved, hx DVT PSH: LSO, gastric sleeve, knee surgery, T&A, breast reduction, breast lumpectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On admission: Orthostatics: 94/63 85 98% (supine) 101/71 83 ___ (standing) GEN - well appearing, well developed Neuro: CN II-XII grossly intact HEENT - normal, mmm RESP - normal WOB ABD - soft, NT, ND. Gravid. Fundus nontender. No contractions palpated EXTR - atraumatic FHT: 130, mod variab + acel - decal Toco: q2-3 min On discharge: AF VSS General: NARD, comfortable Lungs: Easy work of breathing Abd: Soft, fundus firm 2 cm below umbilicus GU: Minimal lochia Extremities: nontender, no edema <PERTINENT RESULTS> ___ 11: 05PM BLOOD WBC-10.0 RBC-3.51* Hgb-10.2* Hct-31.2* MCV-89 MCH-29.1 MCHC-32.7 RDW-11.9 RDWSD-38.3 Plt ___ ___ 08: 01PM BLOOD WBC-11.0* RBC-3.76* Hgb-10.6* Hct-33.8* MCV-90 MCH-28.2 MCHC-31.4* RDW-12.1 RDWSD-39.3 Plt ___ ___ 05: 55PM BLOOD WBC-10.4* RBC-3.73* Hgb-10.5* Hct-32.8* MCV-88 MCH-28.2 MCHC-32.0 RDW-12.1 RDWSD-38.9 Plt ___ ___ 06: 24AM BLOOD Hct-27.9* ___ 11: 05PM BLOOD Glucose-79 UreaN-8 Creat-0.5 Na-139 K-3.6 Cl-103 HCO3-27 AnGap-13 ___ 05: 57AM BLOOD Glucose-67* UreaN-4* Creat-0.5 Na-139 K-3.9 Cl-106 HCO3-26 AnGap-11 ___ 08: 01PM BLOOD Glucose-97 UreaN-5* Creat-0.5 Na-136 K-3.7 Cl-102 HCO3-26 AnGap-12 ___ 05: 55PM BLOOD Glucose-117* UreaN-5* Creat-0.5 Na-137 K-3.6 Cl-103 HCO3-21* AnGap-17 ___ 11: 05PM BLOOD ALT-8 AST-15 ___ 11: 05PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.5* ___ 05: 57AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.5* ___ 08: 01PM BLOOD Calcium-8.9 Phos-3.9 Mg-1.6 ___ 05: 55PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.5* ___ 12: 40AM URINE Color-Yellow Appear-Clear Sp ___ ___ 12: 40AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR ___ 12: 40AM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-1 ___ 01: 27PM URINE Color-Straw Appear-Clear Sp ___ ___ 01: 27PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 12: 40AM URINE Hours-RANDOM Creat-101 TotProt-16 Prot/Cr-0.2 LAMELLAR BODY COUNT Test Result Normal Range ---- ------ --------------- LBC L 50 >50 K/UL Color Straw (Yellow) Fluid Clarity Cloudy (Clear) Reference Range: < 30 K/UL - Immature 30 - 50 K/UL - Indeterminate > 50 K/UL - Mature Test Performed at: ___ Comment: Source: AMNIOTIC FLUID <MEDICATIONS ON ADMISSION> - lorazepam 1mg BID - midodrine 5mg TID - sertraline 100mg qD - docusate - prenatal vitamin <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN Mild Pain Do not exceed 4000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 2. 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: *0 3. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*42 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 5. LORazepam 1 mg PO BID anxiety 6. Midodrine 5 mg PO TID 7. Sertraline 100 mg PO DAILY 8. ___ (norethindrone (contraceptive)) 0.35 mg oral DAILY RX *norethindrone (contraceptive) 0.35 mg 1 tablet(s) by mouth once a day Disp #*28 Tablet Refills: *11 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> recurrent syncopal episodes vaginal delivery <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 son! Please follow the instructions below. Stay well hydrated 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 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 admitted to the antepartum service with increasingly frequent episodes of recurrent syncope with convulsions. She was seen by Neurology and Cardiology. Neurology concluded that this was consistent with vasovagal syncope, and did not recommend further EEG monitoring or imaging. She was placed on telemetry and EKG was obtained. Both showed no evidence of arrhythmia, alnd it was thought to be unlikely of cardiac origin. Given her increasingly frequent syncopal episodes, she was admitted to the antepartum service for close monitoring. She received IV fluids and was continued on midodrine 5mg TID (home medication). She had previously been made betamethasone complete. She underwent an amniocentesis for fetal lung maturity on ___. The lamellar body count returned indeterminate and therefore IOL was delayed with plan to proceed with induction at 38 weeks or sooner if her episodes continued to increase in frequency. Regarding her depression, she was continued on her home medications of Zoloft and Ativan. She was followed by Social Work. On ___ she was noted to have increasing frequent syncopal and convulsive episodes. Therefore induction of labor was recommended (37w4d). She had reassuring fetal status throughout her antepartum course. She had an uncomplicated induction of labor with cytotec followed by Pitocin. On ___ she had an uncomplicated vaginal delivery. Her post-partum course was uncomplicated. She was started on prophylactic lovenox after delivery with a plan to continue for 6 weeks given a personal history of DVT in the setting of PICC. On ___, she was discharged home in stable condition with appropriate follow-up scheduled.
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| 353
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10230631-DS-2
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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> Ultrasound guided suction Dilation and Evacuation <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ yo ___ s/p TAB @ ___ wks on ___ @ planned parent hood 8 days prior to presentation now with severe cramping. Has been cramping more than usual for the last several days. States she has had a TAB in the past and this feels very different. Had light Vaginal Bleeding for 2 days following the procedure, slightly heavier after that but over last 12 hours has used only 1 pad. She had chills, woke up drenched in sweat but no recorded fevers. She denies nausea and vomting Per patient, she was told that she might have had uterine perforation during procedure which prompted terminated of procedure early and she was unsure if all tissue was removed. She was asked to follow up the next ___ but was too uncomfortable to wait. <PAST MEDICAL HISTORY> No significant medical conditions <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denied any gynecological cancers <PHYSICAL EXAM> Physical Examination was conducted by Dr. ___ ___: No Acute Distress, grimacing intermittently with cramping Abdomen: soft, Non-distended, Non-tender Per ED resident: Sterile Speculum Exam with small amount of dark blood, normal appearing cervix and vagina Bimanual Exam: uterus approximately 6wk sized, mobile, + uterine Tenderness To Palpation, mild Cervical Motion Tenderness, no adnexal Tenderness To Palpation Extremities: Non-tender, Non-edematous <PERTINENT RESULTS> ___ 01: 50PM GLUCOSE-111* UREA N-13 CREAT-0.6 SODIUM-139 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12 ___ 01: 50PM estGFR-Using this ___ 01: 50PM WBC-7.3 RBC-3.67* HGB-11.6* HCT-32.5* MCV-89 MCH-31.5# MCHC-35.5* RDW-12.6 ___ 01: 50PM NEUTS-69.2 ___ MONOS-3.6 EOS-1.8 BASOS-0.4 ___ 01: 50PM PLT COUNT-238 ___ 01: 40PM URINE HOURS-RANDOM ___ 01: 40PM URINE HOURS-RANDOM ___ 01: 40PM URINE UCG-POS ___ 01: 40PM URINE GR HOLD-HOLD ___ 01: 40PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01: 40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01: 40PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 ___ 01: 40PM URINE MUCOUS-RARE Ultrasound: 3.3 x 1.3 cm heterogeneous endometrial contents with vascular flow concerning for retained products. <MEDICATIONS ON ADMISSION> Nuvaring <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* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p abortion (TAB) endometritis/retained POCs <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 1. call with fevers >100.5, heavy vaginal bleeding > 1 pad/hr, nausea, vomiting, abdominal pain 2. take Augmentin daily for 10 days (liquid medication has been called into ___ pharmacy in ___
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Ms ___ was admitted into the gynecology service for retained products of conception and was placed on intravecous antibiotics (gentamicin and clindamycin). She was taken into the operating room the next day for an ultrasound-guided dilation and evacuation procedure. Patient tolerated the procedure well and was discharged on post-op day 0 with adequate pain control, tolerating food and pain medicines by mouth, voiding independently and ambulating.
