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11302621-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G3P1 at 31wk 6d (by US on ___ complaining of irregular contractions starting last night, occuring at most every 3 minutes, without changes in breathing or urge to bear down. Notes regular fetal movement. Denies vaginal bleed, LOF, headache, changes in vision, N/V, change in urine, or dysuria. Denies CP or SOB. <PAST MEDICAL HISTORY> Prenatal course: ___ ___ (2)Prenatal labs: O+/Ab-,RI,RPRNR,GC/CT-,HepBsAg- GBS status unknown (3)ERA nl. FFS normal PAST OBSTETRIC HISTORY SAB x 1 SVD, ___, 6lbs14oz, 37wks, no complications. PAST GYNECOLOGIC HISTORY regular menstraul cycles no h/o STDs or abnormal paps PAST MEDICAL HISTORY none PAST SURGICAL HISTORY -D&C for SAB <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: 98.2, 86, 20, 123/79, 16 GENERAL: NAD CV: RRR PULM: No respiratory distress ABDOMEN: Gravid, nontender. EXTREMITIES: No edema. SVE: FT/soft/50/post TOCO: <5 contractions per hour. FHT: Rate 140, moderate variability. + accels, no decels. BPP ___, AFI 17.9, posterior, vtx fFN: Positive <PERTINENT RESULTS> ___ WBC-11.3 RBC-3.97 Hgb-12.0 Hct-34.1 MCV-86 Plt-177 ___ ___ PTT-24.8 ___ ___ UreaN-8 Creat-0.6 ALT-13 AST-19 UricAcd-3.6 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG <MEDICATIONS ON ADMISSION> folic acid <DISCHARGE MEDICATIONS> 1. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp: *90 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 32+1 weeks preterm contractions <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Continue modified bedrest at home. Call your doctor if you have any leaking of fluid, vaginal bleeding, regular or painful contractions, or decreased fetal movement.
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___ G3P1 admitted at 31+6 weeks with preterm contractions. . Mrs ___ was contracting irregularly on arrival to labor and delivery (less than 5 contractions per hour). Her cervix was FT/50%/soft. She did had a positive fetal fibronectin, therefore, was admitted for close observation and given a course of betamethasone (complete ___. She was started on Nifedipine for tocolysis with good result. Fetal testing was reassuring and on ___ she had an ultrasound in the ATU which revealed vertex, AFI 11.1, EFW 1787g(40%), and a BPP ___ (-2 breathing). The BPP was repeated approximately 5 hours later and had BPP ___ with an AFI 15.4. She was discharged home on modified bedrest and will continue taking Nifedipine. She will have close outpatient follow up.
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11303371-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> left lower quadrant pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G7P2 with +HCG (LMP ___ and LLQ pain presented to ED from the office for r/o ectopic evaluation. Patient presented to ___ ED night prior where she was found to have unplanned pregnancy with +HCG. She was managed with percocet and sent for f/u in the office. On the day of admission she reports that she had ___ lower abd pain while in the office and +nausea. She has also had spotting. Per Dr. ___ "US at ___ showed a ~11 x 6 x 8 cm uterus without any IUP. Both ovaries contained 'normal-appearing follicles'. 'A tubular structure near the left ovary is likely an adjacent fallopian tube or a loop of small bowel'. " HCG 963 at ___ per atrius note <PAST MEDICAL HISTORY> ObHx: ___ - G1: TAb - G2: TAb - G3: IOL PEC, 5#14, late preterm - G4: SAb - G5: SVD, full term, 7#12 - G6: SAb GynHx: - h/o abn pap in ___ adn ___, s/p colpo - h/o CT in ___, s/p tx - qmonthly cycles - not using any contraception PMH: - Bipolar disorder: recent suicide attempt, OD in ___ not on meds - ___ disease: now resolved - Obesity BMI=36 PSHx: tonsillectomy, LSC cholecystectomy ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> PE on admission T-98.4 HR-89 BP-107/63 RR-15 O2-99% RA Gen: NAD CV: RRR Pulm: CTAB Abd: soft, minimal LLQ tenderness, no rebound or guarding, nondistended, obese Pelvic: normal appearing external genitalia, inner labial folds. Bimanual exam revealed small, mobile anteverted uterus. No CMT. Minimal left adnexal tenderness. No masses appreciated. Scant light brown blood on glove. Ext: nontender On day of discharge GEN: NAD CV: RRR PULM: CTABL ABD: soft, obese, ND, mildly tender in LLQ, no rebound, no gaurding EXT: wnl <PERTINENT RESULTS> ___ 07: 50PM HCG-979 ___ 07: 18PM WBC-6.7 RBC-4.31 HGB-12.0 HCT-35.3* MCV-82 MCH-27.7 MCHC-33.9 RDW-13.3 ___ 07: 50PM GLUCOSE-78 UREA N-7 CREAT-0.6 SODIUM-141 POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-25 ANION GAP-11 ___ 07: 18PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 07: 18PM URINE RBC-2 WBC-3 BACTERIA-NONE YEAST-NONE EPI-7 ___ 07: 18PM URINE MUCOUS-MOD ___ 10: 57AM BLOOD WBC-6.3# RBC-3.79* Hgb-10.8* Hct-31.0* MCV-82 MCH-28.5 MCHC-34.8 RDW-12.8 Plt ___ ___ 07: 00AM BLOOD HCG-1471 PELVIC ULTRASOUNDS: ___ FINDINGS: The uterus measures 4.3 x 6.8 x 7.1 cm. No focal lesions are identified. The endometrial thickness is 1.3 cm. No gestational sac is seen within the endometrial canal. The right and left ovaries are unremarkable. A corpus luteum is seen in the right ovary. There is trace simple appearing pelvic free fluid, within physiologic range. IMPRESSION: No evidence of IUP. The differential diagnosis is early pregnancy, too early to visualize, miscarriage, cannot rule out ectopic. ___ COMPARISON: ___. FINDINGS: LMP: ___ There is no visualized intrauterine pregnancy. The ovaries are normal. There is a corpus luteum noted on the right. There is trace free fluid. IMPRESSION: No definite IUP. The differential diagnosis is early pregnancy, too early to visualize, miscarriage, cannot rule out ectopic. Requires follow up with serial bHCG levels. Results were called to Dr. ___ at the time of the scan at 9: 40 am by telephone by ___, ___. The patient was an inpatient at ___. <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain do not drive or take with alcohol RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H: PRN Disp #*12 Tablet Refills: *0 2. 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 #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cannot rule out 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 gynecology service for observation of your pelvic pain with a concern that this could be an ectopic pregnancy. You had two measurements of your hCG and two ultrasounds. You need to follow up with your gynecologists office this ___.
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On ___, Ms. ___ was admitted to the gynecology service after for management of a possible ectopic pregnancy. She remained stable during her stay and her pain was well controlled with oral medications. Two hCG levels were drawn (see labs section) and two ultrasounds were performed that could not identify the location of the pregnancy. Since she was stable and without acute or severe pain she was counseled to follow up as an outpatient 2 days after discharge or sooner if she developed severe pain, bleeding, or feeling faint.
| 1,403
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11303428-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Menorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Blood transfusion <HISTORY OF PRESENT ILLNESS> Visit conducted w assistance of ___ interpreter CC: heavy vaginal bleeding HPI: ___ yo G3P3 w/ hx of fibroids p/w 3 weeks of heavy vaginal bleeding. Pt states that she is on day 7 of a 10 day course of 10mg PO Provera QD. This was prescribed by ___ ___ in ___. She denies any improvement in her bleeding w/ the Provera. She is soaking through ___ pads per day with passage of clots. Has occasional mild dizziness. Denies CP, SOB, palpitations, abdominal/pelvic pain, dysuria, hematuria, diarrhea/constipation. She presented to ___ today where her labs were notable for Hgb 7.8/Hct 23.4. She underwent a transvaginal ultrasound that demonstrated fibroids (see below) and received 2 units packed red blood cells prior to transfer. Pt states that she is currently having ongoing heavy bleeding, with large gushes of blood and clot in the toilet each time she voids. Of note, pt underwent hysteroscopy d&c with on ___. Intraoperative findings were notable for polypoid endometrium and pathology c/w proliferative endometrium and fragments of endometrial polyp. She states that her bleeding improved after her D&C, especially while she was taking OCPs. ROS: as per HPI, otherwise negative <PAST MEDICAL HISTORY> OBHx: G3P3 (SVDx3) GynHx: - LMP: 3 weeks ___ - cervical CA screening: ___ years ago - STI: denies - gyn procedures: BTL, hsc d&c - fibroids: yes PMH: anemia - denies hx of HTN, VTE, liver disease PSH: - BTL - breast biopsy - kidney stone surgery - hsc d&c Meds: - provera 10mg daily (started 7 days ago) - iron daily All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> FH: noncontributory <PHYSICAL EXAM> Discharge physical exam Vitals: stable and within normal limits Gen: no acute distress; alert and oriented to person, place, and date CV: regular rate and rhythm; no murmurs, rubs, or gallops Resp: no acute respiratory distress, clear to auscultation bilaterally Abd: soft, appropriately tender, no rebound/guarding GU: Pad with minimal spotting Ext: no tenderness to palpation <PERTINENT RESULTS> ___ 05: 40PM BLOOD WBC-4.6 RBC-3.24* Hgb-10.0* Hct-31.5* MCV-97 MCH-30.9 MCHC-31.7* RDW-19.2* RDWSD-60.7* Plt ___ ___ 05: 40PM BLOOD Neuts-63.7 ___ Monos-8.1 Eos-0.7* Baso-0.4 Im ___ AbsNeut-2.91 AbsLymp-1.23 AbsMono-0.37 AbsEos-0.03* AbsBaso-0.02 ___ 01: 50AM BLOOD WBC-5.9 RBC-3.24* Hgb-9.9* Hct-31.4* MCV-97 MCH-30.6 MCHC-31.5* RDW-20.5* RDWSD-69.5* Plt ___ ___ 01: 50AM BLOOD Neuts-66.9 ___ Monos-7.8 Eos-0.7* Baso-0.2 Im ___ AbsNeut-3.94 AbsLymp-1.42 AbsMono-0.46 AbsEos-0.04 AbsBaso-0.01 ___ 08: 50AM BLOOD WBC-3.9* RBC-3.15* Hgb-9.7* Hct-29.6* MCV-94 MCH-30.8 MCHC-32.8 RDW-20.1* RDWSD-64.5* Plt ___ ___ 05: 40PM BLOOD ___ PTT-21.8* ___ ___ 05: 40PM BLOOD Glucose-96 UreaN-7 Creat-0.5 Na-142 K-4.1 Cl-106 HCO3-23 AnGap-13 ___ 11: 10PM URINE Color-Red* Appear-Hazy* Sp ___ ___ 11: 10PM URINE Blood-LG* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR* ___ 11: 10PM URINE RBC->182* WBC-77* Bacteri-NONE Yeast-NONE Epi-1 ___ 11: 10PM URINE UCG-NEGATIVE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> - provera 10mg daily (started 7 days ago) - iron daily <DISCHARGE MEDICATIONS> 1. Norethindrone-Estradiol 1 TAB PO Q6H Duration: 2 Days Take as instructed in your discharge paperwork. RX *norethindrone-ethin estradiol [Pirmella] 1 mg-35 mcg 1 tablet(s) by mouth every six (6) hours Disp #*90 Tablet Refills: *1 2. Ondansetron 8 mg PO Q8H: PRN Nausea/Vomiting - First Line RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus Menorrhagia <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 due to anemia from heavy vaginal bleeding. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. You should continue a taper of oral contraceptive pills as detailed below: -___: Take 1 pill every 6 hours (4 pills total per day) -___: Take 1 pill every 8 hours (3 pills total per day) -___: Take 1 pill every 12 hours (2 pills total per day) -Starting ___: Take 1 pill every day Please schedule a follow up appointment with Dr. ___ as soon as possible. General instructions: * Take your medications as prescribed. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication
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On ___, Ms. ___ was transferred to the ___ ___ from an OSH. She was admitted to the gynecology service for management of acute blood loss anemia due to menorrhagia. *) heavy vaginal bleeding in the setting of uterine fibroids A PUS completed ___ at the OSH demonstrated 4 x 3.4 x 2.9cm anterior deep intramural fibroid distorting the endometrial cavity. Ms. ___ was 23.4 at the OSH, and she was transfused 2 units of pRBCs prior to arrival at ___ with appropriate rise in her Hct. On ___, she was transitioned from PO Provera to the following OCP taper with norethindrone-ethin estradiol 1 mg-35 mcg tablets: - ___: 5 tablets per day - ___: 4 tablets per day - ___: 3 tablets per day - ___: 2 tablets per day - From ___ on: 1 tablet daily By ___, her vaginal bleeding had significantly decreased after initiation of the OCP taper. Her Hct remained stable for the duration of her admission. Giver her clinical improvement,operative intervention was deferred. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11306020-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> neomycin / ursodiol <ATTENDING> ___. <CHIEF COMPLAINT> repeat cesarean delivery, gestational hypertension, desire for permanent sterilization <MAJOR SURGICAL OR INVASIVE PROCEDURE> Repeat Cesarean delivery and bilateral tubal ligation <PHYSICAL EXAM> Physical 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, incision clean/dry/intact Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> Labs on Admission ___ 03: 17PM BLOOD WBC-5.3 RBC-3.36* Hgb-10.1* Hct-31.0* MCV-92 MCH-30.1 MCHC-32.6 RDW-14.7 RDWSD-49.1* Plt ___ ___ 03: 17PM BLOOD Plt ___ ___ 03: 17PM BLOOD Glucose-80 UreaN-5* Creat-0.5 Na-143 K-3.9 Cl-108 HCO3-25 AnGap-10 ___ 03: 17PM BLOOD estGFR-Using this ___ 03: 17PM BLOOD ALT-8 AST-8 ___ 03: 17PM BLOOD Calcium-8.5 Phos-3.6 Mg-1.7 UricAcd-4.3 Relevant Labs ___ 01: 10PM BLOOD Glucose-85 UreaN-5* Creat-0.4 Na-142 K-3.8 Cl-105 HCO3-26 AnGap-11 ___ 01: 10PM BLOOD ALT-8 AST-9 ___ 01: 10PM BLOOD Calcium-8.6 Phos-3.8 Mg-1.7 UricAcd-4.7 ___ 01: 10PM BLOOD TSH-1.4 <MEDICATIONS ON ADMISSION> Medications - Prescription BREAST PUMP - breast pump . One double electric breast pump to be used every four (4) hours as needed for to maintain milk supply METOCLOPRAMIDE HCL - metoclopramide 10 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for nausea ONDANSETRON [ZUPLENZ] - Zuplenz 4 mg oral soluble film. 1 film(s) by mouth every eight (8) hours as needed for nausea Medications - OTC PRENATAL VIT-IRON FUM-FOLIC AC [PRENATAL VITAMIN] - Dosage uncertain - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain RX *acetaminophen 500 mg ___ tablet(s) by mouth q8hr Disp #*20 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 #*30 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hr Disp #*20 Tablet Refills: *0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth q6hr Disp #*20 Tablet Refills: *0 5. Sertraline 50 mg PO DAILY RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Repeat Cesarean delivery with bilateral tubal ligation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Pelvic rest
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Ms. ___ presented for a repeat elective Caesarean delivery to the Labor and Delivery floor. She underwent a repeat low transverse Caesarean section on ___. Her postpartum course was complicated by gestational hypertension and gastroenteritis. On ___, patient developed nausea and diarrhea concerning for gastroenteritis. She was afebrile with other vital signs stable at the time. Work-up including CBC showed no signs of infection and C. diff was negative. Also on ___, patient was noted to be bradycardic to 40-50s. Patient was asymptomatic. EKG was performed showing sinus bradycardia. Repeat PIH labs, electrolytes, and TSH were within normal limits. Patient was placed on telemetry for continuous O2 monitoring. On the night of ___, patient had chest discomfort. Repeat EKG showed sinus bradycardia. Patient was given IV Pepcid with relief of symptoms. Patient had a moderate range BP on ___ and repeat PIH labs were drawn and within normal limits. She did not require any anti-hypertensive medications. Her pain was treated with oral pain medications. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced without incident. By postpartum day #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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11307110-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> s/p assault <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G3P1 at 22w6d presented to ED overnight s/p assualt from FOB. She has been in abusive relationship with this man for some time and has been seeing social work. They got into an altercation last night that began with verbal assault. The patient was at her house, and was trying to get in her car and leave. She says this man then blocked her from leaving. When she got out of her car he then came up to her and began to break her car windows with a crowbar. He then pressed her against her car and began to choke her. She fought back but it was not until a passer-by came to stop it that she was let go. She was not directly hit in the abdomen but she is very sore both there and in her neck. She was taken to the ED and was cleared medically. Here on L+D she is only feeling some fetal movement. She denies LOF or VB. She has abdominal tenderness and feels some vaginal pressure. She also feels stretching in her bilateral inguinal regions. <PAST MEDICAL HISTORY> PNC: Labs: B+/Ab neg/RI/RPR NR/HIV neg/HepBSag neg/GBS unk PNC overall benign but with significant verbal/emotional abuse from FOB throughout. Pt has poor social support as well. Has been followed by ___ throughout pregnancy. ERA low risk, normal FFS, declined amnio OB Hx: primary LTCS ___ for breech, 8lbs9oz, TAB x 1 GYN Hx: has a known small fibroid PMH: Endoscopy PSH: LTCS <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: 97.6, 119/70, 75, 18 GENERAL: NAD Abdomen soft. TTP across upper abdomen and supropubically. No clear bruising noted TAUS: SIUP in vertex presentation. Anterior placenta. BPP ___ with DVP of 4 cm. FHR seen, normal <PERTINENT RESULTS> ___ WBC-13.0 RBC-4.41 Hgb-12.5 Hct-36.8 MCV-84 Plt-183 ___ WBC-13.5 RBC-4.50 Hgb-13.0 Hct-37.9 MCV-84 Plt-202 ___ ___ PTT-25.5 ___ ___ Glu-104 BUN-8 Creat-0.6 Na-139 K-4.0 Cl-106 HCO3-22 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 <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *60 Capsule(s)* Refills: *3* 2. Terconazole 80 mg Suppository Sig: One (1) Suppository Vaginal HS (at bedtime) for 3 days. Disp: *3 Suppository(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 22 week pregnancy, s/p domestic violence-assault by father of baby ___ Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> increase fruit and fiber in diet to relieve constipation monitor fetal activity
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___ y/o G3P1 admitted at 22w6d s/p assault. She was medically cleared from the emergency room and admitted for observation and a safebed. She had no vaginal bleeding and she was hemodynamically stable. Ultrasound was reassuring on admission. She did not have continuous fetal monitoring given her previable gestational age. Social services was involved and met with her daily. Please see notes in OMR. She remained clinically stable and was able to be safely discharged to home. She will have close outpatient followup with social services.