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10232183-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / codeine / acetaminophen <ATTENDING> ___. <CHIEF COMPLAINT> Post-menopausal bleeding and thickened endometrial stripe <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Total laparoscopic hysterectomy 2. Bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ G0 here for consultation regarding recent endometrial biopsy with EIN. Patient presented to GYN with postmenopausal bleeding and had endometrial biopsy that returned as "focal atypical hyperplasia in a partially necrotic polyp in background of proliferative pattern endometrium." She also had a pelvic ultrasound that showed a 7.2cm fibroid uterus, largest fibroid being 3.6cm at the fundus. There was a normal 3mm endometrial stripe. Patient reports that her bleeding has now resolved. Denies abdominal pain/abnormal discharge/SOB/CP. 10 point ROS negative. <PAST MEDICAL HISTORY> Obstetrical History: G0 Gynecologic History: - LMP ___ years ago - Previous history of menometrorrhagia requiring D&C x 2 with negative path. - Denies history of abnormal Pap tests. Last Pap test ___ negative, no history of abnormal pap. - Denies history of pelvic infections of sexually transmitted infections - Denies history of HRT. <PAST MEDICAL HISTORY> Depression, Anxiety, Hypertension, Pre-diabetes Past Surgical History: Knee surgery x 2, Tonsillectomy, Laparoscopic cholecystectomy, D&C x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> Brother has diabetes. Paternal grandmother had "lots of cancers." No other fam hx of breast/GYN/colon cancer. <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 <PERTINENT RESULTS> ___ 06: 30AM BLOOD WBC-12.1*# RBC-3.74* Hgb-11.5*# Hct-32.4* MCV-87 MCH-30.7 MCHC-35.5* RDW-12.5 Plt ___ ___ 10: 47AM BLOOD WBC-8.0 RBC-4.88 Hgb-14.9 Hct-42.1 MCV-86 MCH-30.4 MCHC-35.3* RDW-12.7 Plt ___ ___ 06: 30AM BLOOD Plt ___ ___ 10: 47AM BLOOD Plt ___ ___ 06: 30AM BLOOD Glucose-108* UreaN-12 Creat-0.7 Na-137 K-4.3 Cl-102 HCO3-29 AnGap-10 ___ 06: 30AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9 <MEDICATIONS ON ADMISSION> 1. atorvastatin 10mg daily 2. buproprion 200mg twice daily 3. buspirone 30mg tablet, 1.5 tablets twice daily 4. lisinopril 20mg daily 5. metoprolol succinate 25mg daily 6. mirtazapine 30mg daily 7. ranitidine 150mg twice daily 8. zolmitriptan 5mg daily at onset of migraine 9. Multivitamin <DISCHARGE MEDICATIONS> 1. BuPROPion (Sustained Release) 200 mg PO BID 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *2 3. Metoprolol Tartrate 25 mg PO BID 4. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain Do not drink alcohol or drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #*30 Tablet Refills: *0 5. Lisinopril 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrial Intraepithelial Neoplasia **Final Pathology Pending** <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 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: . Laparoscopic 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 4 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. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. * 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 to the gynecologic oncology service after undergoing a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. 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 and Toradol. Her diet was advanced without difficulty and she was transitioned to oral ibuprofen and oxycodone. 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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10232463-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> persistent CIN3 <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ with initial presentation of post-coital spotting who presented to care in ___, having never had a pap smear previously. Workup included a pap which resulted as squamous cell carcinoma/+HR HPV. Biopsies showed high-grade dysplasia of the cervix. She then underwent a LEEP and ECC on ___, again showing high gradedysplasia, margins were cauterized but appeared negative. There was no definitive invasion seen. ECC was c/w at least high grade dysplasia. The patient returned for followup, and had a repeat Pap smear which again revealed high-grade dysplasia. On ___, she underwent cold knife cone biopsy cervix and endocervical curettage. There was no evidence of gross tumor present, and no residual cervix remained after the procedure. Final pathology of cone biopsy showed CIN 3 with no invasion and negative margins, and endocervical curettings showed CIN3 with focus of superficial invasion (<1mm). <PAST MEDICAL HISTORY> PMH: - rheumatoid arthritis - insomnia - s/p treatment for H. pylori - Denies hypertension, heart disease, diabetes, asthma, thromboembolic disease PSH: D&C POB: G2P1 - SVD ___ - TAB x1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Aunt diagnosed with breast cancer in her ___ or ___ - Sister died at age ___ of uterine cancer - Paternal uncle with colon cancer diagnosed at age ___ - No known family history of 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 <PERTINENT RESULTS> ___ 12: 20PM WBC-4.2 RBC-3.88* HGB-12.2 HCT-36.7 MCV-95 MCH-31.4 MCHC-33.2 RDW-12.9 RDWSD-44.3 ___ 12: 20PM PLT COUNT-199 <MEDICATIONS ON ADMISSION> acetaminophen prn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4000 mg 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 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN Pain 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 Do not drive while taking, may cause drowsiness RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> history of persistent cervical dysplasia/CIN3 <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: . Laparoscopic 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 4 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. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . 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 laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy. 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 and toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone/acetaminophen/ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. However, she reported feeling like she was unable to empty her bladder completely. After voiding multiple times with voids 100-200cc each, patient was bladder scanned for about 700cc of urine. Therefore, foley was replaced. On post-operative day 2, her foley was removed once again and she voided spontaneously with appropriate post-void residual. She was also 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 and instructions to void every 2 hours while awake at home to prevent significant retention.
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10232572-DS-23
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Minocycline <ATTENDING> ___. <CHIEF COMPLAINT> Admitted for elective C-section <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery ___ Embolization: Right common femoral artery access Left external iliac, inferior epigastric, internal iliac, internal mammary, superior epigastric arteriogram Left inferior epigastric coil embolization and post embolization arteriogram Left superior epigastric Gel-Foam embolization and post embolization arteriogram Right internal iliac, external iliac arteriogram Abdominal aortogram Left common iliac venogram Left common femoral vein non tunneled triple-lumen central venous catheter placement Angio-Seal closure of right common femoral arteriotomy <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> --== Labs --== ___ 01: 10PM BLOOD WBC-12.3* RBC-2.88* Hgb-8.8* Hct-25.6* MCV-89 MCH-30.6 MCHC-34.4 RDW-15.1 RDWSD-48.5* Plt Ct-89* ___ 06: 14AM BLOOD WBC-11.4* RBC-2.72* Hgb-8.3* Hct-24.0* MCV-88 MCH-30.5 MCHC-34.6 RDW-14.9 RDWSD-47.6* Plt Ct-83* ___ 02: 19PM BLOOD WBC-14.4* RBC-3.04* Hgb-9.3* Hct-26.6* MCV-88 MCH-30.6 MCHC-35.0 RDW-14.9 RDWSD-47.1* Plt Ct-89* ___ 10: 23AM BLOOD WBC-13.1* RBC-2.91* Hgb-9.0* Hct-24.8* MCV-87 MCH-30.9 MCHC-35.6 RDW-14.8 RDWSD-45.7 Plt Ct-77* ___ 05: 55AM BLOOD WBC-12.6* RBC-3.07* Hgb-9.3* Hct-26.4* MCV-86 MCH-30.3 MCHC-35.2 RDW-14.3 RDWSD-43.9 Plt Ct-74* ___ 01: 13AM BLOOD WBC-15.3* RBC-3.35* Hgb-10.1* Hct-28.8* MCV-86 MCH-30.1 MCHC-35.1 RDW-14.3 RDWSD-43.9 Plt Ct-79* ___ 08: 22PM BLOOD WBC-14.4* RBC-3.68* Hgb-11.1* Hct-31.6* MCV-86 MCH-30.2 MCHC-35.1 RDW-14.0 RDWSD-43.1 Plt Ct-71* ___ 05: 32PM BLOOD WBC-13.2* RBC-3.70* Hgb-11.3 Hct-31.6* MCV-85 MCH-30.5 MCHC-35.8 RDW-13.8 RDWSD-42.6 Plt Ct-68* ___ 01: 17PM BLOOD WBC-13.2* RBC-3.71*# Hgb-11.2# Hct-32.2*# MCV-87 MCH-30.2 MCHC-34.8 RDW-13.9 RDWSD-43.9 Plt Ct-66* ___ 09: 30AM BLOOD WBC-13.0* RBC-1.99* Hgb-6.1* Hct-18.2* MCV-92 MCH-30.7 MCHC-33.5 RDW-14.6 RDWSD-47.6* Plt Ct-69* ___ 11: 52PM BLOOD WBC-13.8*# RBC-1.66*# Hgb-5.0*# Hct-15.1*# MCV-91 MCH-30.1 MCHC-33.1 RDW-14.1 RDWSD-45.7 Plt ___ ___ 06: 35AM BLOOD WBC-4.3 RBC-4.09 Hgb-12.1 Hct-36.6 MCV-90 MCH-29.6 MCHC-33.1 RDW-14.0 RDWSD-45.3 Plt ___ ___ 02: 19PM BLOOD ___ PTT-26.4 ___ ___ 01: 13AM BLOOD ___ ___ 08: 22PM BLOOD ___ PTT-28.8 ___ ___ 05: 32PM BLOOD ___ PTT-28.1 ___ ___ 01: 17PM BLOOD ___ PTT-47.8* ___ ___ 09: 30AM BLOOD ___ PTT-39.8* ___ ___ 07: 25AM BLOOD ___ PTT-29.8 ___ ___ 05: 32PM BLOOD Ret Aut-1.8 Abs Ret-0.07 ___ 06: 14AM BLOOD Glucose-67* UreaN-6 Creat-0.4 Na-140 K-4.0 Cl-108 HCO3-23 AnGap-13 ___ 02: 19PM BLOOD Glucose-92 UreaN-8 Creat-0.4 Na-134 K-4.0 Cl-103 HCO3-21* AnGap-14 ___ 01: 13AM BLOOD Glucose-109* UreaN-10 Creat-0.6 Na-132* K-4.2 Cl-100 HCO3-19* AnGap-17 ___ 08: 22PM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-130* K-4.0 Cl-99 HCO3-19* AnGap-16 ___ 05: 32PM BLOOD Glucose-95 UreaN-11 Creat-0.5 Na-132* K-3.7 Cl-101 HCO3-19* AnGap-16 ___ 01: 17PM BLOOD Glucose-112* UreaN-13 Creat-0.5 Na-122* K-5.0 Cl-97 HCO3-17* AnGap-13 ___ 09: 30AM BLOOD Glucose-70 UreaN-9 Creat-0.3* Na-126* K-4.8 Cl-99 HCO3-11* AnGap-20 ___ 11: 52PM BLOOD Glucose-103* UreaN-12 Creat-0.5 Na-130* K-4.3 Cl-101 HCO3-18* AnGap-15 ___ 01: 13AM BLOOD ALT-17 AST-45* LD(LDH)-325* AlkPhos-73 TotBili-0.5 ___ 08: 22PM BLOOD ALT-18 AST-48* LD(___)-347* AlkPhos-72 TotBili-0.6 ___ 05: 32PM BLOOD ALT-18 AST-48* LD(LDH)-321* AlkPhos-70 TotBili-0.7 ___ 06: 14AM BLOOD Calcium-7.5* Phos-3.2 Mg-2.2 ___ 02: 19PM BLOOD Calcium-7.8* Phos-3.1 Mg-2.4 ___ 01: 13AM BLOOD Albumin-2.6* Calcium-7.6* Phos-4.1 Mg-2.7* ___ 08: 22PM BLOOD Albumin-2.5* Calcium-7.6* Phos-4.2 Mg-1.9 ___ 05: 32PM BLOOD Calcium-7.6* Phos-4.5 Mg-1.8 ___ 01: 17PM BLOOD Calcium-6.8* Phos-5.0* Mg-1.6 ___ 09: 30AM BLOOD Calcium-6.6* Phos-3.0 Mg-1.0* ___ 11: 52PM BLOOD Calcium-7.1* Phos-4.6* Mg-1.6 ___ 05: 32PM BLOOD Osmolal-274* ___ 08: 39PM BLOOD Type-CENTRAL VE pO2-40* pCO2-34* pH-7.37 calTCO2-20* Base XS--4 ___ 03: 49PM BLOOD Type-MIX pO2-33* pCO2-36 pH-7.34* calTCO2-20* Base XS--6 ___ 08: 39PM BLOOD Lactate-1.9 ___ 03: 49PM BLOOD Lactate-2.5* ___ 08: 39PM BLOOD freeCa-1.09* ___ 03: 49PM BLOOD freeCa-0.99* --== Microbiology --== ___ 04: 13PM URINE Color-Straw Appear-Clear Sp ___ ___ 11: 30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 04: 13PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 11: 30PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 04: 13PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 ___ 11: 30PM URINE RBC-12* WBC-32* Bacteri-FEW Yeast-NONE Epi-1 TransE-1 ___ 11: 30PM URINE Mucous-MANY ___ 04: 13PM URINE Hours-RANDOM Na-<20 ___ 04: 13PM URINE Osmolal-432 ___ 1: 13 am BLOOD CULTURE Source: Line-CVL. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 4: 13 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. --== Imaging --== CXR IMPRESSION: Pulmonary vascular congestion with small layering bilateral pleural effusions. Mild enlargement of the cardiac silhouette Uterine arteriogram: FINDINGS: 1. No active extravasation was identified. 2. Prophylactic coil embolization of the left inferior epigastric artery and Gel-Foam embolization of the left superior epigastric artery. 3. Of note, there is a uterine supplying artery originating off of the left inferior epigastric artery. 4. Extra uterine supply by large caliber ovarian arteries, right larger than left. 5. No discernible right uterine artery. 6. Successful placement of left common femoral vein approach triple-lumen central venous catheter with tip in the left common iliac vein. IMPRESSION: Prophylactic coil embolization of the left inferior epigastric artery to near stasis and Gel-Foam embolization of the superior epigastric artery to stasis. Successful placement of left common femoral vein triple lumen central venous catheter with tip in the common iliac vein. CTA abd/pelvis: IMPRESSION: 1. There is a large rectus abdominis hematoma measuring up to 11.7 cm. 2. There is moderate volume hemoperitoneum without a definite source identified, possibly related to extension of the rectus abdominis hematoma. 3. Enlarged uterus with hematometra and clot, possibly not out of the realm of expected in the immediate postpartum setting. 4. Small right and trace left pleural effusions. 5. Postsurgical changes include small volume pneumoperitoneum and subcutaneous emphysema in the anterior abdominal wall. RECOMMENDATION(S): There is a large rectus abdominis hematoma measuring up to 11.7 cm, possibly with active extravasation. Recommend interventional radiology consultation. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. PNV#90-iron fum,ps-folic-dha 32-1.25-110 mg oral DAILY 4. Vitamin D ___ UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 325-650 mg PO Q6H: PRN Pain - Mild 2. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *2 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp #*45 Tablet Refills: *0 5. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 6. PNV#90-iron fum,ps-folic-dha 32-1.25-110 mg oral DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> s/p primary low transverse cesarean acute blood loss anemia due to rectus sheath hematoma s/p blood transfusion and interventional radiology embolization of left superior and inferior epigastric vessels <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> no heavy lifting for 6 weeks continue prenatal vitamin once daily and take iron supplementation daily as tolerated by bowel movements
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___ G2 now P1 presented on ___ for primary elective cesarean section per maternal request. Her antepartum course was benign. For her history of hepatitis B, she was managed on tenofovir with an undetectable viral load. Her LFTs throughout pregnancy were normal. On PPD#1, patient was noted to be oliguric with vital sign changes notable for HR 110-130s, BP 90-100s/60-80s. On exam, her abdomen was firm, tympanic, moderately TTP with guarding no rebound. Labs were significant for a HCT of 15, down from pre-op of 36.2. She received 2 units packed RBC without improvement in her tachycardia. Repeat hct was 18. A CT abdomen pelvis showed large rectus sheath hematoma with moderate volume hemoperitoneum without definite source and possible hematometria possibly normal. The decision was made to proceed with ___ embolization and transfusion of an additional 3 units packed RBC and 1 unit FFP. There was no active hemorrhage identified, but prophylactic left superior and inferior epigastric gelfoam embolization was performed. She was transferred to the ICU for close hemodynamic monitoring. In the ICU, she received oxycodone and breakthrough dilaudid for pain control. She was noted to have hypovolemic hyponatremia likely ___ acute blood loss vs. SIADH. Her sodium responded s/p colloid resuscitation with packed RBCs. She was also found to have an anion gap metabolic acidosis with low bicarbonate to 11, gap of 18. There was concern for lactic acidosis ___ hypovolemia vs infection vs ketoacidosis. A venous blood gas did not showed significant elevated lactate, and HCO3 improved. On PPD#2, her vitals remained stable and serial labs showed stable hematocrit of 26.6. She was transferred to the postpartum floor for further care. On transfer to the floor, her exam was notable for TTP along lower quadrants, firm fundus 1 cm below umbilicus, no rebound/guarding. Her pain was managed with Tylenol, ibuprofen and oxycodone. Her oliguria was noted to be improving with UOP 2L/24 hrs. Of note, urinalysis and urine culture were negative. Her Cre remained stable at 0.4. Her hematocrit remained stable at ___ patient was started on oral iron for anemia. Patient continued to meet routine postpartum milestones. She met with lactation nurses who assisted with latching and breastfeeding techniques. Of note, patient discontinued tenofovir due to wish to breastfeed. She met with social work due to her history of anxiety, however declined services at the time. By postpartum day 6, 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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| 659
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10232602-DS-23
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Latex / Bactrim / codeine / loperamide / clindamycin <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain, fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ s/p a D&C on ___ for rPOCs presenting to OB/GYN triage on POD#3 for abdominal pain and fevers at home with a Tmax of 103.1 per patient. Please see ___ note for full H&P and initial presentation. Per Dr. ___ patient had a positive UPT at home on ___ and then began bleeding shortly afterward possibly passing fragments of tissue concerning for fetal remains. She had an ultrasound done on ___ that showed a moderate amount of echogenic debris present within the endometrial cavity concerning for a retained POCs. The plan was made for a D&C on ___ for removal of the possible retained tissue. Patient was given 100mg IV doxycline prior to the procedure. A suction D&C with 7-mm curette was performed. A very small amount of retained products was removed. The suction was passed twice and then a sharp curette was performed. Procedure was uncomplicated. Patient prescribed doxycline but was unable to take due to insurance issues in acquiring the medication. Path report from D&C ___: 1. Products of conception --no tissue present 2. Endometrial curettings: --fragments of adipose tissue --fragments of endometrium with chronic endometritis --benign squamous and endocervical mucousa --no chorionic villi identified The patient reports feeling well after the procedure until this AM when she endorses awakening with severe abdominal pain and fever. She reports chills and sweats. She denies an N/V. She endorses several watery stools today. She reports mild vaginal bleeding and foul smell but denies any unusual or foul discharge. She reports taking the "whole bottle of Tylenol and motrin" for pain control today. When pressed to define the number she has taken she states at least >15 of the 600mg ibuprofen and >10 of the 500mg Tylenol. She reports taken pain medications immediately prior to presentation. <PAST MEDICAL HISTORY> Problems (Last Verified ___ by ___: PSYCHIATRIC HISTORY PAIN MANAGEMENT IRRITABLE BOWEL SYNDROME PSEUDOSEIZURE CHRONIC BENZODIAZEPINE THERAPY PYELONEPHRITIS NEPHROLITHIASIS OVERWEIGHT CERVICAL INTRA-EPITHELIAL NEOPLASM II DOMESTIC VIOLENCE HX HOMELESSNESS SECONDARY AMENORRHEA MIGRAINE HEADACHES ASTHMA OBGYN CHLAMYDIA BACTERIAL VAGINOSIS URINARY TRACT INFECTION PULMONARY EOSINOPHILIA Surgical History (Last Verified ___ by ___, MD): APPENDECTOMY DILATION AND CURETTAGE - Multiple D&Cs for TABs/SABs LEEP HYSTEROSCOPY <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On day of discharge: AVFSS Gen - well appearing, NAD CV - RRR Lungs - CTAB Abd - soft, non-distended, non-tender Ext - non-tender, no edema <PERTINENT RESULTS> ___ 06: 16PM BLOOD WBC-14.5* RBC-4.22 Hgb-11.6 Hct-36.4 MCV-86 MCH-27.5 MCHC-31.9* RDW-14.3 RDWSD-45.2 Plt ___ ___ 08: 00AM BLOOD WBC-8.7 RBC-4.41 Hgb-12.2 Hct-37.4 MCV-85 MCH-27.7 MCHC-32.6 RDW-13.9 RDWSD-43.1 Plt ___ ___ 10: 25PM BLOOD ___ PTT-32.3 ___ ___ 06: 16PM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-137 K-4.2 Cl-102 HCO3-25 AnGap-14 ___ 10: 25PM BLOOD ALT-16 AST-14 LD(LDH)-216 AlkPhos-61 TotBili-0.2 DirBili-<0.2 IndBili-0.2 ___ 06: 16PM BLOOD Calcium-8.9 Phos-5.1* Mg-2.2 ___ 10: 25PM BLOOD Acetmnp-NEG ___ 07: 05PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 07: 05PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-SM ___ 07: 05PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-11 SMEAR FOR BACTERIAL VAGINOSIS (Final ___: POSITIVE: GRAM STAIN CONSISTENT WITH BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lithium Carbonate 150 mg PO BID 2. QUEtiapine Fumarate 400 mg PO QHS 3. pramipexole 0.125 mg oral QHS 4. ClonazePAM 1 mg PO TID 5. Mirtazapine 30 mg PO QHS 6. Gabapentin 300 mg PO BID 7. Acyclovir Ointment 5% 5 % topical 5X/DAY <DISCHARGE MEDICATIONS> 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth ever 12 hours Disp #*14 Tablet Refills: *0 2. MetroNIDAZOLE 500 mg PO/NG Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8 hours Disp #*21 Tablet Refills: *0 3. Ondansetron 4 mg PO Q8H nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*12 Tablet Refills: *0 4. Acyclovir Ointment 5% 5 % topical 5X/DAY 5. ClonazePAM 1 mg PO TID 6. Diphenoxylate-Atropine 1 TAB PO Q6H: PRN diarrhea 7. Gabapentin 300 mg PO BID 8. Gabapentin 900 mg PO QHS 9. Hyoscyamine 0.125 mg PO TID: PRN stomach cramps 10. Lithium Carbonate 150 mg PO BID 11. Mirtazapine 30 mg PO QHS 12. Pramipexole 0.125 mg oral QHS 13. QUEtiapine Fumarate 400 mg PO QHS 14. Sucralfate 1 gm PO BID 15.medication Please continue to take your dicyclomine as you had been prior to this hospital admission <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometritis Bacterial vaginosis <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 for abdominal pain and fevers following a D&C for retained products of conception. - You underwent a CT scan which was reassuring and did not reveal any evidence of bowel injury - You were started on antibiotics for endometritis (infection of the lining of the uterus), which you should continue upon discharge - You are on several medications which can prolong the QT interval (affect the electrical activity in your heart). Your EKG on ___ was normal. Please be sure to follow-up with Dr. ___ office on ___ for a repeat EKG. - Please use the Zofran sparingly. Take your antibiotics with food to decrease nausea. You have recovered well and the team believes you are ready to be discharged home. Please follow these 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. * Nothing in the vagina (no sex, tampons, douching) until your follow-up appointment * No heavy lifting of objects >10 lbs until your follow-up appointment * You may eat a regular diet. * You may walk up and down stairs. 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 gynecology service after presenting with abdominal pain, Tmax 103 at home and self reported Tylenol overdose 3 days after having a D&C for possible retained products of conception. Pathology from her D&C showed chronic endometritis and fragments of adipose tissue. Due to this finding in conjunction with her presentation of abdominal pain and fever there was initial concern for uterine perforation and subsequent bowel injury. She was started on IV cipro/flagyl. A CT abdomen/pelvis was performed which showed a small presacral fluid collection, but no bowel wall thickening or enhancement concerning for bowel injury. At the time of her admission she had a leukocytosis of 14.5 which downtrended to 8.7 by hospital day 2. She did have 2 episodes of nausea and emesis during admission likely due to the antibiotics however, given the initial concern for bowel injury, general surgery was consulted. They agreed that there was no evidence of bowel injury on imaging or exam. She remained afebrile thoughout her admission and was transitioned to PO cipro/flagyl after 24 hours of IV antibiotics. Her vaginal cultures performed on admission returned positive for BV however were otherwise negative and this was covered by flagyl. On initial presentation the patient reported ingestion of a large amount of Tylenol and ibuprofen. A serum acetaminophen level was negative and the patient had normal LFTs and Cr. For her depression and chronic pain she was continued on her home doses of lithium, Seroquel, clonazepam, mirtazapine. Due to concern for medication interaction and QT prologation between her psychiatric medications and antiemetics an EKG was performed which showed a normal QT and QTc. She was also seen by social work during the admission. On hospital day 3 she continued to be afebrile and was tolerating a regular diet. She was discharged home on a 7 day course of cipro/flagyl with outpatient follow-up scheduled.