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11307788-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Amoxicillin / Latex <ATTENDING> ___. <CHIEF COMPLAINT> Pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat c-section <HISTORY OF PRESENT ILLNESS> ___ yo G3P2 at 37w6d presents for repeat LTCS for oligohydramnios seen on testing today. Remainder of testing reassuring (BPP ___, reactive NST). Pt denies any VB/LOF/CTX. She endorses AFM. Patient reports that she was having testing for gHTN. She had a neg PEC evaluation ___. Today, pt denies any HA/VC/Epigastric pain. <PAST MEDICAL HISTORY> PNC: - ___ ___ - O+/Ab neg/RI/RPRNR/HbSAg neg - EFW ___ g 42nd % - Fibroid uterus, largest anterior fundal 9 cm POBHx: - ___ SVD c/b gHTN 5# - ___ primary LTCS stat under general for BPP ___ PGynHx: Denies STD's / no abnl paps / has known fibroids PMH: denies PSH: LTCS x1 wisdom teeth <SOCIAL HISTORY> Denies EtOH/ Smoking/ Drugs <PHYSICAL EXAM> PE: 99.2 64 20 140/74 NAD Abd soft, gravid, NT Ext: NT <PERTINENT RESULTS> ___ 12: 15PM WBC-7.2 RBC-3.21* HGB-9.6* HCT-28.7* MCV-89 MCH-30.0 MCHC-33.6 RDW-14.9 ___ 12: 15PM CREAT-0.8 ___ 12: 15PM URIC ACID-6.8* ___ 12: 15PM ALT(SGPT)-18 ___ 12: 15PM URINE HOURS-RANDOM CREAT-37 TOT PROT-6 PROT/CREA-0.2 ___ 04: 47PM URINE 24Creat-___ <MEDICATIONS ON ADMISSION> PNV, iron <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for Pain for 2 weeks. Disp: *40 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain for 2 weeks. Disp: *40 Tablet(s)* Refills: *0* 3. breast pump Sig: One (1) three times a day: dx: large EBL. Disp: *1 * Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> fullterm repeat c-section fibroid uterus anemia, postpartum hemorrhage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> please follow printed instructions
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Patient was admitted to Labor and Delivery for oligohydramnios seen on testing. She underwent a repeat c-section and delivered a live female infant weighing 3105 grams with Apgars 8 and 8. Please see the operative note for details of the procedure. Her pre-operative hematocrit was 28.9 and she received one unit of packed red blood cells intraoperatively due to an estimated blood loss of 2000cc. Her postpartum course was uncomplicated, and although her hematocrit dropped to 20.2, she remained hemodynamically stable with normal vital signs and was asymptomatic for the duration of her admission. She declined further blood transfusion. Prenatally she had undergone workup for gestational hypertension and had a negative pre-eclampsia evaluation on ___. Her admission BP was 140/74, her BP's remained within normal limits and she remained without symptoms of pre-eclampsia throughout her hospital admission. She was discharged on postpartum day 4 tolerating a regular diet, with her pain well controlled on Percocet and Motrin, and with instructions to follow up in 2 and 6 weeks with Dr. ___.
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11307788-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Amoxicillin / Latex <ATTENDING> ___. <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Abdominal myomectomy <HISTORY OF PRESENT ILLNESS> ___ yo F G3P3 with history of LTCS x2 presenting for abdominal myomectomy for symptomatic fibroid uterus. She has a history of menorrhagia which has been well controlled with Mirena IUD, but also complains of pelvic pain, pelvic pressure, and dyspareunia. On ___, she underwent a pelvic ultrasound, which demonstrated a multifibroid uterus measuring 14 x 9 x 5.6 x 7.6 cm. There is a left lower uterine segment fibroid measuring 7 x 5.2 x 6.2 cm, which is unchanged. In the right lower uterine segment, is a 5.2 x 4.5 x 4.4 cm fibroid, which is slightly increased in size. Ovaries are normal appearing. <PAST MEDICAL HISTORY> PMH: anemia PSH: LTCS x2 wisdom teeth removal POBHx: ___ SVD c/b gHTN 5# ___ primary LTCS stat under general for BPP ___ repeat LTCS for oligo, 3100g PGynHx: Denies STD's/no abnl paps/fibroids <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Vitals: T: 98, BP: 127/81, HR: 74, RR: 16, O2: 98% RA Gen: A&Ox3, NAD Neck: no thyromegaly or nodules; no palpable lymphadenopathy Lungs: clear to auscultation bilaterally, no wheezes/rales/rhonchi Heart: RRR, nl s1 and s2, no murmurs/rubs/gallops Abd: soft, non-tender, non-distended, no masses or hepatosplenomegaly appreciated, no hernias, well-healed ___ incision Extremities: no edema or calf tenderness Skin: intact, no skin changes or lesions detected Pelvic: deferred to OR <PERTINENT RESULTS> Pathology report pending for fibroid specimens <MEDICATIONS ON ADMISSION> Medications - OTC BISACODYL - 10 mg Suppository - 1 Suppository(s) rectally once a day or every other day as needed for constipation DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth three times a day FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth twice a day MULTIVITAMIN - Capsule - 1 Capsule(s) by mouth daily <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 2. 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). 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 > 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 gynecology service following scheduled abdominal myomectomy; see operative report for details of surgery. She had an uncomplicated recovery and was discharged home on postoperative day #1 in stable condition.
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11309329-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> doxycycline <ATTENDING> ___ <CHIEF COMPLAINT> ovarian mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Exploratory laparotomy. 2. Total abdominal hysterectomy. 3. Bilateral salpingo-oophorectomies. 4. Radical resection of abdominopelvic tumor. 5. Omentectomy. 6. Cystoscopy. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G3P3 with T2DM, HTN and possible h/o CAD here with newly diagnosed ovarian mass. ___ was initially seen by Dr. ___, but was unable to complete her care with him due to insurance coverage, and was referred to see Dr. ___. She is accompanied by her daughter today. Ms. ___ reports being in her usual state of health until ___ when she developed the stomach flu associated with nausea and vomiting, and subsequently developed right-sided abdominal discomfort and bloating. Her nausea and vomiting have since resolved, but the discomfort and bloating persisted, which prompted her to present for evaluation. A pelvic U/S was performed on ___: "Very large pelvic cystic mass with septations and mural nodules...trace ascites. Gallstones. Borderline ___ile duct without obvious CBD stones identified." Follow-up CT abd/pel on ___: "Abnormal appearance of the gallbladder with cystic changes in its wall and area of enhancing wall thickening measuring 3.4 x 1.2 cm...no evidence of pelvic adenopathy. Bilateral cystic ovarian masses with mural nodules. Right ovarian mass measures 20 x 15.3 x 13.2 cm. Left ovarian mass measures 7.6 x 10 x 12 cm. The uterus is not enlarged measuring 7.3 x 4.4 cm. Mild nodularity and enhancement of the omentum suspicious for carcinomatosis." No serum tumor markers have been collected as of yet. Today, ___ feels overall well. She denies change in appetite, pain with meals, nausea, vomiting, urinary complaints, vaginal bleeding or fever. She has daily bowel movements; denies constipation or diarrhea. No weight loss. She has a h/o possible CAD and septal wall defect; she denies chest pain or SOB at rest. She is able to climb one flight of stairs with some SOB. She denies a personal h/o blood clots, stroke. ROS otherwise negative. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: *) T2DM, dx'd ___ years ago, last HbA1c 5.9 (___), last Cr 0.9 (___), taking metformin and lantus *) HTN, taking metoprolol, losartan, ASA 81mg, statin *) Obesity *) possible h/o CAD, 1990s, hospitalized at ___ for one week after ?MI, was told she had a "whole" in her heart from childhood (?PFO), no recent ECHOs PAST SURGICAL HISTORY: *) Postpartum tubal ligation, ___ *) left breast cyst excision ___: yes, ___ BONE HEALTH: yes, ___ COLONOSCOPY: none reported, overdue GYN HISTORY: LMP: ___ HISTORY of Abnormal pap smears: denies Issues: denies OB HISTORY: G: 3 P: 3 - SVD x3, no complications <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies h/o thromboembolism, gyn malignancies, breast or colon cancers. Mother and brother with DM. <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> ___ 09: 05AM BLOOD WBC-12.4* RBC-3.76* Hgb-9.5* Hct-30.0* MCV-80* MCH-25.2* MCHC-31.6 RDW-17.7* Plt ___ ___ 06: 05AM BLOOD WBC-16.2* RBC-3.60* Hgb-9.1* Hct-28.7* MCV-80* MCH-25.4* MCHC-31.9 RDW-17.2* Plt ___ ___ 06: 00AM BLOOD WBC-14.5* RBC-3.65* Hgb-9.0* Hct-29.2* MCV-80* MCH-24.7* MCHC-30.9* RDW-16.6* Plt ___ ___ 05: 55AM BLOOD WBC-10.9 RBC-2.95* Hgb-7.4* Hct-23.5* MCV-80* MCH-24.9* MCHC-31.3 RDW-16.4* Plt ___ ___ 12: 00AM BLOOD WBC-12.1* RBC-3.17* Hgb-7.7* Hct-24.9* MCV-79* MCH-24.3* MCHC-31.0 RDW-16.7* Plt ___ ___ 07: 20AM BLOOD WBC-12.0* RBC-3.18* Hgb-7.7* Hct-25.2* MCV-79* MCH-24.3* MCHC-30.8* RDW-16.5* Plt ___ ___ 05: 34AM BLOOD WBC-13.3*# RBC-3.39* Hgb-8.4* Hct-27.0* MCV-80* MCH-24.9* MCHC-31.2 RDW-16.1* Plt ___ ___ 09: 05AM BLOOD Neuts-86.2* Lymphs-7.0* Monos-5.7 Eos-1.1 Baso-0.1 ___ 06: 05AM BLOOD Neuts-84.7* Lymphs-6.9* Monos-7.8 Eos-0.5 Baso-0.2 ___ 06: 00AM BLOOD Neuts-81* Bands-0 Lymphs-8* Monos-9 Eos-2 Baso-0 ___ Myelos-0 ___ 09: 05AM BLOOD Glucose-141* UreaN-21* Creat-0.8 Na-137 K-3.8 Cl-103 HCO3-26 AnGap-12 ___ 06: 05AM BLOOD Glucose-137* UreaN-24* Creat-0.6 Na-137 K-4.0 Cl-104 HCO3-25 AnGap-12 ___ 06: 00AM BLOOD Glucose-122* UreaN-31* Creat-0.8 Na-137 K-4.3 Cl-103 HCO3-25 AnGap-13 ___ 05: 55AM BLOOD Glucose-134* UreaN-32* Creat-0.9 Na-139 K-4.5 Cl-105 HCO3-26 AnGap-13 ___ 12: 00AM BLOOD Glucose-156* UreaN-30* Creat-0.8 Na-137 K-4.3 Cl-106 HCO3-22 AnGap-13 ___ 07: 20AM BLOOD Glucose-117* UreaN-21* Creat-0.7 Na-136 K-4.2 Cl-104 HCO3-25 AnGap-11 ___ 05: 34AM BLOOD Glucose-204* UreaN-27* Creat-1.1 Na-136 K-5.0 Cl-104 HCO3-24 AnGap-13 ___ 09: 05AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0 ___ 06: 05AM BLOOD Calcium-8.0* Phos-2.1* Mg-1.7 ___ 06: 00AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.8 ___ 05: 55AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.0 ___ 12: 00AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.0 ___ 07: 20AM BLOOD Calcium-8.4 Phos-2.1*# Mg-1.9 ___ 05: 34AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.5* ___ EXAMINATION: CHEST (PA AND LAT) TECHNIQUE: Chest radiograph with PA and lateral views COMPARISON: None available. FINDINGS: There is diffuse pulmonary vascular congestion and cardiomegaly. There are small bilateral pleural effusions. The patchy opacification and air bronchogram in the right upper lobe could be combination of acute pneumonia and bronchiectasis. The mediastinal silhouette is within normal size. ___ EXAMINATION: CHEST (PA AND LAT) TECHNIQUE: Chest radiograph, PA and lateral views. COMPARISON: Chest radiograph ___ FINDINGS: The right upper lobe patchy opacification is less compared to 1 day prior, consistent with resolving pneumonia or severe aspiration. Small bilateral pleural effusions are unchanged. There is cardiomegaly. Mediastinal and hilar silhouette is within normal size. <MEDICATIONS ON ADMISSION> atorvastatin 80mg, metoprolol ER 25, losartan 50, lantus 35 qam, metformin 1000mg BID, ASA, vitD <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H Do not exceed 4g in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Atorvastatin 80 mg PO QPM 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*50 Capsule Refills: *2 4. Metoprolol Succinate XL 25 mg PO DAILY 5. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking. RX *oxycodone 5 mg ___ tablet(s) by mouth pain Disp #*60 Tablet Refills: *0 6. 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 7. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills: *0 8. Levofloxacin 750 mg PO Q24H RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a day Disp #*5 Tablet Refills: *0 9. Losartan Potassium 50 mg PO DAILY 10. MetFORMIN (Glucophage) 1000 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Stage IIIC optimally cytoreduced ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * 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. * 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 exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomies, radical resection of abdominopelvic tumor, omentectomy, appendectomy, 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 a dilaudid PCA. She was transfused one unit packed red blood cells in the setting of low urine output and a hematocrit of 24.9. Her diet was advanced without difficulty and she was transitioned to oxycodone and tylenol. On post-op day #4 she was noted to have a leukocytosis. A chest x-ray identified consolidation in the right upper lobe as well as vascular congestion. She was started on levofloxacin for hospital acquired pneumonia. She had a repeat chest x-ray the following day, which showed improving consolidation versus resolution of severe aspiration. An EKG was also obtained, and there was no evidence of acute ischemic changes. On post-operative day #4, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day #6, her leukocytosis had improved, 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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11309329-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> doxycycline <ATTENDING> ___. <CHIEF COMPLAINT> shortness of breath <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ year-old ___ s/p TAH/BSO, omentectomy, appendectomy, and debulking for stage IIIc ovarian cancer who presents as a transfer from ___, where she was being treated for respiratory distress. Her immediate post-operative course had been complicated by post-op pneumonia, for which she completed a 7 day course of levofloxacin. She then had a superficial wound separation on POD14 (4 days after her staples were removed), and had been undergoing wet-dry dressing changes. Starting at the time of her wound separation, she felt her legs and hands getting very swollen. She had seen her PCP who started her on lasix as an outpatient. However, 2 days ago, she had severe respiratory distress when getting up to go to the bathroom in the morning. ___ RN came and found that she was hypertensive and hypoxic, so instructed her to go to the ED. At ___, she was 160/80 and 92%RA. CXR showed "perihilar edema, which is likely cardiogenic provided mild cardiac prominence" and moderate bilateral pleural effusions. She had a CTA chest which showed no PE through the first subsegmental branches, but in the left lower lobe, there was diminished enhancement of the distal arterial branches. There was again moderate to large bilateral effusions and moderate cardiomegaly with a small pericardial effusion. She had an echo with LVEF 35-40% with global hypokinesis (most severely at the inferolateral, basal, and mid-inferior wall), reduced diastolic compliance, moderate mitral regurgitation, trace tricuspid regurgigation and normal PA diameter. Reportedly, there was no prior for comparison. She was diuresed 2.5L with 40mg IV lasix BID. Given the possibility of PE, she was started on lovenox 80mg BID. There was plan for thoracentesis, and then she was transferred to ___. Currently, she denies any SOB/CP, palpitations, fever/chills, dizziness, or abdominal pain. Her swelling is decreased, but still present. She has had a dry, nonproductive cough, but no hemoptysis. Having regular bowel movements. Voiding frequently from lasix, but denies dysuria. <PAST MEDICAL HISTORY> Obstetric History: G3P3 - SVD x 3, no complications Gynecologic History: - Postmenopausal since age ___ - no h/o abnormal Pap test or STIs <PAST MEDICAL HISTORY> - T2DM - HTN - obesity - possible h/o CAD (pt denies h/o heart attack or heart failure) Past Surgical History: - TAH/BSO, debulking - left breast cyst excision - PPTL <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies h/o thromboembolism, gyn malignancies, breast or colon cancers. Mother and brother with DM. <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, wound bed clean with no exudate or evidence of infection, surrounding skin non-erythematous, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 07: 00PM BLOOD WBC-9.2 RBC-3.43* Hgb-8.4* Hct-27.0* MCV-79* MCH-24.5* MCHC-31.0 RDW-17.2* Plt ___ ___ 07: 15AM BLOOD WBC-9.5 RBC-3.47* Hgb-8.4* Hct-27.2* MCV-78* MCH-24.2* MCHC-30.8* RDW-17.1* Plt ___ ___ 07: 30AM BLOOD WBC-10.8 RBC-3.41* Hgb-8.2* Hct-26.8* MCV-79* MCH-24.1* MCHC-30.7* RDW-16.8* Plt ___ ___ 06: 43AM BLOOD WBC-9.9 RBC-3.42* Hgb-8.2* Hct-26.7* MCV-78* MCH-23.9* MCHC-30.6* RDW-16.7* Plt ___ ___ 07: 00PM BLOOD Glucose-134* UreaN-24* Creat-0.9 Na-141 K-3.6 Cl-102 HCO3-28 AnGap-15 ___ 07: 15AM BLOOD Glucose-102* UreaN-26* Creat-0.9 Na-140 K-3.4 Cl-100 HCO3-34* AnGap-9 ___ 02: 50PM BLOOD Glucose-103* UreaN-26* Creat-0.8 Na-140 K-3.2* Cl-101 HCO3-32 AnGap-10 ___ 07: 30AM BLOOD Glucose-53* UreaN-25* Creat-0.8 Na-143 K-3.9 Cl-102 HCO3-33* AnGap-12 ___ 03: 20PM BLOOD Glucose-101* UreaN-23* Creat-0.8 Na-140 K-3.9 Cl-102 HCO3-34* AnGap-8 ___ 06: 43AM BLOOD Glucose-83 UreaN-20 Creat-0.9 Na-142 K-3.9 Cl-100 HCO3-33* AnGap-13 ___ 07: 00PM BLOOD CK-MB-3 cTropnT-0.02* proBNP-6972* ___ 07: 00PM BLOOD Calcium-8.5 Phos-4.1# Mg-1.8 ___ 07: 15AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9 ___ 02: 50PM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8 ___ 07: 30AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1 ___ 03: 20PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0 ___ 06: 43AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0 ___ 07: 15AM BLOOD HIV Ab-NEGATIVE ___ 08: 45PM URINE Color-Yellow Appear-Clear Sp ___ ___ 08: 45PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 08: 45PM URINE RBC-2 WBC-8* Bacteri-FEW Yeast-NONE Epi-2 <MEDICATIONS ON ADMISSION> atorvastain 80mg daily, lasix 20 mg daily, lantus 25 units qAM, metoprolol XR 25mg daily, vitamin C, aspirin 81mg daily, vitamin D3, omega 3 fish oil, potassium <DISCHARGE MEDICATIONS> 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Glargine 25 Units Breakfast 4. Losartan Potassium 50 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *1 6. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> systolic heart failure wound separation <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 for management of acute heart failure for which we gave you medication to help remove excess fluid from your body and also adjusted your blood pressure medications. You have recovered well and our team as well as the cardiology team feels that you are safe to be discharged home. Please follow these instructions: * take all medications as prescribed * please weigh yourself daily * no strenous activity until after your post-op appointment with Dr. ___ * No heavy lifting of objects >10 lbs for 6 weeks. * Please eat a low sodium diet <2 grams of sodium per day * It is safe to walk up stairs. Incision Care: * you may shower but please cover the open area of your incision. You may allow soap and water to run over your incision but do not scrub * a visiting nurse ___ come daily to change your dressing
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Ms. ___ was transferred to the gynecologic oncology service at ___ from ___ for more acute management of acute onset heart failure. Upon her arrival her initial presenting shortness of breath was improved and her O2 sat was 98% on 2L NC. She had a repeat chest x-ray performed which revealed mild pulmonary edema. The cardiology service was consulted who did not recommend a thoracentesis but did recommend continued diuresis with IV lasix and adjustments in her blood pressure medications. She had a repeat chest x-ray on hospital day 3 for persistent O2 requirement which was stable from the prior. By hospital day 4 she was weaned off O2, transitioned to torsemide 20mg daily and cleared by cardiology for discharge. She continued to have daily wet to dry dressing changes for her wound separation which showed no evidence of infections. She was also continued on her home insulin regimen with good glucose control. She was discharge on hospital day 4 to home with ___ for wound care in stable condition with outpatient follow-up scheduled.
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11310674-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Persistent CIN 3 <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laproscopic hysterectomy, bilateral salpingoophrectomy Cystoscopy <HISTORY OF PRESENT ILLNESS> ___ woman with a history of recurrent cervical dysplasia. She previously has undergone a cold knife cone biopsy and has no visible cervix vaginally. Colposcopic evaluation reveals no clearly delineated acetowhite change to explain the abnormality. Her Pap smear obtained on ___ revealed high-grade dysplasia. She is here for an examination and a discussion. ___ reports being somewhat anxious about this dysplasia. She has no complaints or concerns. She denies any vaginal bleeding, discharge, hematuria. <PAST MEDICAL HISTORY> PMH: - HTN - Hyperlipidemia - osteoarthritis - herniated disc PSH: - arthoplasty R thumb ___ - LEEP OB/GYN: G2P2, svd x 2. Postmenopausal since ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports her father had lung cancer. She denies any other family history of breast cancer, ovarian cancer, uterine cancer, cervical cancer, or colon cancer. <PHYSICAL EXAM> Preop <PHYSICAL EXAM> She appears her stated age, in no apparent distress. HEENT: Normocephalic, atraumatic. Oral mucosa without evidence of thrush. Eyes, sclerae are anicteric. Neck: Supple. There are no masses. Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. Chest: Lungs clear. Heart: Regular rate and rhythm. Back: No spinal or CVA tenderness. Abdomen: Soft, nontender, nondistended. There are no masses. Extremities: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. Pelvic: Normal external genitalia. Inner labial folds normal. Urethral meatus normal. Walls of the vagina are smooth, apex is normal with the exception of the cervix which is completely flush with the apex of vaginal canal. I cannot actually easily visualize the cervical os. It appears that there is a dimpling fold over in the left upper fornix. It is most likely the cervical os. Bimanual exam reveals a mobile uterus without parametrial nodularity. There is no adnexal mass. There is no cul-de-sac nodularity. Post op exam: AVSS RRR CTAB Abd appropriately TTP, ND, incisions c/d/i ext NT, NE <PERTINENT RESULTS> ___ 07: 30AM BLOOD WBC-7.6 RBC-3.83* Hgb-11.7*# Hct-32.6*# MCV-85 MCH-30.6 MCHC-36.0* RDW-12.4 Plt ___ ___ 07: 30AM BLOOD Plt ___ ___ 07: 30AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-141 K-3.8 Cl-104 HCO3-32 AnGap-9 ___ 07: 30AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0 Pathology: Pending <MEDICATIONS ON ADMISSION> diltiazem 240', lisinopril-hydrochlorothiazide ___, simvastatin 20' <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 3. diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. 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> Persistent cervical dysplasia <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) 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.
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Ms. ___ was admitted following TLH-BSO, and cystoscopy for persistent CIN 3 after LEEP. Please see the operative report for full details. She had routine postoperative care and was discharged on POD 1 in stable condition.
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11311539-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cramping/vaginal spotting w/ positive pregnancy test <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 with unknown LMP with known pregnancy presents with intermittent b/l pelvic cramping. She came to the ED today because she started to have brown spotting which has become a little red tinged. Denies dizziness, CP, SOB, palpitations, abnormal vaginal discharge other than bleeding. She has been in her usual state of health, tolerating regular PO and urinating and having BM without difficulty. In ED, speculum exam revealed closed os and no blood in the os. No pain meds or IV given. <PAST MEDICAL HISTORY> POBHX: G1 P0 PGYNHX: - LMP: "about a month ago" - menstrual triad: 13 x 30 x 4 - Paps: within the last year, never abnormal - STIs: denies - contraception: 2 months ago, was started on OCPs but only took 8 pills and stopped b/c it caused nausea PMH: nil PSH: nil <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On Admission: VS: 97.1 98 120/80 16 100RA GENERAL: NAD CARDIO: RRR PULM: CTAB ABDOMEN: soft, NTND EXTREMITIES: NTNE b/l SSE: def SVE/BME: significant ___ intensity) TTP R adenxa, no palpable masses; uterus NT AV 7cm, L adnexa On Discharge: VSS NAD RRR CTAB Abd soft, ND, mildly tender to deep palpation in right lower quadrant GU w/ minimal brown spotting on the pad Ext w/ out edema, no calf tenderness <PERTINENT RESULTS> ___ 01: 50PM BLOOD WBC-7.3 RBC-4.47 Hgb-14.6 Hct-39.7 MCV-89 MCH-32.7* MCHC-36.8* RDW-12.3 Plt ___ ___ 01: 50PM BLOOD Neuts-61.6 ___ Monos-5.3 Eos-0.5 Baso-0.8 ___ 01: 50PM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-136 K-3.8 Cl-102 HCO3-26 AnGap-12 ___ 01: 50PM BLOOD HCG-777 Pelvic U/S ___: Transabdominal and transvaginal images were acquired, the latter for further characterization of the uterus and adnexa. The uterus measures 7.4 x 3.9 x 3.7 cm. The endometrial stripe measures 7 mm. No intrauterine pregnancy is identified. There is a complex right adnexal cystic lesion measuring overall 2.8 x 2.3 x 2.3 cm, with thick walls, internal septations, and peripheral vascularity. The left ovary is normal. Normal arterial and venous Doppler waveforms are visualized bilaterally. There is a small amount of free fluid in the pelvis, within physiologic limits. <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. prenatal vitamins Sig: One (1) once a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> corpus luteum cyst rule out ectopic <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> no lifting more than 20 lbs, pelvic rest, avoid vigorous physical activity
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Ms. ___ is a ___ G1P0 with a positive pregnancy test and an uncertain LMP who presented to the emergency department with vaginal spotting and crampy abdominal pain. There was no IUP seen on ultrasound and the patient's HCG was 777, below the discriminatory zone of ___. This is an unplanned but desired pregnancy. The patient was admitted to the gynecology service for observation and serial abdominal exams as ecoptic pregnancy was first on the differential which also included ovarian cysts, ovarian torsion, normal pregnancy and SAB. During her hospitalization, the patient's exam remained stable as did her hemodynamic status. She was discharged home on ___, hospital day number two with close follow up scheduled: ___ and ___ for an HCG level and a repeat ultrasound in 7 days. The patient was instructed to call Dr. ___ office with any questions or concerns. Warning signs for ruptured ectopic were reviewed.
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11311596-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal Bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curretage transfusion of 6 units of packed red blood cells <HISTORY OF PRESENT ILLNESS> The patient is a ___ y/o F with no significant PMHx who is being admitted for profuse vaginal bleeding. . The patient began to note vaginal bleeding at home last night, which was the ___ day of her period, though she was two weeks late this month. Bleeding was significant enough at home that she had to change pads every 20 minutes and ultimately had a syncopal episode at home this morning. She initially presented to the ED at ___, where she was noted to have a Hct of 26 (from baseline in the 40___s). Systolic blood pressures there were ___. She complained of lightheadedness and mild vaginal cramping. She denied any injuries associated with her syncope. She was transferred here for GYN evaluation. . Of note, patient reports that her periods are normally every 30 days with moderate to heavy flow. Over the past two months, she has been irregular with intermittent spotting. No prior history of GYN problems or excessive vaginal bleeding. . On arrival to the ED here, her VS were 82 120/70 100%. At that time, she complained of worsened lightheadedness. On examination, she was noted to have a large amount of blood in the vaginal canal, comprised of clots as well as BRB. +orthostatics. OB/GYN was consulted and evaluated the patient as well. A large clot as well as ~ 100 cc of BRB was removed on pelvic exam. Labwork revealed a hematocrit of 21. While in the emergency department, she became pale and lightheaded, with blood pressure drop to 70/40. She was rapidly transfused 2 units of pRBCs (in addition to 4L NS already given), with improved in her SBP's to the 100's. She was given 30 mg of provera. VS prior to admission were 70 110/60 18 98%RA. . On the floor, the patient's initial VS were 98.3 113/67 82 99%RA. She reports that she feels better after the 2 units of pRBCs in the ED. Denies any abdominal pain. Denies any recent fevers or chills. No history of bleeding problems. Reports that she did fall to the ground this morning when she passed out but does not believe that she hit her head. Does not know how long she was unconscious. <PAST MEDICAL HISTORY> Hypertension Depression s/p 3 uncomplicated vaginal deliveries, the second of which required pitocin for postpartum bleeding. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of gyn problems. No family history of bleeding problems. Positive family history of HTN and TIA. <PHYSICAL EXAM> General: Alert, oriented, no acute distress, slightly pale appearing HEENT: Sclera anicteric, PERRL, EOMI, conjunctival pale, MMM, oropharynx clear. No petechiae or ecchymoses on mucous membranes. Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Borderline tachycardia, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Pads and panty on, but draining bright red blood. Ext: warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or edema, no calf tenderness Neuro: CN 2 - 12 grossly intact. Sensation intact. Upper extremity strength ___. <PERTINENT RESULTS> 1. Labs on admission: ___ 04: 00PM BLOOD WBC-9.5 RBC-2.75* Hgb-7.1* Hct-21.6* MCV-79* MCH-25.9* MCHC-32.9 RDW-16.4* Plt ___ ___ 04: 00PM BLOOD ___ PTT-20.3* ___ ___ 01: 10AM BLOOD ___ ___ 04: 00PM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-137 K-4.0 Cl-105 HCO3-21* AnGap-15 ___ 01: 10AM BLOOD Calcium-6.7* Phos-2.9 Mg-1.8 ___ 01: 10AM BLOOD TSH-4.5* ___ 04: 00PM BLOOD HCG-<5 . 2. Labs on discharge: ___ 06: 42AM BLOOD WBC-7.6 RBC-3.20* Hgb-9.1* Hct-26.7* MCV-84 MCH-28.5 MCHC-34.1 RDW-15.6* Plt ___ ___ 12: 19PM BLOOD WBC-8.2 RBC-3.26* Hgb-9.4* Hct-26.8* MCV-82 MCH-28.7 MCHC-35.0 RDW-15.7* Plt ___ ___ 06: 42AM BLOOD ___ PTT-23.3 ___ ___ 03: 35PM BLOOD ___ PTT-25.2 ___ ___ 12: 19PM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-138 K-3.4 Cl-109* HCO3-23 AnGap-9 ___ 12: 19PM BLOOD Calcium-7.1* Phos-2.0* Mg-1.7 . 3. Imaging/diagnostics: - Abdominal ultrasound (___): 1. Large likely clot demonstrated in dilated vaginal vault. Recommend GYN consultation and follow-up ultrasound to resolution and possible tissue sampling to exclude a component of carcinoma. 2. Small posterior uterine fibroid. 3. Normal ovaries. <MEDICATIONS ON ADMISSION> - Aspirin delayed release 81 mg po qd (recently started) - HCTZ 12.5 mg po qd (recently started) - Zoloft 100 mg po qd <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: *0* 2. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. Disp: *60 Tablet(s)* Refills: *2* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> anovulatory bleeding acute blood loss anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for heavy vaginal bleeding thought to be due to anovulatory cycles. You required blood transfusion and admission to the ICU due to low blood pressure. A D&C was performed to help control the bleeding. You are now ready to go home. Please take your medications as prescribed. Please follow-up as directed for the pathology results from your D&C. You will also need to monitor your bleeding carefully and call if you fill more than 1 pad in an hour.