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10235631-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G3P1 @ 33w 2d with onset of regular uterine CTX beginning at 0200. Denies fever, chills, other abdominal pain, abdominal trauma, dysuria, vaginal discharge, vaginal bleeding, DFM, LOF. PNC: - ___ ___ by LMP - Labs Rh neg s/p Rhogam on ___ /Abs neg /Rub I /RPR NR/HBsAg neg /HIV neg /GBS pending - Screening: LR Quad screen - FFS: normal anatomy - GLT: normal - Issues: none <PAST MEDICAL HISTORY> PObHx: No history of PTD - 1 x SVD, term in ___, 7# - 1 x ectopic s/p LSC salpingectomy PGynHx: No history of LEEP or other cervical procedure PMHx: denies PSHx: denies <ALLERGIES> NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> On admission: temp 98.7 HR 85 BP 108/58 RR 16 General: NAD. Appears uncomfortable and having regular painful CTX. Cardiac: RRR Pulm: CTA Abdomen: soft, no fundal tenderness, CTX palpable Ext: no erythema, no edema SSE: Normal external anatomy, cervical os visually closed, no blood in vaginal vault. SVE: ___ @ 0600 NST: 140/mod var/+accels/-decels TOCO: q2-3 TAUS: vtx On discharge: AF VSS General NARD, comfortable Resp easy work of breathing Abdomen soft gravid nontender GU pad dry Ext nontender <PERTINENT RESULTS> ___ 06: 26AM BLOOD WBC-10.7* RBC-4.39 Hgb-13.7 Hct-40.4 MCV-92 MCH-31.2 MCHC-33.9 RDW-12.7 RDWSD-42.4 Plt ___ ___ 06: 26AM BLOOD Neuts-71.1* ___ Monos-6.7 Eos-1.7 Baso-0.2 Im ___ AbsNeut-7.64* AbsLymp-2.10 AbsMono-0.72 AbsEos-0.18 AbsBaso-0.02 ___ 06: 26AM URINE Color-Straw Appear-Clear Sp ___ ___ 06: 26AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 06: 26AM URINE RBC->182* WBC-5 Bacteri-NONE Yeast-NONE Epi-1 ___ 06: 26AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 06: 00AM OTHER BODY FLUID FetalFN-POSITIVE ___ 6: 00 am SWAB Source: Vaginal. **FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. ___ 6: 00 am SWAB Source: Vaginal. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PANTHER System, APTIMA COMBO 2 Assay. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by PANTHER System, APTIMA COMBO 2 Assay. ___ 5: 52 am ANORECTAL/VAGINAL CULTURE Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP. ___ 6: 26 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 33w5d preterm contracations <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service due to preterm contractions and concern for preterm labor. Your contractions improved and you had no evidence of ongoing preterm labor. You received a course of betamethasone for fetal lung maturity and fetal testing was reassuring. Please maintain pelvic rest (nothing in the vagina) and avoid strenuous exercice. Stay well hydrated.
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Ms. ___ was admitted to the antepartum service after presenting with painful contractions at 33 weeks 2 days gestation. She was found to be contracting and made cervical change from ___ to ___. She was given betamethasone for fetal lung maturity and nifedipine for tocolysis. She was without evidence of infection of abruption. Her contractions improved and her cervical exam then remained unchanged. She was then transferred to the antepartum service. Infectious work-up was negative. She was bethamethasone complete on ___. She was seen by the NICU. She underwent a formal ultrasound with a BPP ___ (-2 for no fetal breathing), anterior placenta, and EFW in the 25%ile. She remained clinically stable without evidence of continued labor. She was discharged home on hospital day #3 once she was betamethasone complete, with outpatient followup scheduled.
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10237457-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Nonreassuring fetal testing <MAJOR SURGICAL OR INVASIVE PROCEDURE> C-section <HISTORY OF PRESENT ILLNESS> ___ G4P0030 @ 35+wks with chtn and type 2 DM here for cmfm with nonreactive NST today and bpp ___ (-2 for no fetal tone and no fetal movt). Patient reports +FM. no ctxs/lof/vb. no ha, visual sxs, upper abd pain <PAST MEDICAL HISTORY> PRENATAL COURSE *)Dating: EDC ___ by early OB US *)Labs: O-/Ab-,RPRnr,RI,HbsAg-,HIV- *)Screening: ERA (serum only, unable to get NT): - T21 ___, T13/18 1/>10,000 - FFS limited ___ body habitus, 2VC and limited cardiac views - Fetal echo at childrens: WNL, needs f/u in ___ ISSUES: *Class C T2DM poorly controlled: A1C >11 @ conception, noncompliant, has not yet seen ___, needs eye exam. Fetal echo WNL but limited, for f/u in ___. *Single umbilical artery *alpha thal *CHTN * Antepartum admission at 20 weeks GA for poor glycemic control OB Hx: SAB x3, TABx1 Gyn Hx: denies STI's, last pap ___ WNL, denies abnl pap PMH: -Class C T2DM since ___ but started insulin with pregnancy, last eye exam ___ -anemia -alpha thal -obesity although has lost weight from 300lbs prior to 205lbs now -CHTN: no meds during preg, baseline labs WNL, baseline 24 hour urine 78 -hypercholesterolemia Surg Hx: wisdom teeth x4, DxC x1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Admission exam by Dr. ___: BP ___ Gen: NAD CV: RRR PULM: CTAB Abd: soft, gravid Ext; nontender FHT: 110 minimal variability no accels no decels Toco: none <PERTINENT RESULTS> ___ 01: 12PM BLOOD WBC-8.2 RBC-4.38 Hgb-9.7* Hct-31.6* MCV-72* MCH-22.1* MCHC-30.7* RDW-14.9 Plt ___ ___ 01: 12PM BLOOD Creat-0.6 ___ 01: 12PM BLOOD ALT-9 ___ 01: 12PM BLOOD UricAcd-5.6 ___ 02: 28PM BLOOD Type-ART pO2-16* pCO2-164* pH-6.71* calTCO2-24 Base XS--23 Comment-CORD ___ ___ 02: 23PM BLOOD ___ pO2-44* pCO2-61* pH-7.21* calTCO2-26 Base XS--4 Comment-CORD VEIN ___ 02: 38PM URINE Color-Straw Appear-Clear Sp ___ ___ 02: 38PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM ___ 02: 38PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 02: 38PM URINE Hours-RANDOM Creat-11 TotProt-13 Prot/Cr-1.2* ___ 02: 38PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG <MEDICATIONS ON ADMISSION> pnv, humalog (see omr), labetolol 200mg twice daily <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: *0* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for Pain. Disp: *40 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *0* 4. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): increase dose as instructed by endocrinologist. Disp: *90 Tablet(s)* Refills: *2* 5. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp: *180 Tablet(s)* Refills: *2* 6. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp: *14 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic hypertension, diabetes, ___ s/p emergency c-section, neonatal demise, siladenitis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Pelvic rest 6 weeks, no heavy lifting 6 weeks, no driving while taking narcotics
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Ms. ___ was sent to L+D for evaluation after nonreassuring fetal testing in the ___ with a BPP ___. Upon arrival to L+D the patient's FHT was noted to have minimal variability without accels or decels. The patient also had elevated BP up to 180/120 and received 5mg IV hydralazine with good effect. The decision was made to proceed with delivery by stat cesarean section. She underwent delivery and the infant was noted to have Weight of 2720g with Apgars of 0 at one minute, 1 at five minutes, and 3 at 10 minutes of life. The operation was otherwise uncomplicated and the infant was taken to the NICU. . Post-operatively she did well and was admitted to the post-partum service. Because of her preeclampsia she received 24 hours of post-partum magnesium which she tolerated well. With regards to her type 2 diabetes, ___ followed her throughout her hospital stay. She was restarted on her home metformin 500 mg daily on ___. Her fingersticks remained in good control. . Unfortunately the infant did not do well upon arrival to the NICU and continued to decline. On ___ the infant died while in the NICU. Please see NICU records for full details. She was seen by social work following the neonatal death who believed she was coping well. By post-operative day 4 she was tolerating a regular diet, ambulating, controlling her pain with oral pain medications and voiding spontaneously. She was discharged home in on POD4 with follow-up.
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| 331
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10244502-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Stress urinary incontinence, rectocele <MAJOR SURGICAL OR INVASIVE PROCEDURE> TVT, anterior and posterior repair, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ is a ___ woman who presents with urinary incontinence for many years, which is getting worse. She notes leakage with both coughing and sneezing as well as with urge. She also goes to the bathroom frequently every two to two and a half hours and wakes up one to two times at night to urinate. She does admit noting some pressure and tissue protrusion in the vagina, however, denies any defecatory dysfunction. She does wear a pad every day, which she changes once a day. She states that she has tried ___ exercises. She denies recurrent bladder infections, kidney stones, or hematuria. She has intermittent flow. She does not strain to urinate. She does not splint to urinate or defecate. She has rare constipation and no fecal incontinence. She is not sexually active. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Significant for depression, diabetes, hypercholesterolemia, hypertension, and urinary incontinence. Past Surgical History: None. <FAMILY HISTORY> Mother, breast cancer. Maternal grandmother diabetic. Sister, breast cancer. Father, stroke. Past OB History: Gravida 1, para 1, one prior vaginal delivery. Birth weight of largest baby delivered vaginally 9 pounds. Past GYN History: Menopause at age ___. Last Pap ___, was normal with no history of abnormal Paps. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Upon discharge: AF VSS NAD RRR CTAB Abd soft, NT, ND, no r/g GU minimal vaginal bleeding Ext no TTP , no edema <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> benztropine 1mg ___, byetta 10mcg BID, haldol 5mg ___, metformin 1000mg BID, simvastatin 10mg ___, valsartan 160mg ___ 81mg ___, calcium, fish oil <DISCHARGE MEDICATIONS> 1. Benztropine Mesylate 1 mg PO DAILY 2. Haloperidol 5 mg PO DAILY 3. Ibuprofen 600 mg PO Q8H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q8 hours Disp #*30 Tablet Refills: *2 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4 hours Disp #*20 Tablet Refills: *0 5. Valsartan 160 mg PO DAILY 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *2 7. MetFORMIN (Glucophage) 1000 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> urinary incontinence, 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 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 ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing tension-free vaginal tape insertion, anterior and posterior repair and cystoscopy for urinary incontinence and rectocele. 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 vaginal packing was removed and her urine output was adequate so her foley was removed. A voiding trial was performed with the following results: 300cc instilled, 350cc voided, straight catheterized 20cc; 300cc instilled, 400cc voided, no bladder scan performed. Her diet was advanced without difficulty and she was transitioned to 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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10245377-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy <HISTORY OF PRESENT ILLNESS> ___ G2P2 who reported experiencing deep pelvic pain that was sharp for one day in ___. This resolved but recurred four days later. She was evaluated and had a pelvic ultrasound at ___. This revealed a 9 x 8 x 6 cm fibroid extending from the left uterine cornual region. The mass was described as being echogenic centrally, raising the question of hemorrhage and possibly even malignant transformation. She has and reports a long history of menorrhagia. She had also noted on that ultrasound a complex ovarian cyst that is consistent with a physiologic cyst. An MRI was performed at the open MRI system in ___. This revealed a fibroid uterus with a prominent left-sided dominant fibroid measuring 6 x 7 x 8 cm. There is no evidence of central necrosis on that MRI. A right ovarian cyst is noted without enhancement or nodularity. She was referred for consultation regarding hysterectomy. After reviewing her options, laparoscopic hysterectomy was offered. All consents were signed and placed in the chart. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> none Past Surgical History: She had a tubal ligation and a stress incontinence sling performed. OB/GYN History: SVD x2. No abnormal paps. <SOCIAL HISTORY> ___ <FAMILY HISTORY> sister died of leukemia at the age of ___. father had some form of cancer, myasthenia ___. <PHYSICAL EXAM> On discharge: VSS, afebrile NAD RRR CTAB Abdomen soft, minimally tender, non-distended +BS Incisions w/ tegaderm dressings, clean, dry, intact. ___ <PERTINENT RESULTS> ___ 07: 20AM BLOOD WBC-9.2 RBC-4.12* Hgb-10.9* Hct-33.6* MCV-82 MCH-26.4* MCHC-32.4 RDW-14.0 Plt ___ ___ 07: 20AM BLOOD Glucose-78 UreaN-8 Creat-0.8 Na-138 K-4.5 Cl-103 HCO3-29 AnGap-11 <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 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> Call your doctor for: * fever > 101 * 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. **if no cervix p LSC hyst, nothing in vagina for 3 months * 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, you may remove them in 7 days.
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Mrs. ___ was admitted and underwent an uncomplicated total laparoscopic hysterectomy. Intraoperative findings included a fibroid uterus with normal ovaries. Cystoscopy was also performed demonstrating bilateral ureteral jets. She recovered well in the PACU and was taken to the floor. On POD#1, she was able to ambulate. Her catheter was removed. She tolerated a regular diet and oral pain medications. She was discharged home in god condition.
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10246371-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fibroid uterus, endometriosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> attempted total laparoscopic hysterectomy converted to open, bilateral salpingo-oophorectomy, cystoscopy, lysis of adhesions <HISTORY OF PRESENT ILLNESS> The patient is a ___ who has a known fibroid uterus and bilateral endometriomas with cyclic pelvic pain. She was counseled regarding her options for management and elected for hysterectomy. Initially, the planned procedure was a laparoscopic-assisted vaginal hysterectomy, but given the endometriomas, the patient was counseled extensively that a laparoscopic or vaginal approach may not be feasible and of the risk of converting to an open hysterectomy. All consents were signed and placed in the chart. <PAST MEDICAL HISTORY> Hepatitis A + HBsAB, negative HBsAg <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother died of esophageal cancer at age ___ and father died of a myocardial infarction after bilateral leg amputations from "blood clots" at age ___. <PHYSICAL EXAM> Upon discharge: AF VSS NAD RRR CTAB Abd soft, appropriately TTP, ND, no r/g Incisions c/d/i GU minimal vaginal bleeding Ext no TTP, no edema <PERTINENT RESULTS> ___ 04: 47PM BLOOD WBC-16.4*# RBC-3.65* Hgb-10.4* Hct-31.5* MCV-86 MCH-28.6 MCHC-33.1 RDW-14.0 Plt ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 3 PUFF IH Q6H: PRN asthma <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler 3 PUFF IH Q6H: PRN asthma 2. 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> fibroid uterus, 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 are being discharged from the hospital after undergoing the procedures listed below. Please follow these 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. 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 attempted total laparoscopic hysterectomy converted to open total abdominal hysterectomy, bilateral salpingo-oophorectomy, lysis of adhesions and cystoscopy for fibroids and endometriosis. Please see the operative report for full details. Immediately post-op in the PACU she was noted to be intermittently tachycardic to the 120s. She was asymptomatic and was otherwise hemodynamically stable with vitals wnl. An ECG demonstrated intermittent sinus tachycardia without evidence of ischemic changes. A PACU hematocrit was appropriate at 31.5. Upon review of ___ clinic notes, it was discovered that her tachycardia had been noted pre-op and a work-up was to be initiated by her PCP. Upon transfer to the floor, her tachycardia resolved. Her post-operative course was uncomplicated. Her pain was controlled with IV dilaudid, toradol and tylenol. 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 percocet and motrin. An estradiol patch was placed for surgical menopause prophylaxis. 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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10246556-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Primary cesarean section with a T-shaped uterine incision 2. Examination under anesthesia; manual vaginal dilatation; exploratory laparotomy; repair of vaginal laceration. <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ with known fetal multidysplastic kidney (singular in pelvis), micronagthia, possible TE fistula, and early onset oligohydramnios presents with contractions since 3PM, regular q3min. She ate take-out rice and chicken at 230pm on day of arrival and had +emesis @ 4pm with an episode of chills and body aches. The chills and body aches resolved and she was able to sleep for a few hours. No recent intercourse. No LOF, no VB. Also endorses decreased FM today. No abdominal pain, diarrhea, dysuria, or any other complaints. <PAST MEDICAL HISTORY> denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> no consanguinity <PHYSICAL EXAM> On admission: <PERTINENT RESULTS> ___ 09: 36PM WBC-12.7* RBC-2.53* HGB-8.4* HCT-22.9* MCV-91 MCH-33.1* MCHC-36.6* RDW-13.6 ___ 09: 36PM PLT COUNT-181 ___ 11: 26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 11: 26PM URINE COLOR-Straw APPEAR-Clear SP ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q3-4H () as needed. Disp: *40 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *60 Tablet(s)* Refills: *0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *50 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean delivery Re-exploration and repair Critically ill infant at 28 weeks <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> good
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Pt initially admitted to Labor and Delivery for preterm labor at 28wks gestational age. Upon arrival, her initial cervical exam demonstrated a short vagina with a nonpalpable cervix and question of blind vaginal pouch. Attempts were made to arrest her contractions with IV fluids, Nifedepine and magnesium, however pt continued to contract despite treatment with magnesium. As it was difficult to access labor through vaginal exam, rectovaginal exam was attempted which demonstrated the fetal head to be at +2 station. Fetal heart tracing also became non-reassuring. At this time, the decision was made to proceed to cesarean delivery. Once again, the patient was informed of the guarded prognosis on the fetus with this type of anomaly, especially at 28 weeks of gestation s/p beta-methasone x1. In addition, there were discussions about the possibility of a difficult intubation due to possible micrognathia. The delivery was complicated by fetal head lodged in the posterior fossa and cervix opening into the posterior fossa of the pelvic cavity. Pt tolerated the procedure well and went back to labor and delivery for recovery. Post-operatively there was concern for mullerian abnormality as cervix was found to be in pelvic cavity rather than vagina. Pt had no lochia per vagina after delivery. Pt had progressive increase in abdominal pain with tachycardia. Hematocrit was checked q4hours. Hct proceeded to decreased from 33 to 22.1. This coupled with increasing abdominal pain and no lochia per vagina raised concern for developing intraabdominal hematoma from lochia. Gyn-Oncology contacted for consultation. Decision was made for CT scan to look for possible hemoperitoneum or collection of blood in abdomen/pelvis. Pt also spiked temp to 101.3 and started on Kefzol, gentamycin, and clindamycin for presumed endometritis from chorioamnionitis. Pt became increasingly distended after ingesting PO contrast. Pt then desaturated on RA to 92-93%. Desaturation was attributed to abdominal distension as pt not tachycardic. CT of abdomen and pelvis was read by radiology attending on call who reported it difficult secondary to anatomical anomalies but saw a loculated fluid collection behind the uterus extending down to the vagina. Given the location, it was decided that it would be too difficult to access the fluid through ___ or colpotomy. Findings discussed with pt and her husband. Images reviewed again with Dr. ___ radiologists. Surgical management recommended. With pt reviewed risk of infection, bleeding, and hysterectomy. pt was at increased risk given her chorioamnionitis. Pt consented for exploratory laparotomy. Dr. ___, Dr. ___ Dr. ___ with the operation. Intra-operatively, pt was found to have a ruptured posterior cul-de sac, and her cervix was found to be in the abdominal cavity. There was minimal lochia found in the intra-abdominal cavity. JP drain placed. Cervix was moved back into the vagina and posterior wall was repaired without complications. Post-operatively pt recovered excellently. She stayed on labor and delivery initially for close monitoring. While on labor and delivery pt had tachycardia and O2 desaturation while in sleep. EKG ordered which demonstrated NSR. CTA showed no PE, but did exhibit small bilateral pleural effusions. Pt remained afebrile with no further desaturation and was transferred to postpartum floor. Pt's postpartum course was relatively uncomplicated. She was transitioned to PO pain meds as her diet was advanced as tolerated with return of bowel function. Pt remained on Kefzol, gentamycin, and clindamycin until 48hours afebrile for presumed endometritis. Pt had an episode of chest pain with deep inspiration at her sternum. Exam and vital signs were all normal. Repeat EKG again demonstrated normal sinus rhythm with no ST elevations. As pain resolved quickly and all vital signs were WNL, suspicion for PE was very low and no CTA was obtained. Pt had not further episodes of chest pain during her hospital course. Her JP drain was d/c'ed on HD #4 after putting out <30cc/shift. Pt continued to steadily improve. She was seen by social work regarding the deteriorating status of her infant in NICU. Pt was discharged on HD#7 in good condition.