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___ y/o F with no significant PMHx who is being admitted to the FICU for profuse vaginal bleeding with hypotension. In this perimenopausal woman with no trauma history or bleeding disorder, the etiology is most likely anovulatory/perimenopausal bleeding from unopposed estrogen. Ultrasound showed blood/clot in the vagina vault with a posterior fibroid. Hct down to 21 in the ED from baseline line of ___. Currently hemodynamically stable with sBP in the 110s, but was as low as ___ in the ED with orthostatic symptoms. Received 2 units of pRBC as well as 30 mg po medroxyprogestrerone acetate. Gynecology was consulted, evaluated the patient and recommended stabilizing her hemodynamically before considering D&C. She continued to be transfused overnight, for a total of 6 units pRBCs. She was kept NPO for possible operative intervention. Her laboratory studies were carefully followed to evaluate for DIC. The following morning, her blood pressure remained stable and INR was 1.2. She was taken to the OR afor a D&C. Please see operative note for details. Theprocedure was uncompliacted. Post-operatively, her vaginal bleeding ceased. Her pain was controlled, her vital signs stable, hematocrit stable, she ambulated and urinated without difficulty. She was discharged to home in stable condition with follow-up.
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11312324-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> trazodone <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Pt is a ___ G1P1 who is ___ s/p vaginal oocyte retreival ___ with 19 eggs retrieved. Since then, she has noted mild constant sharp RLQ pain punctuated by intermittent intense RLQ pain. Also feels some rt flank pain and mild nausea with emesis x 1 earlier. Pain is slightly worse when moving, but episodes of intense pain occur while supine (pt resting all day s/p retrieval). Reports baseline mild constipation, last BM ___ days ago straining. Very scant vaginal spotting today. No UTI sx, no f/c/CP/SOB. A PUS done in the ED revealed nl uterus, smooth stripe, moderate simple free fluid with some echoes in right adnexa and in ___ pouch. 8.9x5.9x5.0cm organized clot adjacent to left ovary. Right ovary measured 4.6cm with nl dopplers, and the left ovary measured 5.95x3.8x4.18cm with nl dopplers. <PAST MEDICAL HISTORY> ObGyn Hx: G1P1 - ___ FT LTCS, spontaneously conceived after 3 mos, same partner - this is second VOR, pt is s/p 1 failed IVF cycle and failed clomid/IUI x2 for unexplained secondary infertility - denies abnl Pap/STI Med Hx: - Migraine - Allergic rhinitis - Insomnia - exercise-induced asthma Surg Hx: - turbinectomy - wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> AF VSS NAD CTAB RRR Abd +BS, soft, mildly distended and tympanic to percussion in all 4 quad, mildly TTP, no r/g Gyn minimal VB Ext no edema <PERTINENT RESULTS> ___ 11: 30PM BLOOD WBC-20.5* RBC-4.08* Hgb-12.3 Hct-35.4* MCV-87 MCH-30.1 MCHC-34.7 RDW-12.8 Plt ___ ___ 11: 30PM BLOOD Neuts-87.5* Lymphs-9.2* Monos-3.2 Eos-0.1 Baso-0.1 ___ 08: 00AM BLOOD WBC-17.0* RBC-3.14* Hgb-9.5* Hct-27.7* MCV-88 MCH-30.5 MCHC-34.4 RDW-13.9 Plt ___ ___ 08: 00AM BLOOD Neuts-77.7* Lymphs-17.8* Monos-3.7 Eos-0.4 Baso-0.3 ___ 04: 00PM BLOOD WBC-12.7* RBC-3.23* Hgb-9.8* Hct-28.7* MCV-89 MCH-30.4 MCHC-34.2 RDW-14.0 Plt ___ ___ 12: 10AM BLOOD ___ PTT-31.9 ___ ___ 08: 00AM BLOOD ___ 11: 05AM BLOOD ___ 05: 03PM BLOOD ___ <MEDICATIONS ON ADMISSION> PNV progesterone <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN constipation start when tolerating PO RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain start when tolerating PO, hold for sedation or RR < 12 RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic hematoma <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 observation of your abdominal pain. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * 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 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 for observation of a pelvic hematoma following a vaginal oocyte retrieval with 19 eggs retrieved on ___. During her hospitalization, her pain improved, and she required no pain medications. Her hematocrit was significant for a drop from 35.4 to a nadir of 27.7, but it remained stable thereafter, and she required no blood products. Her abdominal exam remained benign, and she was hemodynamically stable throughout her hospital course. On hospital day 1, her exam was stable and improved, her pain was well controlled without pain medications, she was tolerating a regular diet, she was ambulating and voiding independently. She was discharged home in good condition with follow-up scheduled.
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11313297-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> bilateral ovarian cysts <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic bilateral salpingo-oopherectomy, lysis of adhesions <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ G2 P2, who was found to have fullness on her pelvic exam in ___. She was advised to undergo imaging for further evaluation; however, delayed doing this. In ___, she started experiencing bilateral lower pelvic "aches" and presented in ___ for her annual exam. Again, recommendations were made for a pelvic ultrasound. She completed this on ___. Pelvic US showed a normal uterus measuring 6.5 x 4.1 x 3.1 cm. The endometrial stripe measured 5 mm. The ovaries appeared to consist of large complex cystic lesions. On the right, it measured 10.4 x 7.1 x 6.4 cm. On the left, the mass measured 5.9 x 5.3 x 5.0 cm. There was no free fluid in the cul-de-sac. Both kidneys were normal. Surgical consultation was recommended. She had a CA-125 level drawn on ___, which was normal at 14.5. She met with Dr. ___ who recommended surgical evaluation with laparoscopy. Given her significant past medical history of a congenital AVM with an intracranial bleed ___ years ago, she was sent for preoperative clearance by both, her primary care physician as well as her neurologist who is here at ___. Given the need for close blood pressure monitoring during her surgery, it was recommended that she have surgery performed at a Tertiary Care Center. She was therefore sent here for further evaluation and treatment. <PAST MEDICAL HISTORY> AVM with h/o intracerebral bleed and seizure activity, hypercholesterolemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family history is negative for any breast, ovarian, uterine or colon cancers. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <MEDICATIONS ON ADMISSION> pheonobarbital 32.4mg TID, ibuprofen prn, calcium <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN pain Do not drink or drive while taking. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 5. PHENObarbital 32.4 mg PO TID 6. Pregabalin 50 mg PO ON CALL TO OR preop analgesia Duration: 1 Dose <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> bilateral ovarian cysts <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) until after your post-operative appointment. * 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. * 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 laparoscopic bilateral salpingo-oopherectomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid. Her diet was advanced without difficulty and she was transitioned to PO oxycodone/acetaminophen/ibuprofen. On post-operative day #0, 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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11313297-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Unstaged low-grade serous neoplasm of GYN origin <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, omentectomy, peritoneal biopsies <HISTORY OF PRESENT ILLNESS> ___ woman who was found to have fullness on her pelvic exam in ___. She was advised to undergo imaging for further evaluation; however, delayed doing this. In ___, a repeat exam again confirmed pelvic fullness and she underwent an ultrasound on ___, which revealed a right-sided ovarian complex cyst measuring 10 cm and a left complex mass measuring 6 cm. The CA-125 was normal at 14.5. On ___, she underwent a laparoscopic bilateral salpingo-oophorectomy and washings with lysis of adhesions. Findings were notable for smooth peritoneal surfaces with no obvious abnormalities in the upper abdomen. In the pelvis, both ovaries were replaced by multicystic nodular masses grossly consistent with cystadenofibromas. The right ovary was dominant and measured about approximately 12 cm. It was densely adherent to the posterior pelvic peritoneum as well as the uterosacral ligament. The left ovary was slightly smaller, but also solid and cystic in nature. The uterus itself was small and normal in appearance. Grossly, the left ovary was sent for frozen section and was without worrisome features. Microscopic evaluation and final pathology revealed a low-grade serous neoplasia involving the left fallopian tube as well as the right ovary and fallopian tube. Of note, tumor was composed of small papillae of mildly atypical serous epithelium with surrounding stromal reaction, with prominent psammomatous calcification. The tumor was negative for p53 and the morphology was consistent with a low-grade neoplasia consistent either with a borderline tumor or a low-grade carcinoma. Invasion was difficult to characterize, but low-grade serous carcinoma was favored. Tumor was also seen on concurrent pelvic washing cytology. The origin of the neoplasm was uncertain. Gynecologic origin was confirmed by PAX8 expression. The tumor may have arisen in the right serous cystadenoma with auto implants and spread to the pelvic peritoneum or possibly arising along the peritoneum and foci of endosalpingiosis. Given the tumor in both tubes, an endometrial primary could not be entirely excluded. She was advised to have further surgery for staging. Prior to proposed surgery, she a had an endometrial biopsy to evaluate for endometrial origin. Biopsy showed atrophic endometrium and an endocervical polyp. She also had a CT torso which showed: 1. Multiple hypodensities in the liver, 1 of which is likely a cyst, 1 of which is too small to characterize definitively, and a 1.6 cm segment IV a lesion is likely benign 2. Status post bilateral salpingo oophorectomy. No evidence of local recurrence. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> AVM with the intracerebral bleed and seizure activity, hypercholesterolemia. Her health maintenance is notable for a normal mammogram in ___. She has never undergone colonoscopy. Past Surgical History: back surgery at ___ in ___. OB History: She is a G2 P2 with normal spontaneous vaginal deliveries in ___ and ___. Gynecologic History: Her last menstrual period was in ___. She denied any postmenopausal bleeding. Her last Pap smear was in ___, which was normal and she has never had an abnormal Pap smear. She did undergo surgical tubal ligation. She denies any hormone replacement use. She denies any significant gynecologic infections or issues in the past or present. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family history is negative for any breast, ovarian, uterine or colon cancers. <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, incisions clean/dry/intact, no rebound/guarding GU: pad with minimal staining ___: nontender, nonedematous <PERTINENT RESULTS> ___ 08: 30AM BLOOD WBC-6.0 RBC-4.39 Hgb-12.9 Hct-39.5 MCV-90 MCH-29.4 MCHC-32.7 RDW-12.9 RDWSD-43.0 Plt ___ ___ 08: 30AM BLOOD Glucose-148* UreaN-7 Creat-0.7 Na-143 K-4.3 Cl-106 HCO3-27 AnGap-14 ___ 08: 30AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9 <MEDICATIONS ON ADMISSION> 1. PHENObarbital 32.4 mg PO TID <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000mg a day RX *acetaminophen 500 mg ___ tablet(s) by mouth every 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 per day Disp #*60 Tablet Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain Please take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate ___ cause sedation. Do not take with alcohol or while driving RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 5. PHENObarbital 32.4 mg PO TID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: 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.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing Total laparoscopic hysterectomy, omentectomy, peritoneal biopsies for staging. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV Toradol + PO Tylenol/oxycodone prn. Her diet was advanced without difficulty and she was transitioned to ibuprofen once tolerating PO. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. For her seizure disorder, she was continued on her phenobarbitol. Her blood pressure remained within normal limits throughout her hospitalization. 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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11314388-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Acetaminophen <ATTENDING> ___. <CHIEF COMPLAINT> HELLP syndrome <MAJOR SURGICAL OR INVASIVE PROCEDURE> c/section at ___ prior to admission here. <HISTORY OF PRESENT ILLNESS> ___ w/ h/o severe preeclampsia who was transferred from an OSH for management of HELLP syndrome after emergent c-section on day prior to transfer at 33weeks gestation. She initially presented to OSH 2 days PTA w/right arm and RUQ pain as well as N/V. Initial vitals were BP 150s-170s/80s-120s max reported BP 178/123. Her platelets were 91, LFTs were AST 289 ALT 279 Uric Acid 7.6 and Cr 1.07. BP was stabilized and she was emergently taken to the OR for c-section. In the OR, she received 3L IVF and had 700ccEBL. C-section was c/b oozine ang bleeding at the site. She was subsequently transfused w/1 unit of platelets and 4 units of PRBCs. Per report, baby was stable with apgars of ___. Post op, she received Mag sulfate bolus and then IV drip at 2mg/kg and dexamethasone 10 mg IV x 2 ___s dilaudid IV for pain and zofran. She had episodes of hypotension throughout the day. Labs were closely monitored and were notable for rising potassium and Cr. . Prior to transfer, she had HD line placed and was emergently dialyzed for hyperkalemia to 6.7 in the setting of possible ATN. Per report, they were only able to ultrafilter her due to hypotension. . ROS: She notes that she had spotty vision ___ weeks prior to presentation. She otherwise denies HA/dizzyness/focal weakness. The patient denies any fevers, chills, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, rash or skin changes. <PAST MEDICAL HISTORY> h/o severe preeclampsia requiring urgent c-section w/her first child in ___ no h/o abnormal paps/STDs <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother- HTN, h/o eclampsia, and sister w/h/o eclampsia; father- throat CA. <PHYSICAL EXAM> On Admission: Vitals: T: 97.2 BP: 114/71 HR: 95 RR: 18 O2Sat: 94% 4LNC GEN: anasarcic, no acute distress HEENT: + facial edema, EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: difficult to assess JVP w/edema, no cervical lymphadenopathy, trachea midline COR: RRR, + soft systolic murmur, no G/R, normal S1 S2, radial pulses +2 PULM: Lungs crackles at bases ___, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses; wound c/d/i EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II XII grossly intact. Moves all 4 extremities. Strength ___ in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. <PERTINENT RESULTS> Admission Labs: ___ 01: 49AM WBC-18.3*# RBC-3.02*# HGB-9.3* HCT-25.5* MCV-84 MCH-30.7 MCHC-36.5* RDW-16.1* ___ 01: 49AM NEUTS-80.0* LYMPHS-13.2* MONOS-6.7 EOS-0.1 BASOS-0.1 ___ 01: 49AM PLT COUNT-79* LPLT-1+ ___ 01: 49AM ___ PTT-30.3 ___ ___ 01: 49AM ___ 01: 49AM GLUCOSE-149* UREA N-35* CREAT-2.6*# SODIUM-133 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-11 ___ 01: 49AM ___ AST(SGOT)-2427* LD(LDH)-3055* ALK PHOS-132* TOT BILI-0.8 ___ 01: 49AM ALBUMIN-2.1* CALCIUM-4.4* PHOSPHATE-6.1* MAGNESIUM-7.5* URIC ACID-7.0* . ___ 10: 16AM BLOOD WBC-7.3 RBC-2.91* Hgb-8.8* Hct-25.4* MCV-87 MCH-30.3 MCHC-34.8 RDW-15.2 Plt ___ ___ 05: 39AM BLOOD WBC-8.9 RBC-2.79* Hgb-8.5* Hct-24.3* MCV-87 MCH-30.5 MCHC-35.0 RDW-15.3 Plt ___ ___ 01: 52AM BLOOD WBC-10.8 RBC-2.88* Hgb-8.7* Hct-24.8* MCV-86 MCH-30.1 MCHC-35.0 RDW-15.5 Plt ___ ___ 07: 51PM BLOOD WBC-11.0 RBC-2.73* Hgb-8.4* Hct-23.4* MCV-86 MCH-30.7 MCHC-35.8* RDW-15.4 Plt ___ ___ 06: 28AM BLOOD WBC-10.6 RBC-2.72* Hgb-8.3* Hct-23.6* MCV-87 MCH-30.6 MCHC-35.3* RDW-15.5 Plt ___ ___ 05: 50AM BLOOD WBC-12.6* RBC-2.89* Hgb-8.6* Hct-24.9* MCV-86 MCH-29.8 MCHC-34.6 RDW-15.4 Plt ___ ___ 12: 02PM BLOOD WBC-14.4* RBC-2.77* Hgb-8.4* Hct-23.9* MCV-86 MCH-30.2 MCHC-35.1* RDW-16.0* Plt ___ ___ 06: 16AM BLOOD WBC-15.7* RBC-2.75* Hgb-8.2* Hct-23.6* MCV-86 MCH-29.7 MCHC-34.6 RDW-16.0* Plt ___ ___ 11: 45PM BLOOD WBC-17.3* RBC-2.73* Hgb-8.5* Hct-23.0* MCV-85 MCH-31.1 MCHC-36.8* RDW-16.3* Plt Ct-88* ___ 11: 50AM BLOOD WBC-17.3* RBC-2.83* Hgb-8.6* Hct-23.8* MCV-84 MCH-30.5 MCHC-36.2* RDW-15.5 Plt Ct-85* ___ 01: 49AM BLOOD WBC-18.3*# RBC-3.02*# Hgb-9.3* Hct-25.5* MCV-84 MCH-30.7 MCHC-36.5* RDW-16.1* Plt Ct-79* ___ 01: 49AM BLOOD Neuts-80.0* Lymphs-13.2* Monos-6.7 Eos-0.1 Baso-0.1 ___ 10: 16AM BLOOD Plt ___ ___ 01: 52AM BLOOD Plt ___ ___ 01: 52AM BLOOD ___ PTT-22.6 ___ ___ 05: 50AM BLOOD Plt ___ ___ 12: 02PM BLOOD Plt ___ ___ 04: 57PM BLOOD ___ PTT-24.0 ___ ___ 01: 49AM BLOOD Plt Ct-79* LPlt-1+ ___ 10: 16AM BLOOD ___ ___ 05: 39AM BLOOD ___ ___ 01: 52AM BLOOD ___ ___ 12: 02PM BLOOD ___ 04: 57PM BLOOD ___ ___ 01: 49AM BLOOD ___ 10: 16AM BLOOD Creat-0.7 ___ 01: 52AM BLOOD Creat-0.8 ___ 05: 50AM BLOOD Glucose-83 UreaN-37* Creat-1.1 Na-143 K-4.2 Cl-107 HCO3-29 AnGap-11 ___ 05: 34AM BLOOD Glucose-88 UreaN-55* Creat-1.7* Na-141 K-4.3 Cl-107 HCO3-28 AnGap-10 ___ 11: 45PM BLOOD Glucose-104 UreaN-52* Creat-2.5* Na-137 K-4.4 Cl-101 HCO3-24.7 AnGap-16 ___ 06: 39AM BLOOD Glucose-121* UreaN-43* Creat-2.8* Na-134 K-4.3 Cl-101 HCO3-25 AnGap-12 ___ 10: 16AM BLOOD ALT-190* AST-48* TotBili-1.4 DirBili-0.5* IndBili-0.9 ___ 01: 52AM BLOOD ALT-329* ___ 06: 28AM BLOOD ALT-393* AST-89* ___ 04: 33AM BLOOD ALT-1205* AST-730* LD(___)-997* AlkPhos-154* TotBili-1.2 ___ 04: 05PM BLOOD ALT-1526* AST-1304* LD(___)-___* AlkPhos-139* TotBili-0.8 ___ 06: 39AM BLOOD ALT-1828* ___ LD(___)-2600* AlkPhos-134* TotBili-0.8 ___ 01: 49AM BLOOD ___ AST-2427* LD(___)-3055* AlkPhos-132* TotBili-0.8 ___ 10: 16AM BLOOD UricAcd-4.5 ___ 05: 39AM BLOOD UricAcd-5.0 ___ 09: 30AM BLOOD Albumin-2.6* Iron-46 ___ 01: 52AM BLOOD UricAcd-6.3* ___ 05: 34AM BLOOD Calcium-6.8* Phos-5.2* Mg-3.4* ___ 04: 33AM BLOOD Calcium-7.7* Phos-5.9* Mg-4.7* UricAcd-11.0* ___ 04: 05PM BLOOD Calcium-6.5* Phos-5.6* Mg-6.0* UricAcd-9.1* ___ 01: 49AM BLOOD Albumin-2.1* Calcium-4.4* Phos-6.1* Mg-7.5* UricAcd-7.0* <MEDICATIONS ON ADMISSION> none <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. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp: *60 Tablet(s)* Refills: *2* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *50 Tablet(s)* Refills: *2* 4. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p c/section. severe HELLP syndrome. acute tubular necrosis. hepatic imfact. <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per post c/section instruction sheet. call for increased abd pain, headache, vaginal bleeding
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___ w/h/o severe preeclampsia who is transferred for management of HELLP syndrome after emergent c-section. She is also s/p emergent HD for hyperkalemia in the setting of ARF prior to transfer. Pt initially admitted to ICU then transferred once hemodynamically more stable pt transferred to postpartum floor on ___. . # HELLP syndrome: The patient presented with LFTs to 3000s, platelets to 40,000s and ARF to ___ s/p c-section. DIC labs were sent (details above). Once in the ICU the patient was clinically volume overloaded and subsequently diureses 2L after a dose of lasix. Pt treated with Mg for 24hours. The patient's LFTs and Cr continued to improve, while the CBC remained stable. Upon transfer from ICU, daily CBC and LFT's followed and continued to trend downward. On HD#5 pt c/o increasing RUQ pain. Repete labs were checked and stat CT ordered to r/o hepatic pathology. Repeat labs demonstrated decreased LFTs and Uric Acid. Hct and Plt increased. CT scan demonstrated perfusion defects consistent with HELLP. Gen Surg consulted who then consulted hepato-billiary. Hepatobilliary requested RUQ U/S and dopplers to r/o portal vein thrombus. Imaging demonstrated heterogeneous appearance of the liver, however, without focal lesion. Widely patent portal vein, hepatic arteries and vein. Note was made of mildly elevated velocities in the main portal vein of undetermined significance. LFTs continued to trend downward and pain in RUQ decreased significantly. Pt tolerated regular diet, was ambulating, and having bowelm movements when discharged. . # Heme: The patient was initially oozing at the site, HCT stable x 24 h; had hypotension post-op, but hemodynamically stable on transfer to ___ ICU. Records from the OSH revealed no subcapsular liver hematoma. CT scan from outside hospital showed moderate intraperitoneal free fluid, likely represents hemoperitenum. Pt initially grossly fluid overloaded w/increased oxygen requirement. Pt then diuresed with IV lasix goal. Cr trended downward to normal range. HCT stabilized at 24. Repete CT ___ demonstrated no subcapsular liver hematoma. . # Renal: ARF c/b hyperkalemia: in the setting of relative hypotension on post-op day 1/day of transfer. A hemodialysis catheter was placed ___ with HD subsequently performed evening of ___ at outside hospital. Renal was consulted, the patient was started on Cipro for a UTI. Pt diuresed as needed by ICU team. No need for further lasix when pt transfered to floor. Cr and K stabilized WNL with no need for further HD. Calcium repleted as needed. Anion gap metabolic acidosis on arrival in the setting of ARF and elevated BUN/Cr, no evidence of sepsis, but also possible lactate elevated in the setting of hepatic failure. Resolved with resolution of HELLP. . # CV: Pt initially hypotensive on POD#1 and then BPs became elevated consistent with PreEclampsia 140-160s/80-90. BP normalized with labetolol 200mg BID. . #Pulm: On arrival to ICU pt had oxygen requirements. Pulmonary effusions resolved with lasix in ICU. Transferred out of ICU on 2LNC. Pt gradually weaned to room air. . #GI: Pt had illeus in ICU which resolved by time of transfer to the floor. Diet advanced slowly until pt able to tolerate regular diet without problem.
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| 771
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11315603-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> - elevated blood pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> - dilation and evacuation <HISTORY OF PRESENT ILLNESS> On admission: ___ G3P1 at 23wks with a history of CHTN presents with hypertensive urgency from Dr. ___ where her blood pressure was noted to be 200/100. On presentation to OB triage her blood pressure was 202/110. Patient denies headache, visual changes, or RUQ pain. Reports possible blurry vision. Denies nausea/vomiting. Denies weakness/numbness. Denies contractions or abdominal pain. Denies vaginal bleeding or loss of fluid. Reports active fetal movement. <PAST MEDICAL HISTORY> - C/S x 1, for NRFHT after failed IOL for superimposed pre-eclampsia on cHTN, 5#5 - SAB x 1, s/p D&C - chronic hypertension - hyperlipidemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> - non-contributory <PHYSICAL EXAM> On admission: Vitals - T: 98.6 BP: 202/110 HR: 84 RR: 18 repeat BP: ___, 178/111, 171/96, 167/98, 164/96 Gen: NAD CV: RRR Resp: CTAB Abd: soft, gravid, NT ___: 1+ edema b/l, NT <PERTINENT RESULTS> ___ WBC-11.0 Hgb-12.6 Hct-34.9 Plt ___ ___ WBC-15.8 Hgb-12.2 Hct-34.1 Plt ___ ___ WBC-15.5 Hgb-10.6 Hct-29.7 Plt ___ . ___ ___ PTT-28.6 ___ ___ ___ PTT-26.9 ___ . ___ Creat-0.6 ___ Creat-0.8 . ___ ALT-61 AST-57 TotBili-0.2 ___ ALT-56 AST-57 ___ ALT-52 AST-48 . ___ UricAcd-6.3 ___ Mg-5.6 UricAcd-6.9 . ___ URINE Blood-NEG Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG . ___ URINE Hours-RANDOM Creat-53 TotProt-680 Prot/Cr-12.8 ___ URINE Hours-RANDOM Creat-40 TotProt-325 Prot/Cr-8.1 . ___ MRI HEAD: IMPRESSION: 1. Scattered tiny FLAIR hyperintense foci in the cerebral white matter on both sides which are nonspecific in appearance, and ___ relate to vasculitis, small vessel occlusive disease, less likely demyelinating etiology or post-inflammatory or post-infectious causes. Given the lack of IV contrast images, assessment is somewhat limited. Further evaluation with IV contrast can be considered. The distribution and appearance is not characteristic of posterior reversible encephalopathy with the hyperintense foci predominantly noted in the frontal and the parietal lobes, rather than the occipital lobes. 2. A 2-mm focal prominence of the A2 segment on the axial T2-weighted images ___ relate to tortuosity of the artery. Further evaluation with dedicated MR angiogram can be considered to confirm the nature. 3. Partially empty sella with thin rim of pituitary in the floor. To correlate clinically and with labs and if necessary dedicated imaging. . ___ RUQ ULTRASOUND: IMPRESSIONS: Normal liver by ultrasound. No specific followup is required for CT findings. <MEDICATIONS ON ADMISSION> - pre-natal vitamins <DISCHARGE MEDICATIONS> 1. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp: 120 Capsule(s) Refills: 1 2. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp: 30 Tablet Sustained Release(s) Refills: 1 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: 30 Tablet(s) Refills: 1 4. Nasonex Nasal <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - chronic hypertension with superimposed severe preeclampsia - intrauterine growth restriction - status post dilation and evacuation <DISCHARGE CONDITION> - stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns - nothing per vagina (no tampons, intercourse, douching for 4 weeks - please keep your follow-up appointments as outlined below - please take all of your medication as directed
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*)Pre-eclampsia She was admitted for blood pressure control and evaluation and was given multiple doses of IV hydralazine and labetalol. An ultrasound was done which gave an estimated fetal weight of 270g/<3%, consistent with severe growth restriction. Pr/Cr ratio was significantly elevated at 12.8; during her prior pregnancy it had been 0.3. Persistently elevated blood pressures and IUGR were consistent with a diagnosis of severe pre-eclampsia, and in the setting of pre-viable gestational age and a very low estimated fetal weight, she was counseled that she would not be a candidate for expectant management to viability and that the fetus would be quite unlikely to survive even if she was able to reach 24 weeks. After counseling regarding her various options, taking into account her history of a prior Cesarean delivery, she elected to proceed with dilation and evacuation. Laminaria were placed, and she underwent the procedure on the following day. The procedure was uneventful; please see the operative report for full details. Post-operatively she again required several doses of IV anti-hypertensive and was initially started on labetalol 600mg po TID. However, this was discontinued due to a decreased heart rate, and she was started on nifedipine CR 30mg BID. On POD#2 blood pressure was again elevated to a SBP in the 180-190's and she received IV labetalol once. Early in the morning on POD#3 blood pressures were again elevated to SBP in the 190's, and she received 2 doses of IV hydralazine. Hydrochlorothiazide and lisinopril were re-started that day, and nifedipine was reduced to once daily instead of BID. On the evening of POD#4 diastolic blood pressures were in the 110's and she was given an additional dose of hydrochlorothiazide, which was then increased to 25mg BID. The following day a Medicine consult was obtained, and recommended maintaining her regimen of nifedipine CR 30mg daily, HCTZ 25mg BID, and increasing her lisinopril to 20mg daily. Please see their note for full details of their recommendations. Her blood pressure was reasonably controlled on discharge and she was to follow up with her primary care physician shortly thereafter. . *)Blurred Vision On the morning of POD#3 she noted newly blurred vision in her left eye, shortly after having elevated blood pressures to the 190's systolic. Her neurologic exam was unremarkable, and she did not complain of any other symptoms. This persisted, and a Neurology consult was obtained. MRI of the head was remarkable for scattered white matter hyperintensities that were thought to be unrelated to her symptoms. Please see the note in ___ for full details of their recommendations. Her symptoms were persistent but stable for the remainder of her hospital course, and she was to follow up with Ophthalmology as an outpatient. . *)Tachycardia Due to her significantly elevated blood pressure and the need for IV anti-hypertensives, she was placed on telemetry. Tachycardia to the 140's was noted with activity; she was asymptomatic and ECG showed sinus tachycardia only. A CTA was negative for pulmonary embolism, and hematocrit was stable. As her heart rate was only intermittently elevated, she was to follow up with her primary care physician as an outpatient. . *)Possible Liver Lesions On CTA, patchy nodular enhancement of the liver was noted. A RUQ ultrasound was performed, which was normal. . *)Possible Left Lung Base Consolidation On CTA, small left pleural effusion was noted along with a ground-glass appearance concerning for infection/consolidation. The consulting internist felt that as she was asymptomatic this was unlikely to represent pneumonia. She was to follow up as an outpatient for likely repeat CXR/CT in ___ months.