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10246556-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> desires termination of pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy Hysterotomy Evacuation of uterus/pregnancy termination <HISTORY OF PRESENT ILLNESS> ___ year old Gravida 3 Para 1 at 21+6 wks initially referred for consultation due to a history of prior pregnancy with ___ Sequence, ambiguous genitalia, hirsuitism, and neonatal death at day 10 of life due to pulmonary hypoplasia (baby born @ 28 wks after PTL). Autopsy and genetic work-up revealed duplication on chromosome 2 (HOX gene). This delivery was complicated by preterm labor and then C/S with re-exploration laparotomy due to posterior vaginal wall rupture with baby's head & cervix protruding into ___ Pouch and hemoperitoneum. She has seen multiple physicians and had extensive work-up for these issues, and the general consensus has been that she has a complex mullerian anomaly that likely involves a vaginal septum. Currently 21+6 weeks pregnant and has been seen by outside maternal fetal medicine and outside radiologists regarding the findings of likely Potter sequence in this pregnancy. She and her husband presented to us at 18wks with desire for a second opinion and discussion regarding possible termination. After follow up ultrasounds and time to consider her options, she has elected to proceed with termination. <PAST MEDICAL HISTORY> OBHx: - Prior to ___, 8 wk ectopic treated with methotrexate in ___ - ___ - pregnancy described above, 28 wk PTD following spontaneous PTL, neonatal death PMH: denies PSH: Prior laparoscopic appendectomy (no rupture), umbilical/incisional hernia repair with mesh (post ___, C/S described above PObGyn Hx: as above Abnormal PAP smear: denies Cervical surgery: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> AVSS NAD RRR CTAB soft, gravid, non tender, vertical scar with keyloid, no palpable hernia NT/NE Pelvic: deferred to OR <PERTINENT RESULTS> ___ 12: 11PM HGB-10.8* calcHCT-32 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 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* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pregnancy at 21 weeks gestation with severe oligohydramnios Uterine/vaginal anatomic abnormalities <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. * If you have staples, they will be removed at your follow-up visit.
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Ms. ___ is a ___ G3P1 who presented at 21w6d for scheduled hysterotomy for termination of pregnancy due to severe oligohydramnios and Potter's sequence, as well as Mullerian anomalies necessitating abdominal approach with hysterotomy. The procedure was uncomplicated; please see full operative note for details. Her postoperative course was uncomplicated. She was discharged home in stable condition on POD#2.
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10246556-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> leaking fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, hysterotomy <HISTORY OF PRESENT ILLNESS> ___ year old G4P___ at ___ presents with a gush of fluid this morning after getting up to go to the bathroom. She felt a lot of pressure just prior to the gush of fluid, which was relieved with the gush. Has not really started to feel fetal movement yet. Had vaginal spotting yesterday during the day. <PAST MEDICAL HISTORY> PNC: ___ ___ by IVF dating Labs: O+/ab neg/HBsAg neg/RPRNR/ Rubella immune (as of ___ Glucose screening: Early glucola -> positive (GLT 188) Genetics screening: Not done Issues: * IVF pregnancy, female chosen to avoid ___ * positive PPD (negative CXR in ___ * h/o 2 prior hysterotomies PObHx: - G1: ectopic s/p MTX - G2: PTL -> Low vertical C/S c/b multiple uterine anomalies, with delivery complicated by need for re-exploration laparotomy due to posterior vaginal wall rupture with baby's head and cervix protruding into ___ pouch. This was thought ___ to complex Mullerian anomaly - G3: Classical C/S at 22 weeks in setting of termination for ___ sequence - G4: current PGynHx: - congenital genital organ anomalies: double vagina with thick transverse septum. Septum in close proximity to urethra. vaginal adhesions s/p laser incision PMHx: hypothyroidism PSHx: - right inguinal hernia repair with mesh - bilateral breast reduction via liposuction in ___ - Hysterotomy (classical cesarean section) - Low vertical cesarean section c/b posterior vaginal rupture requring exploratory laparotomy - Laparoscopic appendectomy Meds: levothyroxine 100 mcg daily, last TSH 0.66 <ALLERGIES> PCN -> rash <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no c/c/e <MEDICATIONS ON ADMISSION> levothyroxine 100mcg po daily <DISCHARGE MEDICATIONS> 1. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain Do not drive or drink alcohol, causes sedation RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Ibuprofen 600 mg PO Q6H: PRN pain take wtih food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *1 4. Docusate Sodium 100 mg PO BID Take while using oxycodone to prevent constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 5. Acetaminophen ___ mg PO Q6H pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> previable premature rupture of membranes <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 ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing exploratory laparotomy and hysterotomy for delivery of a nonviable fetus after previable preterm premature rupture of membranes. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with a Tap Block, dilaudid PCA and IV 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, ibuprofen and tylenol (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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10250316-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Benadryl Decongestant / Amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> Fever, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> right transgluteal drain placement <HISTORY OF PRESENT ILLNESS> 40 ___ s/p embryo transfer on ___ w/ negative HCG presenting with abdominal pain and fevers since ___. Was evaluated in the ___ ED ___ and had a pelvic ultrasound which showed a small amount of hemoperitoneum with bilateral hemorrhagic ovarian cysts. No evidence of torsion or IUP. Asymmetrically enlarged right ovary. WBC 14.1. Pt d/c'd home w/ tylenol and vicodin for pain control, but continued to have pain and fevers at home up to 102. Pain this AM triggered nausea and feeling that she was "going to black out." Abdominal pain has been migratory to rectum, RUQ and periumbilical. Has now subsided and is no longer present at rest. Exacerbated by changes in position/laughing. Pt has had intermittent headache since sxs started. Has had decreased appetite, and brief episodes of nausea, but has not had sustained nausea, no vomiting. Reports loose formed stools, but denies diarrhea. No urinary or vaginal sxs. Menses started yesterday. <PAST MEDICAL HISTORY> ObHx: ___ NVD 36wks3d, liveborn male, 5lb7oz GYN Hx: ___ ___, neg colpo, nl f/u Genital Herpes since ___, stopped taking acyclovir appx ___ has not had an outbreak in ___. PMH: -Umbilical hernia -Hemorrhoids -Postcoital UTIs, take Macrobid PRN. Last UTI in ___ -Plantar wart on big toe -Slipped disc in lumbar region PSH: Adenoidectomy as a child, L broken arm <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> T 101.2 -> 101.8 HR115 -> 108 BP135/84 RR20 rpt T ___ s/p Motrin Gen: Well appearing, talkative, NAD RRR; no murmurs appreciated CTAB Abd: soft, ND, mild tenderness to firm palpation in infraumbilical area and lower quadrants, no guarding, no rebound- shotty tender inguinal lymph nodes bilaterally Bimanual: adnexal fullness bilateral, +adnexal tenderness - R>L, +CMT, tenderness to palpation suprapubically, no blood or discharge on glove <PERTINENT RESULTS> ___ WBC-5.8 RBC-3.79* Hgb-11.5* Hct-34.5* MCV-91 MCH-30.4 MCHC-33.4 RDW-12.1 Plt ___ ___ WBC-8.9 RBC-3.71* Hgb-11.1* Hct-34.0* MCV-92 MCH-29.8 MCHC-32.6 RDW-12.6 Plt ___ ___ WBC-11.9* RBC-3.84* Hgb-11.5* Hct-35.3* MCV-92 MCH-30.0 MCHC-32.7 RDW-12.6 Plt ___ ___ WBC-12.5* RBC-3.88* Hgb-12.0 Hct-35.8* MCV-92 MCH-30.8 MCHC-33.4 RDW-12.2 Plt ___ ___ WBC-20.4* RBC-3.96* Hgb-12.0 Hct-35.9* MCV-91 MCH-30.2 MCHC-33.3 RDW-12.5 Plt ___ ___ WBC-20.6* RBC-3.76* Hgb-11.3* Hct-34.0* MCV-90 MCH-30.0 MCHC-33.2 RDW-12.8 Plt ___ ___ WBC-25.5* RBC-3.98* Hgb-12.3 Hct-36.3 MCV-91 MCH-30.8 MCHC-33.9 RDW-12.1 Plt ___ ___ WBC-27.0* RBC-3.63* Hgb-10.8* Hct-32.6* MCV-90 MCH-29.9 MCHC-33.2 RDW-12.1 Plt ___ ___ WBC-28.5* RBC-3.95* Hgb-11.8* Hct-35.0* MCV-89 MCH-29.9 MCHC-33.7 RDW-12.5 Plt ___ ___ WBC-23.2* RBC-3.80* Hgb-11.7* Hct-34.2* MCV-90 MCH-30.7 MCHC-34.1 RDW-12.1 Plt ___ ___ WBC-22.6* RBC-4.02* Hgb-12.2 Hct-36.1 MCV-90 MCH-30.3 MCHC-33.8 RDW-12.6 Plt ___ ___ WBC-22.0* RBC-4.29 Hgb-12.7 Hct-38.4 MCV-90 MCH-29.7 MCHC-33.1 RDW-12.4 Plt ___ ___ WBC-17.8* RBC-3.96* Hgb-12.1 Hct-35.2* MCV-89 MCH-30.6 MCHC-34.5 RDW-12.3 Plt ___ ___ WBC-13.4* RBC-3.82* Hgb-11.6* Hct-33.5* MCV-88 MCH-30.3 MCHC-34.5 RDW-11.9 Plt ___ ___ WBC-14.6* RBC-4.09* Hgb-12.6 Hct-36.0 MCV-88 MCH-30.7 MCHC-34.9 RDW-11.9 Plt ___ ___ Neuts-72* Bands-0 ___ Monos-6 Eos-2 Baso-1 ___ Myelos-0 ___ Neuts-61 Bands-1 ___ Monos-7 Eos-0 Baso-0 Atyps-1* ___ Myelos-3* ___ Neuts-78* Bands-0 Lymphs-11* Monos-7 Eos-1 Baso-1 ___ Metas-2* Myelos-0 ___ Neuts-70 Bands-2 Lymphs-10* Monos-12* Eos-1 Baso-2 Atyps-1* Metas-1* Myelos-1* ___ Neuts-69 Bands-5 Lymphs-11* Monos-9 Eos-2 Baso-0 ___ Metas-2* Myelos-1* Promyel-1* ___ Neuts-80* Bands-0 Lymphs-13* Monos-3 Eos-2 Baso-0 Atyps-1* ___ Myelos-1* ___ Neuts-80.7* Lymphs-12.1* Monos-5.2 Eos-0.9 Baso-1.1 ___ Neuts-84* Bands-2 Lymphs-5* Monos-8 Eos-0 Baso-0 ___ Myelos-1* ___ Neuts-79* Bands-6* Lymphs-7* Monos-5 Eos-0 Baso-1 ___ Metas-2* Myelos-0 ___ Neuts-82* Bands-0 Lymphs-8* Monos-6 Eos-1 Baso-0 ___ Myelos-0 Hyperse-3* ___ Neuts-84* Bands-0 Lymphs-7* Monos-8 Eos-0 Baso-0 ___ Myelos-0 Hyperse-1* ___ Neuts-75* Bands-0 Lymphs-11* Monos-14* Eos-0 Baso-0 ___ Myelos-0 ___ Neuts-85* Bands-0 Lymphs-7* Monos-8 Eos-0 Baso-0 ___ Myelos-0 ___ Neuts-85* Bands-0 Lymphs-11* Monos-3 Eos-0 Baso-0 Atyps-1* ___ Myelos-0 ___ ___ PTT-36.5* ___ ___ Glucose-113* UreaN-7 Creat-0.7 Na-137 K-4.7 Cl-99 HCO3-29 AnGap-14 ___ Glucose-123* UreaN-9 Creat-0.7 Na-136 K-3.8 Cl-97 HCO3-27 AnGap-16 ___ Glucose-97 UreaN-12 Creat-0.7 Na-135 K-3.8 Cl-96 HCO3-28 AnGap-15 ___ ALT-23 AST-21 AlkPhos-94 TotBili-0.4 ___ ALT-33 AST-26 AlkPhos-108* TotBili-0.3 ___ Albumin-3.6 ___ Calcium-9.3 Phos-3.2 Mg-1.8 ___ HCG-<5 ___ Vanco-14.6 ___ Vanco-8.0* ___ CT abdomen and pelvis: 1. Bilateral enlarged ovaries and multiple follicles identified in keeping with known ovarian hyperstimulation. 2. Free fluid is noted within the pouch of ___. Differential diagnosis includes physiologic free fluid in the setting of ovarian hyperstimulation; however, given the elevated white cell count and patient symptomatology, pelvic abscess, tuboovarian abscess, hydrosalpinx, or pyosalpinx cannot be excluded. Further correlation with pelvic ultrasound is recommended ___ Pelvic U/S: 1. Bilateral enlarged ovaries with bilateral hemorrhagic cysts in keeping with know ovarian hyperstimulation. 2. Echogenic material within a dilated right fallopian tube. This could be blood or pus. 3. Normal arterial and venous waveforms in bilateral ovaries. ___ CT abdomen and pelvis: 1. Large rim-enhancing multiloculated pelvic collection measuring 10.3 x 7.6 x 8.6 cm. Given clinical symptoms and morphology suggesting that the locules communicate and appear somewhat tubular, these findings are highly suspicious for a pelvic abscess; however, hematosalpinx can also have a similar appearance. Mild mass effect on the uterus and the rectosigmoid junction. This collection is amenable to imaging guided percutaneous drainage. 2. Nodular enhancing elements within this cystic lesion are unchanged since the prior study and is of unclear significance. This can be followed up after resolution of the acute symptoms. 3. Mildly enlarged retroperitoneal lymph nodes, likely are reactive secondary to the pelvic inflammation. Followup examination, with either a CT or an MRI after resolution of inflammatory symptoms should be considered to document expected improvement. 4. Mild prominence of the central biliary tree and CBD, of unclear significance. Recommended correlation with liver function tests. ___ MRI pelvis: 1. 8.5 x 6.8 cm multiseptated, rim-enhancing, midline pelvic fluid collection compatible with an abscess, slightly decreased in size in the interval. 2. New percutaneous pigtail catheter terminating within the largest pocket of the collection. 3. 11 mm cystic lesion in the left ovary, possibly a hemorrhagic cyst or endometrioma. ___ Pelvic U/S: Complex fluid collection within the pelvis is again seen measuring 7.1 x 5.2 x 4.9 cm on today's examination, slightly decreased in size from the prior MRI. Catheter is seen within the posterior aspect of the collection. <MEDICATIONS ON ADMISSION> Prenatal Vitamins, tylenol, progesterone vaginal suppositories, acyclovir 100mg TID (since ___, Macrobid prn <DISCHARGE MEDICATIONS> 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: do not take more thatn 4g in 24 hrs. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO Daily () as needed for infection: Continue for additional 2 weeks after drain removed. Disp: *30 Tablet(s)* Refills: *1* 6. Saline Flush 0.9 % Syringe Sig: One (1) 10 mL Injection once a day for while drain in place doses. Disp: *15 * Refills: *2* 7. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *40 Tablet(s)* Refills: *1* 8. prochlorperazine maleate 5 mg Tablet Sig: ___ Tablets PO every eight (8) hours as needed for nausea: Do not exceed 8 tablets per day. Disp: *40 Tablet(s)* Refills: *1* 9. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp: *12 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Pelvic abscess <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. * 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. 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 GYN service for antibiotics and observation. She continued to spike on antibiotics and was seen by infectious disease in consultation. She was then started on vancomycin, cefepime, flagyl. CT of her pelvis revealed a multiloculated pelvic mass which was amenable to drainage. She then had a right transgluteal drain placed by radiology after which her WBC decreased to normal and she became afebrile. She was sent home with the drain and ___ services. She was sent home on moxifloxacin which she will continue for 2 weeks after the drain is removed. She will follow-up in clinic with Dr. ___.
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10250707-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Ace Inhibitors / Penicillins / Amoxicillin <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingoophorectomy, diagnostic cystoscopy <HISTORY OF PRESENT ILLNESS> ___ G5P4 with history of an ennalrged fibroid uterus that cuases significant abdominal distension and pelvic pressure. She has monthly bleeding which is dark with a foul odor. Endometrial biopsy performed on ___ whas negative. <PAST MEDICAL HISTORY> Hypertension Depression/Anxiety <SOCIAL HISTORY> Primary caregiver for two disabled children <PHYSICAL EXAM> AVSS NAD RRR, no M/R/G CTAB Abd: soft, NT, ND Incision: C/D/I Ext: no calf tenderness <MEDICATIONS ON ADMISSION> Atenolol, Nifedipine, Triamtene, HCTZ, Nexium <DISCHARGE MEDICATIONS> 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: Two (2) Cap PO DAILY (Daily). 4. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4-6h as needed for pain for 2 weeks. Disp: *30 Tablet(s)* Refills: *0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *30 Capsule(s)* Refills: *2* 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for 2 weeks. Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please take all of your home medications. Please call for any of the following: fever, increased pain, redness/pain/drainage from your incision site, chest pain, shortness of breath or any other concerns that may worry you.
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Pt underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and diagnostic cystoscopy. Pt tolerated the procedure well. Immediately post-operatively patient had a few apeneic spells in PACU after receiving 1mg of Dilaudid IV. Dilaudid dosage decreased and patient kept in PACU until apeneic episodes resolved a few hours later. The rest of her post-operative course was relatively uncomplicated. Diet was slowly advanced to regular. Patient ambulated and resumed all of her home medications. Patient had some abdominal pain likely secondary to gas pain on post-operative day#2 which was relieved with simethicone. Pt was discharged on post-operative day #3 in good condition.
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10253060-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Benadryl <ATTENDING> ___ <CHIEF COMPLAINT> Hypertension <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 36+5 WGA with BP's 130's-150's/80-90's . Pt also reports h/a today but denies RUQ/epigastric pain and vision changes. Pt also reports hand swelling and that she just doesn't feel well. Denies vaginal bleeding and contractions. +FM. Pt reports increased vaginal discharge over the past 2 days. ROS: denies CP and SOB <PAST MEDICAL HISTORY> PNC: 1)Dating: EDC ___ 2)Routine testing: O+, antibody neg, RPR NR, rubella immune, HbsAg NR, GBS unk 3)Screening: Nl ERA, nl FFS 4) Issues: - marginal previa that resolved - h/o narcotic use for ankle pain/surgery although now using 1 time per week or less. OB Hx: G1P0 Gyn Hx: PMH: h/o depression-no current meds Surg Hx: ankle surgery from car accident <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory. <PHYSICAL EXAM> On admission: Gen: NAD VS: T 98.8 BP 136/92 HR 77 RR/18 CV: rrr w/o m/g/r Chest: CTA B Abd: gravid, soft, nontender Back: - CVAT Ext: -edema B SSE: small amt whitish creamy discharge, neg pooling, neg pH, neg ferns. EFM: 135 ___, mod variability, +accels, no decels, reactive. Toco: no contractions TAUS today: cephalic, + fetal cardiac motion seen, BPP ___, AFI 18.8. <PERTINENT RESULTS> ___ 12: 02PM URINE HOURS-RANDOM CREAT-53 TOT PROT-12 PROT/CREA-0.2 ___: 02PM CREAT-0.6 ___ 12: 02PM ALT(SGPT)-9 ___ 12: 02PM URIC ACID-6.4* ___ 12: 02PM WBC-12.6* RBC-4.23 HGB-12.6 HCT-35.4* MCV-84 MCH-29.8 MCHC-35.6* RDW-12.5 ___ 12: 02PM PLT COUNT-183 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> PNV <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 36w6d hypertension <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for evaluation of preeclampsia. While you were here, there was no evidence of preeclampsia and your blood pressures improved significantly. It is recommended that you check your blood pressure on ___ call your doctor if it is elevated.
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Ms. ___ is a ___ yo G1P0 who was admitted to the antepartum service for observation of her blood pressures and collection of a 24 hour urine. Her 24 hour urine returned at 240mg, which is negative for pre-eclampsia. Her blood pressures were 130-140/70-84. She remained asymptomatic. She was discharged home with close follow-up from her primary OB and with fetal testing.