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| 841
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11316104-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> decreased fetal movement at 39 ___ wks pregnant <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal birth <HISTORY OF PRESENT ILLNESS> ___ G1 P0 at ___ who presents for r/o laborwith decreased fetal movement today. She has not felt the baby move all day which is unusual for her. She does not think she has had any loss of fluid but has noticed increased vaginal moisture. Membranes were stripped on 3 days ago in the office and since then has noticed bloody show. She has also had intermittent cramping since then. ROS (+) cough, subjective fever, rhinorrhea <PAST MEDICAL HISTORY> Depression, Asthma - rarely uses albuterol <SOCIAL HISTORY> ___ <FAMILY HISTORY> Hypertension: Yes: Mother, father. Diabetes: Yes: Maternal uncle. Heart disease: Yes. Father with prostate cancer. ___ <PHYSICAL EXAM> PE: T 98.2 HR 75 RR 20 BP 132/79 NAD CTA bilaterally RRR Abd soft, gravid, NT EFW 8lb 5 oz ___ SVE: ___ FHT: 140/mod var/(+) accels/(-) decels Toco: Q2-8 min TAUS: Fluid visibly low. AFI 6 BPP ___ (-2 breathing) <PERTINENT RESULTS> ___ 07: 28PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 07: 28PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG ___ 12: 10AM BLOOD WBC-6.6 RBC-4.37 Hgb-12.7 Hct-35.8* MCV-82 MCH-29.1 MCHC-35.6* RDW-14.1 Plt ___ ___ 08: 50AM BLOOD Hct-30.3* ___ 12: 10AM BLOOD ___ PTT-25.0 ___ ___ 12: 10AM BLOOD Plt ___ ___ 12: 10AM BLOOD Creat-0.6 ___ 12: 10AM BLOOD ALT-11 AST-18 ___ 12: 10AM BLOOD UricAcd-4.4 ___ 10: 21PM BLOOD ___ pO2-32* pCO2-46* pH-7.29* calTCO2-23 Base XS--5 Intubat-NOT INTUBA Comment-CORD VEIN <DISCHARGE INSTRUCTIONS> Pelvic rest
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Pt was admitted to labor and delivery for IOL for low AFI of 6 with decreased fetal movement at term. Her cervix was favorable at 2cm dilated and 50% effaced. She was started on Pitocin. She was given IV PCN for + GBS status. She had clear artificial rupture of membranes. She received an epidural. On ___ she delivered a baby boy with Apgars 2, 7 at 1 and 5 minutes weighing 3155g. A first degree laceration was repaired. Postpartum the pt did well. She was both breast and bottle feeding. Her post op HCT was 30.3 and she remained with stable vitals and afebrile. She was discharged on postpartum day #2 in good condition. She will follow up in 2 wks and 6 wks with Dr. ___ ___ on Admission: albuterol, PNV 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:*1* Discharge Disposition: Home Discharge Diagnosis: Vaginal birth Discharge Condition: stable Followup Instructions: ___
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11318225-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding, anemia <MAJOR SURGICAL OR INVASIVE PROCEDURE> hysteroscopy, dilation and curretage <HISTORY OF PRESENT ILLNESS> ___ yo G3P3 with known submucosal fibroid presents from ___ with 3 weeks of ongoing vaginal bleeding changing pads as often as 1x/hour and plum sized clots. Seen one week prior by Dr ___ provera course was increased from 10mg daily (started ___ to 20mg daily. Pelvic US: 3.4 cm submucosal myoma and a 9mm intramural myoma. <PAST MEDICAL HISTORY> ob/gyn hx: SVD x3 at term PMHx: colonic adenoma, thyroid nodule, H pylori, pos PPD. notable no hx obesity, HTN, VTE, smoking, etc PSHx: eye surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> no hx VTE <PHYSICAL EXAM> Upon presentation: O: temp 97.5 HR 87 BP 94/60 RR 16 99% RA NAD, appears well but somewhat pale. thin woman. RRR CTAB abd soft, NT, ND BME uterus slightly enlarged, nontender pelvic: watery bright red blood cleared from vault with 9 scopettes. os closed with minimal slow ooze Upon discharge: Vital signs stable No acute distress, well-appearing Abdomen soft, nondistended, nontender Vaginal bleeding minimal <PERTINENT RESULTS> Intraoperative findings: Exam under anesthesia: Ten week size retroverted uterus with dilated external cervical os and closed internal os. Uterine cavity: Proliferative endometrium with blood, normal ostia bilaterally, no hysteroscopic evidence of fibroids. Laboratory results: ___ 02: 50AM ___ PTT-25.2 ___ ___ 02: 50AM PLT COUNT-202 ___ 02: 50AM NEUTS-46.7* LYMPHS-44.4* MONOS-6.5 EOS-2.4 BASOS-0.1 ___ 02: 50AM WBC-3.5* RBC-2.33* HGB-6.2* HCT-19.7* MCV-85 MCH-26.4* MCHC-31.3 RDW-17.3* ___ 02: 50AM GLUCOSE-95 UREA N-8 CREAT-0.5 SODIUM-138 POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-23 ANION GAP-11 ___ 02: 57AM HGB-6.1* calcHCT-18 ___ 02: 57AM ___ COMMENTS-GREEN TOP ___ 08: 28AM URINE MUCOUS-OCC ___ 08: 28AM URINE RBC-12* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 08: 28AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG ___ 08: 28AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08: 28AM URINE UCG-NEGATIVE ___ 08: 28AM URINE HOURS-RANDOM ___ 03: 10PM PLT COUNT-155 ___ 03: 10PM WBC-3.2* RBC-3.20*# HGB-9.1*# HCT-27.3*# MCV-85 MCH-28.4 MCHC-33.2 RDW-17.0* <MEDICATIONS ON ADMISSION> provera <DISCHARGE MEDICATIONS> 1. Ferrous Sulfate 325 mg PO BID 2. Ibuprofen 600 mg PO Q6H: PRN Pain 3. Provera (medroxyPROGESTERone) 10 mg oral every 6 hours 4. tranexamic acid 1.3 g oral TID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Abnormal uterine bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You had a hysteroscopy which did not show a large fibroid in the cavity of the uterus, as we had expected. It is most likely deep in the wall of the uterus. I would like you to continue with 2 medications after discharge to help prevent another episode of heavy bleeding before you follow-up with Dr. ___. 1. Tranexamic acid: 1300mg every 8 hours until your bleeding stops, no more than 5 ___ 2. Please follow the instructions below for Provera taper: * Take 40mg Provera daily (10mg every 6 hours) until you stop bleeding plus two days * Then take 30mg Provera daily (10mg every 8 hours) for 5 days * Then take 20mg Provera daily (10mg every 12 hours) for 5 days * Then take 10mg Provera daily for 5 days ferrous sulfate (iron) 325mg twice a day this is to help your body rebuild blood cells Your prescriptions have been sent to ___all Dr. ___ for: * vaginal bleeding requiring >1 pad/hr
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The patient was admitted to the gynecology service for significant abnormal uterine bleeding with symptomatic anemia after failing a prolonged progestin course. Progestin had been increased from 10mg to 20mg the week prior to presentation. She initially presented to ___ and was transferred to ___ the next day. Pelvic ultrasound demonstrated a 4cm submucosal fibroid. Given that she was symptomatically anemic with a hematocrit of 19.7, she was transfused two units packed red blood cells, and her hematocrit responded appropriately. She was started on tranexamic acid. On hospital day two, she was taken to the operating room for planned hysteroscopic myomectomy. Upon entry into the unterine cavity, no submucosal fibroid was visible. She patient tolerated the procedure well and was discharged home later that day with plan for continued tranexamic acid, progestin course of 40mg daily with taper upon discontinuation of vaginal bleeding, and plan for follow up appointment with Dr. ___ to address alternative management options for control of abnormal uterine bleeding.
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11318294-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> - fever, chills <MAJOR SURGICAL OR INVASIVE PROCEDURE> - incision and drainage of right Bartholin's gland abscess <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p I&D of right Bartholin's gland abscess in the ED on ___, p/w fevers/rigors/chills to the ED on the day of admission. In the ED on ___ had an uncomplicated bedside I&D, with no catheter or packing, and was sent home on po Flagyl. On presentation ___ was febrile at home to ___, to 102.2F in the ED. Also with flank pain and musculoskeletal pain, described as "achy." No dysuria, constipation, diarrhea. No respiratory complaints. Was admitted to the Gynecology service for further eval and mgmt. <PAST MEDICAL HISTORY> - Crohn's (followed by Dr. ___, diagnosed in ___ - h/o C. Diff after Augmentin - GERD - congenital hyperpigmentation of skin - acne <SOCIAL HISTORY> ___ <FAMILY HISTORY> - non-contributory <PHYSICAL EXAM> On admission: ___: 102.2, HR 128, BP 136/90, RR 18, 98% RA 2200: 99.8, HR 88, BP 110/55, RR 18, 96% RA Pt is diaphoretic, warm, appears comfortable CTA bilaterally RRR Abd: bowel sounds. Soft, NT, ND. No CVA tenderness No ___ edema, NT SVE: Vulva examined and there is minimal swelling of R labium major in comparison to left. Prior incision is visualized and appears to be still patent with no further drainage noted. There is tenderness to palpation of R labium with no obvious fluctuation, erythema. Minimal induration. Skin: hyperpigmentation noted <PERTINENT RESULTS> ___ URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ URINE ___ WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ URINE ___ BACTERIA-OCC YEAST-NONE ___ . ___ WBC-7.7 Hgb-12.7 Hct-37.9 Plt-262 ___ WBC-11.4 Hgb-12.6 Hct-36.6 Plt-325 ___ Neuts-93.4 ___ Monos-3.1 Eos-0.1 Baso-0 ___ WBC-12.7 Hgb-12.1 Hct-36.4 Plt-309 ___ Neuts-71.1 ___ Monos-7.4 Eos-0.5 Baso-0.1 . GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S) <MEDICATIONS ON ADMISSION> - Asacol 800 BID - omeprazole - topical erythromycin and benzoyl peroxide <DISCHARGE MEDICATIONS> 1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp: 14 Tablet(s) Refills: 0 2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. 3. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - right Bartholin's gland abscess, s/p incision and drainage <DISCHARGE CONDITION> - good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___ baths or warm compresses to affected area ___ times daily for 2 WEEKS. . ___ call MD ___ for the following: - temperature greater than 100.4F - increased pain, swelling, warmth at the affected area - fevers, chills, nausea, vomiting
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1. Fever On presentation no localizing sx of infection aside from right Bartholin's gland abscess. s/p recent I&D, likely transient bacteremia. Tmax at ___. Was started on IV ceftriaxone and metronidazole. Over the course of her hospitalization she defervesced and symptomatically improved, with no further rigors/chills. On exam, the I&D site appeared patent, with no continued drainage noted and with no area of significant fluctuance for further I&D. On discharge home she was afebrile and in good condition, with rx given for po ciprofloxacin and metronidazole. 2. Right Bartholin's gland abscess s/p I&D in the ED on ___ on this admission was not found to have significant fluctuance for repeat I&D. No spreading erythema or frank drainage noted on exam; opening appeared patent. In good condition on discharge home, with instructions for ___ baths and warm compresses to the affected area.
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11319989-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Sulfa (Sulfonamide Antibiotics) / niacin <ATTENDING> ___. <CHIEF COMPLAINT> grade 2 endometrial adenocarcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Laparoscopic Hysterectomy, Bilateral Salpingo-oophorectomy, Pelvic Lymph Node Dissection <HISTORY OF PRESENT ILLNESS> ___ female presented to gynecology ___ clinic with endometrial adenocarcinoma grade 2 found on D&C/Hysteroscopy ___. She initially presented to her PCP with vaginal bleeding with wiping only at the end of ___. PCP referred her to Dr. ___ further evaluation. Patient underwent a pelvic ultrasound ___ that showed 2 small (<2 cm) intramural fibroids, a 4 mm endometrial stripe, and normal ovaries. She had an endometrial biopsy ___ which showed inactive endometrium. The procedure was painful for the patient so the decision was made that any further procedures would be done at the SPU with IVCS. The patient continued to have vaginal bleeding with wiping only and returned for follow up care ___ underwent hysteroscopy on ___. This showed: ENDOMETRIAL ADENOCARCINOMA, endometrioid type, moderately differentiated, grade 2 of 3.A benign endometrial polyp is also present. CERVICAL POLYP: Endocervical polyp. Additionally, she reports intermittent LLQ pain x unknown period of time. She also reports abdominal bloating but has irregular and inconsistent bowel pattern. <PAST MEDICAL HISTORY> PMH: Endometriosis, Invasive Ductal Carcinoma left breast- ___ S/P Chemotherapy, XRT and Tamoxifen x ___ years, Right Breast - carcinoma in situ, AIN being followed by Dr ___ adenoma on colonoscopy ___ , S/P MVA with multiple fractures ___ PSH: Left Mastectomy- ___, Tram Flap- ___, Laparoscopy, Right ___ Mastectomy with ___ Ankle Surgery ___, Right Leg Fusion ___ ___: Maternal Grandmother: ___ CA and ___ CA, Sister x 2: ___ CA-genetic testing negative per patient,Paternal Aunt: Stomach CA, Grandmother: Stomach CA, Father: CAD and Lung CA OB/GYN HX: LMP ___ due to chemotherapy for breast cancer PAP ___ negative with +HRHPV (not ___ or ___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> FamHx: noncontributory <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm pulm: clear to ausculatation bilaterally abd: soft, nontender, nondistended, incision clean/dry/intact ___: nontender, nonedematous <PERTINENT RESULTS> ___ 07: 15AM BLOOD WBC-12.4* RBC-3.82* Hgb-11.8* Hct-36.0 MCV-94 MCH-30.9 MCHC-32.7 RDW-12.9 Plt ___ ___ 12: 33PM BLOOD WBC-12.7*# RBC-4.30 Hgb-13.6 Hct-40.9 MCV-95 MCH-31.7 MCHC-33.3 RDW-13.0 Plt ___ ___ 07: 15AM BLOOD Glucose-109* UreaN-13 Creat-0.7 Na-136 K-4.0 Cl-99 HCO3-29 AnGap-12 ___ 12: 33PM BLOOD Glucose-135* UreaN-13 Creat-0.8 Na-138 K-4.2 Cl-102 HCO3-27 AnGap-13 ___ 07: 15AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.7 ___ 12: 33PM BLOOD Calcium-8.9 Phos-3.4 <MEDICATIONS ON ADMISSION> atenolol 25 q day, lipitor 20 QHS, buproprion 100mg BID, prozac 20 q day, HCTZ 25 qday, omeprazole 20q day <DISCHARGE MEDICATIONS> 1. Atenolol 25 mg PO DAILY 2. BuPROPion 100 mg PO BID 3. Fluoxetine 20 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Ibuprofen 600 mg PO Q6H: PRN pain Take with food. Do not exceed 3200mg/day. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 7. Docusate Sodium 100 mg PO BID Take while taking narcotic pain medication to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *1 8. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H: PRN pain RX *hydrocodone-acetaminophen 5 mg-300 mg 1 tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> grade 2 endometrial 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: * 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 >10lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up 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 oncology service after undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection. 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/acetaminophen/toradol. Her diet was advanced without difficulty and she was transitioned to vicodin/motrin. 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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11320016-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Hydrochlorothiazide <ATTENDING> ___. <CHIEF COMPLAINT> Bleeding, dizziness. <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion <HISTORY OF PRESENT ILLNESS> ___ P2 who presented to the ED w/ "a month" of vaginal bleeding, starting to pass clots ___. She says that she does not soak through pads, but was mostly concerned because she was passing large clots frequently, including Today she felt dizzy, and while getting a CXR for evaluation of dyspnea w/ exertion, had a syncopal/pre-syncopal episode, started to fall but was caught by staff and did not hit head. No abdominal pain, other symptoms. No CP or SOB at rest. Of note, she also recently has had some urinary incontinence. The pt is reluctant to participate in interview, and answers questions with very brief responses. <PAST MEDICAL HISTORY> GYN: - Menses irregular for past several years, sometimes misses a month, sometimes has more than one period a month; heavy as above - H/o abdominal myomectomy w/ Dr. ___ ___ ___, no further medical management since. Prior to her myomectomy, her Hct was 21 ___ records, however her most recent Hct was 35 in ___, again per ___ records - No paps in ___ or ___ systems since ___, no abnl paps - No contraception, sexually active OB: TAB x 1, SVD x 2 MED: HTN Anemia as above Constipation SURG: ___ Abd myomectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father, sister w/ stroke; family h/o DM, HTN Paternal uncle w/ breast cancer, grandmother cervical cancer, mother lymphoma Physical ___: PE: 98.7 95 108/64 16 100%RA NAD - appears sleepy but awakens and participates appropriately RRR, CTAB Abd soft, NTND Pelvic exam deferred, but per ED exam: Vaginal vault w/ 1 inch clot, several scopettes of thin blood, some oozing at the os. No uterine or adnexal tenderness on exam <PERTINENT RESULTS> ___ 11: 00AM ___ PTT-22.7 ___ ___ 10: 55AM GLUCOSE-93 UREA N-7 CREAT-0.7 SODIUM-139 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14 ___ 10: 55AM estGFR-Using this ___ 10: 55AM URINE HOURS-RANDOM ___ 10: 55AM URINE GR HOLD-HOLD ___ 10: 55AM WBC-6.8 RBC-2.56*# HGB-6.2*# HCT-20.8*# MCV-81* MCH-24.3* MCHC-30.0* RDW-15.1 ___ 10: 55AM NEUTS-78.5* LYMPHS-17.4* MONOS-2.8 EOS-1.0 BASOS-0.2 ___ 10: 55AM PLT COUNT-385 ___ 10: 55AM URINE COLOR-Red APPEAR-Cloudy SP ___ ___ 10: 55AM URINE BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE-500 KETONE-15 BILIRUBIN-LG UROBILNGN-4* PH-8.5* LEUK-LG ___ 10: 55AM URINE RBC->50 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0 <MEDICATIONS ON ADMISSION> Lisinopril 2.5mg recently prescribed, but pt has not yet started <DISCHARGE MEDICATIONS> provera iron colace <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> menometrorrhagia, fibroids, symptomatic blood loss anemia <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> please call if you have heavy vaginal bleeding (saturating greater than 1 pad/hour), shortness of breath, chest pain, dizziness
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Ms. ___ was admitted to the GYN service on ___ for blood loss anemia. Her issues during her hospital stay are listed below by systems: 1) Heme: - Hct ___ -> 20.8, normal coags in the ED - She was transfused 2uPRBC in ED and then 2uPRBC evening of ___ given that after her first 2 units her Hct did not increase appropriately although the patient reported no symptoms and bleeding had decreased. Her Hct after the second 2 units increased appropriately to 27.2. An ultrasound showed a multifibroid uterus, difficult to assess stripe due to blood/clot but appears thickened. During her hospitalization she would have intermittent vaginal bleeding, with ten hour periods of no bleeding and then one episode of a gush with passage of a clot. She was started on provera for this on HD#2, which she was advised to continue until her appointment with Dr. ___. . 2) CV: She had a near-syncopal episode while getting a CXR in the ED- this was thought to be likely due to anemia. EKG and telemetry in the ED normal. We decided to hold her Lisinopril, as blood pressures were lower than her usual and the pt stated she had not been taking it at home anyway. . 3) Pulm: She complained of some dyspnea on exertion when she first arrived to the ED- she had no symptoms at rest, no tachypnea, hypoxia. The dyspnea on exertion was likely due to significant anemia. CXR done in the ED was negative for any acute cardiopulmonary process. . 4) GU: Pt complained of urinary incontinence, which seemed to be a long-standing issue. Urinalysis showed large blood, 0 WBC, few bacteria. Urine Culture was pending at time of discharge. We advised her to set up an appointment with urogynecology at ___. ___ for this issue. 5) Access: For access, a Right external jugular line was obtained in the ED and a foley catheter was also placed. Both the foley and EJ line were discontinued on HD2. She was discharged home on HD2 in stable condition.
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11324139-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ibuprofen / Lovenox <ATTENDING> ___ <CHIEF COMPLAINT> Endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic hysterectomy, bilateral salphingo-oopherectomy, lymph node dissection for endometrial cancer <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G2P0 who has been menopausal since her mid ___. She had an episode of postmenopausal bleeding last month and was evaluated by her primary ob-gyn. An endometrial biopsy was performed and showed a grade ___ endometrioid endometrial adenocarcinoma. <PAST MEDICAL HISTORY> Past medical history: 1. Asthma (mild, currently not on treatment). 2. Left eye cataract. Past Surgical History: 1. D&C. 2. Tonsillectomy. 3. Left Achilles tendon repair. 4. Fracture repair of her tibia and fibula. Past OB/GYN History: G2, P0, TAB2. Menarche at 13 and menopause at 55. Reports having had normal Pap smears on a regular basis. No significant STIs. She notes having been given a diagnosis of endometriosis in the past. Her last mammogram was in ___, and several years ago, she had a colonoscopy, which showed some polyps. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for breast, ovarian, or uterine cancer. Her mother had colon cancer. <PHYSICAL EXAM> At pre-op visit: Gen: no acute distress, appears her stated age. HEENT: Eyes anicteric. Mouth moist. Neck: Supple. No supraclavicular lymphadenopathy. Heart: Regular rate and rhythm. Lungs: Clear bilaterally. No CVA tenderness. Abd: soft, nontender, nondistended, slightly obese, no hernias, hepatosplenomegaly, or masses. NO CVAT Pelvic: External genitalia unremarkable. Lower extremities unremarkable. No groin adenopathy. Introitus smooth. Vaginal mucosa smooth. Cervix is smooth and nulliparous. On rectovaginal exam, uterus is mobile, approximately 6-7 cm and no adnexal or pelvic masses are appreciated. <MEDICATIONS ON ADMISSION> multivitamins, calcium, aspirin 81 mg, and fish oil. <DISCHARGE MEDICATIONS> 1. Acetaminophen 500 mg Capsule Sig: ___ Capsules PO Q6H (every 6 hours) as needed for pain. 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q4H (every 4 hours) as needed for wheezing, SOB. 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 weeks. Disp: *56 Capsule(s)* Refills: *0* 4. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp: *50 Tablet(s)* 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> Please call your doctor or return to the hospital if you have: -Increased pain -Redness or unusual discharge from your incision -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -No intercourse, tampons, or douching for 6 weeks -No heavy lifting or vigorous activity for 6 weeks -You can shower and clean your wound, but do not use perfumed soaps or lotions. Be sure to pat completely dry after washing. -You may resume your regular diet and home medications.
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Ms. ___ underwent a robotic hysterectomy, bilateral salphingo-oopherectomy, and lymph node dissection for treatment and staging of her endometrial cancer. Please see operative note in OMR for further details. . Post-operatively she was admitted to the gyn oncology service for care. She had some headaches and dizziness on narcotics initially postoperatively, and this was significantly improved at the time of discharge to home on POD#2. She was ambulating, tolerating a regular diet, and had adequate po pain control.
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11324139-DS-23
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lovenox <ATTENDING> ___ <CHIEF COMPLAINT> Lower extremity tingling <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound-guided drainage of pelvic lymphocele <HISTORY OF PRESENT ILLNESS> ___ year-old woman status post total robotic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection on ___ for stage I, grade 2 endometrial cancer presented to the emergency department on ___ with lower extremity numbness and paresthesias. Prior to this, was noted to have a pelvic mass on exam at her ___ office visit - was asymptomatic at the time. A CT scan revealed a large bilobed cystic collection with the larger lobe measuring 11.6 x 16.3 cm and the cystic lesion to the right, that is considerably smaller in size measuring 3.5 x 3.3 cm, consistent with a lymphocele or seroma. . Her current symptoms are stable, not worsening, and consist of bilateral foot numbness and outer thigh paresthesias with the left> right. The sensation in her feet is similar to when they "fall asleep". On her thigh she feels like she has small insects crawling on her. She has no associated ___ pain or swelling. She also reports bilateral lower back discomfort and pelvic pressure. . Continues to deny weakness, gait instability, falls, incontinence, urinary frequency or retention, constipation, upper extremity symptoms, dizziness, confusion, chest pain, SOB, palpitations. She has had normal bowel movements, is passing flatus, has normal appetite. Denies abdominal pain. . She was admitted to ___ for a planned image-guided drainage of her pelvic lymphocele by interventional radiology. <PAST MEDICAL HISTORY> Past medical history: 1. Asthma 2. Left eye cataract. 3. Elevated BPs 4. Colon Polyps . Past Surgical History: 1. Dilation and curettage 2. Tonsillectomy. 3. Left Achilles tendon repair. 4. Fracture repair of her tibia and fibula. 5. Total robotic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection . Past OB/GYN History: Gravida 2, Para 0, elective pregnancy termination x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for breast, ovarian, or uterine cancer. Her mother had colon cancer. <PHYSICAL EXAM> Physical Exam (from emergency department ___ VS Temp 98.9 BP 163/86 P 90 RR 18 O2 99% RA Gen: no acute distress. HEENT: Eyes anicteric. Heart: Regular rate and rhythm. Lungs: Clear bilaterally. No CVA tenderness. Abd: soft, nontender, nondistended. Well healed incisions. Large midline mass palpated, mobile with > fullness on the left compared to right. Pelvic: External genitalia unremarkable. No groin adenopathy. Mass appreciated on BME as above. Smooth recto-vaginal septum. <PERTINENT RESULTS> ___ 11: 30 am ABSCESS LT LOWER QUADRANT. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. <MEDICATIONS ON ADMISSION> Aspirin 81mg daily Multivitmin Calcium <DISCHARGE MEDICATIONS> 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 3. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic lymphocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please resume your normal diet, medications and activities.
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Ms. ___ was admitted to the hospital for image-guided drainage of her pelvic fluid collection. Five-hundred cc of fluid were aspirated under ultrasound guidance and sent for gram stain and culture. Gram stain yielded no leukocytes or microorganisms. Culture is pending. She had immediate relief of her neurological symptoms upon drainage. See dictated radiological report for full procedure details. After the procedure she was stable and was discharged home.
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11324139-DS-24
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lovenox <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal Pain/Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> CT guided drain placement <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old female with stage 1a, grade 2 endometriod adenocarcinoma s/p total robotic hysterectomy, BSO, LND with recurrent lymphocyst who presents with increasing lower abdominal discomfort for approximately 2 weeks associated with nausea but no emesis. Last bowel movement was today, loose due to oral CT contrast, +flatus. Patient also endorses a fever to ___ and flu-like symptoms 2 weeks ago, lasting for 4 days, but states that she has been afebrile since that time. Ms. ___ presented to clinic today with this complaint and was sent to radiology for a CT of the abdomen and pelvis which demonstrated a 5.4 cm left pelvic abscess, infected lymphocele which may or may not be communicating with small bowel. She was admitted to ___ today for a planned image-guided drainage of her pelvic lymphocele by interventional radiology. <PAST MEDICAL HISTORY> Past medical history: 1. Asthma 2. Left eye cataract 3. Hypertension 4. Colon Polyps Past Surgical History: 1. D&C 2. Tonsillectomy 3. Left Achilles tendon repair 4. Fracture repair of her tibia and fibula 5. Total robotic hysterectomy/BSO/PLND 6. Diagnostic Laparoscopy, Intraperitoneal drainage of left pelvic lymphocyst with peritoneal window Past OB/GYN History: G2, P0, TAB2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for breast, ovarian, or uterine cancer. Her mother had colon cancer. <PHYSICAL EXAM> VS Temp 97.7 BP 144/84 P ___ RR 20 O2 98%RA Gen: alert, oriented, lying ___ bed, frustrated at times Lungs: CTAB, no WRR CV: RRR, rate 96 Abd: soft, mildly tender to deep palpation LLQ, no rebound/guarding, +BS Ext: no edema, no calf TTP <PERTINENT RESULTS> ___ 11: 00AM BLOOD WBC-13.3*# RBC-4.36 Hgb-11.6* Hct-36.3 MCV-83 MCH-26.7* MCHC-32.0 RDW-13.1 Plt ___ ___ 07: 09PM BLOOD WBC-14.3* RBC-4.38 Hgb-12.0 Hct-36.9 MCV-84 MCH-27.4 MCHC-32.6 RDW-13.4 Plt ___ ___ 07: 23AM BLOOD WBC-13.0* RBC-4.16* Hgb-11.2* Hct-34.6* MCV-83 MCH-26.9* MCHC-32.3 RDW-13.4 Plt ___ ___ 06: 54AM BLOOD WBC-11.8* RBC-4.19* Hgb-11.3* Hct-34.3* MCV-82 MCH-27.0 MCHC-32.9 RDW-13.0 Plt ___ ___ 07: 09PM BLOOD Neuts-84.7* Lymphs-7.2* Monos-5.3 Eos-2.3 Baso-0.5 ___ 07: 23AM BLOOD Neuts-83.8* Lymphs-7.6* Monos-5.1 Eos-2.9 Baso-0.5 ___ 06: 54AM BLOOD Neuts-83.1* Lymphs-8.0* Monos-5.2 Eos-3.2 Baso-0.4 ___ 07: 09PM BLOOD ___ PTT-28.9 ___ ___: Abscess GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. HEAVY GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. ___ and ___ Blood Cx: no grwoth to date ___ URINE CULTURE (Final ___: <10,000 organisms/ml ___ CT Abd/Pelvis: 1. Air and fluid collection within the left anterior pelvis ___ the area of prior lyphocele resection, with connection to a loop of distal small bowel. Oral contrast is seen within the superior aspect of this collection, concerning for a fistula. Slightly thickened appearance to the wall of the sigmoid colon and adjacent inflammatory changes may be secondary although connection with the sigmoid colon cannot be excluded as no oral contrast has yet progressed to the sigmoid colon. 2. Cholelithiasis. ___: CT Guided Drainage CT-guided aspiration and drainage of fluid collection ___ the left hemipelvis. A small quantity of milky aspirate was removed and collected for laboratory analysis. Following placement of the drainage catheter, diluted contrast was administered through the catheter, which demonstrated a fistula connection between the fluid collection and adjacent small bowel. Results were discussed with the covering inpatient team at the time of the procedure. <DISCHARGE INSTRUCTIONS> - Take Augmentin 500mg three times per day until your drainage catheter is removed. - You do not need to flush your drainage catheter. - Take Motrin and Tylenol as needed for pain.