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10253421-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abnormal endometrium <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ woman with a thickened abnormal endometrium. She has been brought to the operating room twice for hysteroscopy D&C. We brought her to the operating room for the first time in ___. At that point, no visible abnormalities to the endometrium were identified. We did a D&C at that point. At the end of ___, we went ahead and did a hysteroscopy D&C. This proved to be a fairly challenging procedure because of cervical stenosis, but when we looked in the endometrial cavity, we saw essentially fibrotic irregularities consistent with scarring of the endometrial cavity. <PAST MEDICAL HISTORY> PGynHx: - LMP: ___ - Periods prior were regular since the age of ___ - Last pap: ___, NILM. Denies h/o abnormal paps. - STDs: denies - Not currently sexually active POBHx: G1P0 - SAB while in high school (___) PMHx: - MGUS, stable in ___ - Adenomatous colonic polyp on ___ colonoscopy, ___ colonoscopy notable only for diverticulosis - GERD - Osteoporosis PSHx: - Left oophorectomy for 'infection', ___ - B/L cataract surgery, ___ and ___ - Bunionectomy (left), ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> sister with h/o stomach cancer. Denies h/o endometrial, cervical, ovarian, breast cancers in her family. <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 <PERTINENT RESULTS> ___ 06: 05AM BLOOD WBC-11.1* RBC-3.16* Hgb-10.4* Hct-30.7* MCV-97 MCH-32.9* MCHC-33.9 RDW-12.4 Plt ___ ___ 06: 05AM BLOOD Glucose-91 UreaN-13 Creat-0.6 Na-141 K-4.0 Cl-106 HCO3-29 AnGap-10 ___ 06: 05AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID do not exceed 4000mg in 24 hours RX *acetaminophen 325 mg ___ tablet(s) by mouth every eight (8) 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 #*60 Capsule Refills: *2 3. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain 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 4. 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 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abnormal endometrium **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: . Laparoscopic 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 4 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. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . 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 laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with dilaudid PCA and tylenol. Her diet was advanced without difficulty and she was transitioned to oxycodone, tylenol and ibuprofen for pain. 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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10253998-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> elev BP from ATU <MAJOR SURGICAL OR INVASIVE PROCEDURE> spontaneous vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ who presents from ATU with BP 154/88 and 142/90; BPP ___, AFI 16, NRNST. She was seen in ATU for hx of itching intially reported on ___ (2 days ago); she had labs drawn on that day showing ALT 47, AST 41, Hct 34, plts 134 (bile acids pending). BPs have never been abnl this pregnancy. Currently reports mild HA (has not eaten all day), denies VC, RUQ pain. Occ. ctx, no VB, LOF. +FM. PNC: - ___: ___ - labs: O+/Ab-/RPRNR/RI/HsBAg-/HCV-/HIV-/GBS unknown - screening: CF screen neg, low risk ERA, nl FFS (post plac) - issues: FOB not involved <PAST MEDICAL HISTORY> POBHX: G1 P0 PGYNHX: - LMP: ___ - Paps: no abnl - STIs: denies PMH: nil PSH: nil <SOCIAL HISTORY> lives with family, FOB not involved, feels safe, no T/E/D <PHYSICAL EXAM> VS: 99.4 57 20 128/86 123/86 129/86 125/83 119/80 GENERAL: NAD CARDIO: RRR PULM: CTAB ABDOMEN: soft, gravid, NT, EFW 6# by ___ EXTREMITIES: 2+ DTRs b/l SSE: def SVE/BME: L/C/P TOCO: q10min FHT: 130, mod var, reactive, no decels BPP: ___, AFI 16, cephalic presentation <PERTINENT RESULTS> ___ 12: 15PM BLOOD WBC-8.3 RBC-3.99* Hgb-12.7 Hct-35.7* MCV-89 MCH-31.9 MCHC-35.6* RDW-13.2 Plt ___ ___ 05: 41PM BLOOD WBC-8.1 RBC-4.17* Hgb-13.1 Hct-37.6 MCV-90 MCH-31.3 MCHC-34.8 RDW-13.1 Plt ___ ___ 11: 59PM BLOOD WBC-11.9* RBC-4.14* Hgb-13.0 Hct-36.8 MCV-89 MCH-31.4 MCHC-35.3* RDW-13.1 Plt ___ ___ 07: 04AM BLOOD WBC-12.6* RBC-4.03* Hgb-12.5 Hct-35.6* MCV-89 MCH-30.9 MCHC-35.0 RDW-13.2 Plt ___ ___ 10: 37AM BLOOD WBC-12.0* RBC-3.90* Hgb-12.6 Hct-35.2* MCV-90 MCH-32.3* MCHC-35.8* RDW-13.0 Plt ___ ___ 02: 17PM BLOOD WBC-13.1* RBC-3.91* Hgb-12.4 Hct-35.3* MCV-90 MCH-31.7 MCHC-35.1* RDW-13.1 Plt ___ ___ 07: 48PM BLOOD WBC-14.7* RBC-3.64* Hgb-11.5* Hct-33.2* MCV-91 MCH-31.6 MCHC-34.6 RDW-13.3 Plt ___ ___ 01: 17AM BLOOD WBC-15.4* RBC-2.59*# Hgb-8.0*# Hct-23.1*# MCV-89 MCH-31.0 MCHC-34.8 RDW-13.7 Plt ___ ___ 07: 00AM BLOOD WBC-21.7* RBC-3.03* Hgb-9.3* Hct-26.7* MCV-88 MCH-30.7 MCHC-34.7 RDW-13.8 Plt ___ ___ 05: 40PM BLOOD WBC-15.3* RBC-2.66* Hgb-8.5* Hct-23.9* MCV-90 MCH-31.9 MCHC-35.4* RDW-13.7 Plt ___ ___ 07: 27AM BLOOD WBC-14.3* RBC-2.42* Hgb-7.7* Hct-22.3* MCV-92 MCH-31.6 MCHC-34.4 RDW-14.4 Plt ___ ___ 12: 15PM BLOOD ___ PTT-27.6 ___ ___ 02: 17PM BLOOD ___ PTT-25.0 ___ ___ 12: 15PM BLOOD ___ ___ 02: 17PM BLOOD ___ ___ 12: 15PM BLOOD Creat-0.9 ___ 05: 41PM BLOOD Creat-0.9 ___ 11: 59PM BLOOD Creat-0.9 ___ 07: 04AM BLOOD Creat-1.0 ___ 10: 37AM BLOOD Creat-1.1 ___ 02: 17PM BLOOD Creat-1.2* ___ 07: 30PM BLOOD Creat-1.2* ___ 01: 17AM BLOOD UreaN-18 Creat-1.2* ___ 07: 00AM BLOOD Creat-1.3* ___ 05: 40PM BLOOD Creat-1.1 ___ 07: 27AM BLOOD UreaN-15 Creat-0.9 ___ 12: 15PM BLOOD ALT-64* AST-58* LD(LDH)-216 TotBili-0.2 ___ 05: 41PM BLOOD ALT-70* AST-62* ___ 11: 59PM BLOOD ALT-87* AST-76* ___ 07: 04AM BLOOD ALT-113* AST-101* ___ 10: 37AM BLOOD ALT-119* AST-101* ___ 02: 17PM BLOOD ALT-133* AST-112* ___ 07: 30PM BLOOD ALT-158* AST-140* ___ 01: 17AM BLOOD ALT-176* AST-170* ___ 07: 00AM BLOOD ALT-215* AST-198* ___ 05: 40PM BLOOD ALT-178* AST-148* ___ 07: 27AM BLOOD ALT-144* AST-110* ___ 12: 15PM BLOOD UricAcd-6.0* ___ 05: 41PM BLOOD UricAcd-6.1* ___ 11: 59PM BLOOD Mg-9.4* UricAcd-6.4* ___ 07: 04AM BLOOD Mg-8.1* UricAcd-6.8* ___ 10: 37AM BLOOD Mg-6.9* UricAcd-7.3* ___ 02: 17PM BLOOD Mg-6.1* UricAcd-7.3* ___ 07: 30PM BLOOD Mg-4.5* UricAcd-7.4* ___ 01: 17AM BLOOD Mg-5.8* UricAcd-7.4* ___ 07: 00AM BLOOD UricAcd-7.5* ___ 05: 40PM BLOOD Mg-7.4* UricAcd-7.4* ___ 07: 27AM BLOOD UricAcd-7.1* ___ 12: 14PM URINE Hours-RANDOM Creat-18 TotProt-75 Prot/Cr-4.2* <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *25 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *50 Tablet(s)* Refills: *1* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy, delivered pre-eclampsia <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) No driving 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 Warning signs: Refer to OB discharge packet Feelings of anxiety, fear, or panic that last all day, persistent sadness, thoughts of harming self or baby. Passing clots larger than a fist Heavy vaginal bleeding Fever greater than 101 Foul smelling blood Pain not adequately relieved with medication Nausea/vomiting unable to keep down food/fluids Shortness of breath, dizziness, chest pain, palpitations
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Ms ___ was admitted to labor and delivery for induction of labor given pre-eclampsia at term and underwent spontaneous vaginal delivery. She received magnesium prophylaxis for 24 hours postpartum. Postpartum Ms ___ blood pressures were within goal on no antihypertensive medications and she had no symptoms of pre-eclampsia. Her transaminitis and thrombocytopenia were followed and by late on postpartum day #2 her labs were all improving. Ms ___ was discharged home in stable condition on postpartum day #3.
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10255388-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> painful ctx, DFM <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G4P2012 at 34/0 who presents w/ decreased FM, also with L sided abdominal pain ?ctx. Denies any LOF, no VB. Pt denies any recent cough/cold/flu symptoms, no F/C, no N/V/D. No recent intercourse <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ - Labs Rh +/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS pnd - Screening low risk Panorama - FFS normal, anterior placenta - GLT 109 - U/S ___ 2367g 67th% - Issues *) h/o 19wk loss - cont on baby ASA *) h/o T cell cutaneous lymphoma on triamcinolone cream OBHx: G4P2012 - SVD x 2 at term - 19wk loss s/p D&E GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: migraine HA, asthma, T cell cutaneous lymphoma PSH: laparoscopuc cholecystectomy, D&C, wisdom teetch Meds: PNV, triamcinolone cream All: no known drug allergies <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/a <PHYSICAL EXAM> Physical Exam ___ 20: 04BP: 131/70 (81) ___ ___: 88 ___ 20: 15Temp.: 98.5°F ___ 20: 15Resp.: 18 / min Gen: A&O, comfortable Abd: soft, gravid, nontender Ext: no calf tenderness TAUS: cephalic, MVP 4cm SSE: cervix, closed, no pooling, physiologic discharge SVE: closed/long/posterior --> 1/long/posterior in 2 hrs FHT: 135/mod var/+accels/no decels Toco: irritable -> q3-4mins <PERTINENT RESULTS> ___ 12: 45AM BLOOD WBC-10.3* RBC-3.89* Hgb-10.9* Hct-33.6* MCV-86 MCH-28.0 MCHC-32.4 RDW-13.6 RDWSD-42.1 Plt ___ ___ 09: 29PM URINE Color-Straw Appear-Clear Sp ___ ___ 09: 29PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 09: 29PM OTHER BODY FLUID CT-NEG NG-NEG <MEDICATIONS ON ADMISSION> PNV, triamcinolone cream <DISCHARGE MEDICATIONS> PNV, triamcinolone cream <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm contractions <DISCHARGE CONDITION> preterm contractions <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call if heavy vaginal bleeding, leaking of fluid, decreased fetal movement, or contractions.
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___ G4P2012 at 34/0 who presented with decreased fetal movement, also with left sided abdominal pain and contractions with concern for preterm labor. Her vaginal exam changed form long closed posterior to 1 long posterior. Thus she was given betamethasone for fetal lung maturity. Her urinalysis, GC, CT were negative for infection. She was also seen by NICU. She had reassuring fetal testing and her cervix did not dilate upon further exams. Thus she was deemed stable for discharge home with close follow up.
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