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Ms. ___ is a ___ year old female with stage 1a grade 2 endometrial cancer status post robotic hysterectomy, BSO and pelvic lymph node dissection with recurrent lymphocyst who initially presented with subjective fevers and worsening lower abdominal pain. She underwent a CT of the abdomen and pelvis which demonstrated an air-fluid collection within the left anterior pelvis with connection to a loop of small bowel which was concerning for fistula. Given this finding, the patient was admitted to the Gyn Oncology service for further management. On HD#2, Ms. ___ underwent a CT guided placement of a drain with drainage of fluid collection. Per the radiology impression, there appeared to be evidence of a fistula. Following this procedure, the patient was started on IV antibiotics given concern for abscess/fistula and evidence of leukocytosis. As per recommendations made by the consulting ID team, she was started on Ceftriaxone and Flagyl. She remained on these antibiotics until culture data returned which demonstrated pan-sensitive staph aureus. She was transitioned to Augmentin and will remain on this antibiotic until the drain is removed. She remained afebrile during her hospital course and her leukocytosis improved. She was discharged home ___ stable condition on HD#4. She will follow-up with Dr. ___ Infectious ___ as an outpatient. Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 2. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 weeks. Disp:*65 Tablet(s)* Refills:*0* 3. Motrin 400 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Endometrial Cancer Fistula Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11325145-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Dilaudid <ATTENDING> ___. <CHIEF COMPLAINT> right flank pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ y/o G2P0 at 24w1d with persistent R flank pain for which she was given oxycodone and flexeril yesterday but now is vomiting and can't keep the oxycodone down. Yesterday the pain was felt to be musculoskeletal in nature secondary to lying in an awkward position but at this point the pain is quite intense and she has persistent n/v. Has been unable to keep any food or fluids down since last night. She reports good FM. Denies VB, fever, chills, LOF, lower abdominal pain, chills, dysuria, diarrhea, constipation. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP (7 wk scan with ___ ___ - Opos/Abneg/RI/RPRNR/HIVneg/HBsAgneg - LR NIPT - FFS: mild b/l hydronephris -> normal f/u ___ - U/S ___ EFW 572g, 30% - Issues: *) Ulcerative colitis s/p total colectomy, for cesarean section POB/GYNH: - LEEP x2 - SAb x1 - Remote hx of chlamydia <PAST MEDICAL HISTORY> - Ulcerative Colitis (see below for extensive surgical history related to this) - ADD - Hx pancreatitis in ___ Past Surgical History: - LEEP x 2 - ___- Total abdominal colectomy with end ileostomy for toxic megacolon in the setting of proctosigmoiditis/UC, included an appendectomy - ___- Ileo-anal pouch to anal canal anastomosis with temporary diverting loop ileostomy - ___- Ileostomy take down <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal aunt with UC. Maternal GM with spastic colon. Father with GERD. Various family members with IBS. <PHYSICAL EXAM> on admission: T-97.9 HR-91 BP-141/88 RR-16 NAD, lying stoically with eyes closed in bed Skin: pale CV: RRR Pulm: CTAB Abd: +BS, soft, nondistended. No fundal tenderness. No epigastric or RUQ tenderness on deep palpation but does have back pain on RUQ deep palpation. No suprapubic tenderness Multiple well healed surgical scars. Back: right sided CVA tenderness present Ext: nontender <PERTINENT RESULTS> ___ 07: 30AM BLOOD WBC-12.2* RBC-3.54* Hgb-9.4* Hct-30.0* MCV-85 MCH-26.6* MCHC-31.3 RDW-13.8 Plt ___ ___ 01: 00PM BLOOD WBC-12.9* RBC-3.51* Hgb-9.4* Hct-30.3* MCV-86 MCH-26.8* MCHC-31.1 RDW-14.0 Plt ___ ___ 07: 25AM BLOOD WBC-13.8* RBC-3.39* Hgb-9.0* Hct-28.2* MCV-83 MCH-26.5* MCHC-31.8 RDW-13.9 Plt ___ ___ 05: 30PM BLOOD WBC-20.3* RBC-4.11* Hgb-11.0* Hct-34.5* MCV-84 MCH-26.8* MCHC-31.9 RDW-13.7 Plt ___ ___ 10: 14AM BLOOD WBC-28.3*# RBC-4.43 Hgb-11.9* Hct-36.7 MCV-83 MCH-26.8* MCHC-32.3 RDW-13.5 Plt ___ ___ 07: 55PM BLOOD WBC-14.8* RBC-4.59 Hgb-12.2 Hct-38.9 MCV-85# MCH-26.5* MCHC-31.3 RDW-13.9 Plt ___ ___ 07: 30AM BLOOD Neuts-80.2* Lymphs-12.5* Monos-6.3 Eos-0.9 Baso-0.1 ___ 07: 25AM BLOOD Neuts-81.4* Lymphs-11.6* Monos-6.4 Eos-0.5 Baso-0.1 ___ 05: 30PM BLOOD Neuts-88.2* Lymphs-7.7* Monos-4.0 Eos-0.1 Baso-0.1 ___ 10: 14AM BLOOD Neuts-92.5* Lymphs-5.3* Monos-2.1 Eos-0.1 Baso-0.1 ___ 07: 55PM BLOOD Neuts-88.2* Lymphs-8.7* Monos-2.8 Eos-0.2 Baso-0.1 ___ 01: 00PM BLOOD ___ PTT-26.8 ___ ___ 01: 00PM BLOOD ___ ___ 07: 30AM BLOOD UreaN-7 Creat-0.6 ___ 07: 25AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-138 K-3.7 Cl-106 HCO3-24 AnGap-12 ___ 10: 14AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-136 K-3.8 Cl-101 HCO3-24 AnGap-15 ___ 07: 55PM BLOOD Glucose-101* UreaN-14 Creat-0.5 Na-138 K-3.7 Cl-103 HCO3-24 AnGap-15 ___ 07: 25AM BLOOD ALT-10 AST-14 ___ 07: 55PM BLOOD ALT-17 AST-18 Amylase-32 TotBili-0.2 DirBili-0.1 IndBili-0.1 ___ 07: 25AM BLOOD Lipase-11 ___ 07: 55PM BLOOD Lipase-13 ___ 07: 25AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.6 ___ 07: 55PM BLOOD Calcium-9.3 Phos-3.3# Mg-2.0 Renal u/s ___: Moderate right-sided hydronephrosis without obstructing stone visualized. The renal parenchyma also demonstrates abnormal echogenicity and there is a small amount of perinephric fluid both of which can be seen in the setting of obstruction and/or pyelonephritis. Therefore, it is not clear on this exam whether the patient has pyelonephritis and physiologic hydronephrosis of pregnancy, or if the patient has an obstructing calculus causing the hydronephrosis and possibly precipitating pyelonephritis. <MEDICATIONS ON ADMISSION> Adderall 30mg daily, zofran prn <DISCHARGE MEDICATIONS> 1. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp #*36 Capsule Refills: *0 2. Metoclopramide 10 mg PO QID nausea RX *metoclopramide HCl 10 mg 1 tab by mouth q6hrs Disp #*30 Tablet Refills: *1 3. Ondansetron 8 mg PO Q8H: PRN nausea RX *ondansetron 4 mg ___ tablet,disintegrating(s) by mouth q6hrs 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 q4hrs Disp #*30 Tablet Refills: *0 5. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 24 weeks flank pain, ?kidney stone <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service due to flank pain and nausea/vomiting. The exact etiology of your pain is unclear, but likely due to a kidney stone. Although initially there was concern for a kidney infection, your urine culture was contaminated and did not have any significant growth. You will continue the antibiotic for a total of 10 days. You may have passed a small stone while you were here, and it was sent to pathology for evaluation. Your pain was controlled with po percocet and you were tolerating a regular diet. It is important that you stay hydrated. Continue taking percocet for pain as needed. You should continue taking a stool softener while taking percocet to avoid constipation.
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Ms. ___ was admitted to the ___ service for right sided flank pain with suspicion for nephrolithiasis and/or pyelonephritis. Her nausea, vomiting and leukocytosis of 28 upon admission were suspicious for pyelonephritis. However, she was afebrile and her urinalysis upon admission was not suspicious for UTI. She was started on IV morphine prn for pain control and ceftriaxone for pyelonephritis. She had reassuring fetal status with an appropriate for gestational age NST on admission. She continued to be afebrile. Her WBC trended down over the course of her hospital stay. On hospital day 3 she was transitioned to oral pain medication and antibiotics. She also passed a possible stone while she was hospitalized. It was sent to pathology, report pending. By hospital day 4 she was tolerating a regular diet, on oral medications, ambulating. Her pain was well controlled. She was discharged home with follow-up on hospital day 4.
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11325145-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Dilaudid <ATTENDING> ___. <CHIEF COMPLAINT> cesarean section <MAJOR SURGICAL OR INVASIVE PROCEDURE> Primary low transverse cesarean section using a prior vertical midline skin incision. <HISTORY OF PRESENT ILLNESS> ___ G2P0 with history of multiple abdominal surgeries in the setting of ulcerative colitis/toxic megacolon. She developed gestational hypertension in her pregnancy. She presented for a scheduled 37 week c-section. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ (7 wk scan with ___ ___ - Opos/Abneg/RI/RPRNR/HIVneg/HBsAgneg/GBS neg - LR NIPT - FFS: mild b/l hydronephris -> normal f/u ___ - U/S ___ EFW 572g, 30% - Issues: *)H/O pyelo vs stone this pregnancy for which she now takes prophylactic macrodantin 100mg daily *) Ulcerative colitis s/p total colectomy, for cesarean section POB/GYNH: - LEEP x2 - SAb x1 - Remote hx of chlamydia <PAST MEDICAL HISTORY> - Ulcerative Colitis (see below for extensive surgical history related to this) - ADD - Hx pancreatitis in ___ Past Surgical History: - LEEP x 2 - ___- Total abdominal colectomy with end ileostomy for toxic megacolon in the setting of proctosigmoiditis/UC, included an appendectomy - ___- Ileo-anal pouch to anal canal anastomosis with temporary diverting loop ileostomy - ___- Ileostomy take down <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal aunt with UC. Maternal GM with spastic colon. Father with GERD. Various family members with IBS. ___, ___ ancestry. FOB ___ (non ___ and ___. No hx of neural tube defect, cardiac defect, MR, downs syndrome, frequent SAB <PHYSICAL EXAM> On the day of discharge: VS: afebrile, vital signs within normal limits Gen: well-appearing, comfortable, NAD Resp: nl respiratory effort Abd: soft, minimally distended, non-tender, no rebound or guarding, fundus firm, incision clean/dry/intact healing well GU: pad with minimal spotting Ext: no lower extremity edema, no calf tenderness <PERTINENT RESULTS> ___ 07: 06AM BLOOD WBC-15.2* RBC-4.62 Hgb-11.2* Hct-35.0* MCV-76* MCH-24.2* MCHC-31.8 RDW-14.8 Plt ___ ___ 07: 06AM BLOOD WBC-15.2* RBC-4.62 Hgb-11.2* Hct-35.0* MCV-76* MCH-24.2* MCHC-31.8 RDW-14.8 Plt ___ ___ 03: 15PM BLOOD WBC-6.7# RBC-4.87 Hgb-11.8* Hct-37.1 MCV-76* MCH-24.3* MCHC-31.9 RDW-15.1 Plt ___ ___ 03: 15PM BLOOD Neuts-35* Bands-44* Lymphs-16* Monos-3 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 ___ 04: 10AM BLOOD WBC-7.8 RBC-4.38 Hgb-10.6* Hct-33.8* MCV-77* MCH-24.1* MCHC-31.2 RDW-15.0 Plt ___ ___ 04: 10AM BLOOD Neuts-46* Bands-25* ___ Monos-5 Eos-0 Baso-0 ___ Metas-1* Myelos-2* ___ 10: 00PM BLOOD WBC-5.4 RBC-4.32 Hgb-10.3* Hct-33.0* MCV-76* MCH-23.9* MCHC-31.3 RDW-15.1 Plt ___ ___ 10: 00PM BLOOD Neuts-50 Bands-13* ___ Monos-11 Eos-1 Baso-0 ___ Metas-1* Myelos-0 ___ 04: 05AM BLOOD WBC-5.5 RBC-4.21 Hgb-9.8* Hct-32.4* MCV-77* MCH-23.3* MCHC-30.2* RDW-14.9 Plt ___ ___ 04: 05AM BLOOD Neuts-60.6 ___ Monos-12.2* Eos-1.5 Baso-0.5 ___ 09: 00AM BLOOD WBC-11.3*# RBC-6.00*# Hgb-14.4# Hct-46.2# MCV-77* MCH-24.0* MCHC-31.2 RDW-14.6 Plt ___ ___ 07: 25AM BLOOD WBC-14.7* RBC-6.24* Hgb-14.8 Hct-47.6 MCV-76* MCH-23.7* MCHC-31.1 RDW-14.6 Plt ___ ___ 01: 15PM BLOOD WBC-16.9* RBC-5.86* Hgb-14.1 Hct-44.5 MCV-76* MCH-24.1* MCHC-31.7 RDW-14.6 Plt ___ ___ 07: 07AM BLOOD Creat-0.5 ___ 03: 15PM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-140 K-4.6 Cl-104 HCO3-24 AnGap-17 ___ 04: 10AM BLOOD Glucose-117* UreaN-16 Creat-0.7 Na-140 K-3.9 Cl-104 HCO3-24 AnGap-16 ___ 10: 00PM BLOOD Glucose-107* UreaN-14 Creat-0.6 Na-143 K-4.2 Cl-108 HCO3-26 AnGap-13 ___ 04: 05AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-142 K-4.1 Cl-110* HCO3-24 AnGap-12 ___ 05: 00PM BLOOD Glucose-82 UreaN-10 Creat-0.6 Na-144 K-3.9 Cl-108 HCO3-27 AnGap-13 ___ 04: 00AM BLOOD Glucose-94 UreaN-9 Creat-0.6 Na-145 K-3.8 Cl-110* HCO3-27 AnGap-12 ___ 08: 50AM BLOOD Glucose-80 UreaN-9 Creat-0.7 Na-143 K-3.8 Cl-108 HCO3-28 AnGap-11 ___ 06: 35AM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-25 AnGap-15 ___ 07: 45AM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-133 K-4.2 Cl-96 HCO3-23 AnGap-18 ___ 09: 00AM BLOOD Glucose-91 UreaN-25* Creat-0.8 Na-127* K-4.4 Cl-90* HCO3-21* AnGap-20 ___ 07: 30PM BLOOD Glucose-112* UreaN-28* Creat-0.9 Na-129* K-4.0 Cl-93* HCO3-23 AnGap-17 ___ 07: 25AM BLOOD Glucose-91 UreaN-29* Creat-1.0 Na-130* K-4.6 Cl-93* HCO3-21* AnGap-21* ___ 01: 15PM BLOOD Glucose-111* UreaN-26* Creat-0.8 Na-128* K-4.2 Cl-93* HCO3-21* AnGap-18 ___ 07: 07AM BLOOD ALT-9 AST-20 ___ 07: 07AM BLOOD UricAcd-4.5 ___ 03: 15PM BLOOD Calcium-8.9 Phos-4.0 Mg-1.8 ___ 04: 10AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.7 ___ 10: 00PM BLOOD Calcium-8.0* Phos-2.0* Mg-2.4 ___ 04: 05AM BLOOD Calcium-7.9* Phos-2.0* Mg-2.4 ___ 05: 00PM BLOOD Calcium-8.1* Phos-3.6# Mg-2.4 ___ 04: 00AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.3 ___ 08: 50AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.3 ___ 06: 35AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.8 ___ 07: 45AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.2 ___ 09: 00AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.5 ___ 07: 30PM BLOOD Calcium-9.4 Phos-3.7 Mg-2.5 ___ 07: 25AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.6 ---- SURGICAL PATHOLOGY REPORT - Final PATHOLOGIC DIAGNOSIS: ___ placenta (508 grams; 50th percentile for 38 weeks gestation): Uremarkable chorionic villi, umbilical cord and fetal membranes. ---- KUB ___: HISTORY: ___ year-old female status post C-section 1 day ago, and multiple prior abdominal surgeries, now with nausea and vomiting. Evaluate for small bowel obstruction. COMPARISON: Radiograph of the abdomen dated ___ and CT of the abdomen pelvis dated ___. FINDINGS: Supine and upright radiographs of the abdomen demonstrate multiple dilated loops of small bowel with multiple air-fluid levels consistent with high-grade small bowel obstruction. There is free air beneath the right hemidiaphragm. There is no pneumatosis. The visualized osseous structures are unremarkable. Multiple chain sutures project over the pelvis and right hemiabdomen. IMPRESSION: 1. Multiple dilated loops of small bowel with multiple air-fluid levels concerning for high-grade small bowel obstruction. 2. Small amount of free air beneath the right hemidiaphragm, which is expected postoperatively. ---- PORTABLE CHEST, ___ COMPARISON: Radiograph ___. Radiograph centered at thoracoabdominal junction was obtained for assessment of a nasogastric tube, which now terminates within the body of the stomach. However, the side port is just above the expected location of the GE junction. Within the imaged portion of the upper abdomen, dilated loops of bowel are present, in keeping with history of high-grade small bowel obstruction, more fully evaluated by dedicated abdominal series of one day earlier. Previously identified post-operative free intraperitoneal air is less apparent, but positional differences may contribute to this change. Within the lungs, patchy and linear opacities in the right juxtahilar and both basilar regions may reflect atelectasis and/or aspiration. <MEDICATIONS ON ADMISSION> Prenatal vitamins <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN Pain max 4000mg tylenol in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth q6 hours Disp #*50 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN Pain take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth q6 hours Disp #*50 Tablet Refills: *1 3. Metoclopramide 10 mg PO Q8H: PRN nausea do not take concurrently with other anti-nausea med. RX *metoclopramide HCl 5 mg 1 by mouth q8 hours Disp #*24 Tablet Refills: *0 4. Ondansetron 4 mg PO Q8H: PRN nausea do not take concurrently with other anti-nausea med. RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth q8 hours Disp #*24 Tablet Refills: *0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain do not drive. RX *oxycodone 5 mg ___ tablet(s) by mouth q4 hours Disp #*50 Tablet Refills: *0 6. Prochlorperazine 10 mg PO Q6H: PRN nausea do not take concurrently with other anti-nausea med. RX *prochlorperazine maleate 5 mg 1 tablet(s) by mouth q8 hours Disp #*24 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy, delivered by cesarean section ulcerative colitis bowel obstruction <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 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
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On ___, Ms. ___ presented to labor and delivery and underwent a primary low transverse cesarean section. Her procedure was uncomplicated. Viable female infant, with a weight of 2845 g and Apgars 9 and 9 at one and five minutes, with clear amniotic fluid. There were no adhesions were observed intra-abdominally. Please see the operative report for full details. Her postpartum course was complicated by a small bowel obstruction. On post-partum day 1, the patient developed nausea and multiple bouts of bilious emesis. She reported normal bowel movements and no flatus at baseline secondary to J pouch. Exam revealed tender and distended abdomen, tympanic, hypoactive bowel sounds. Colorectal surgery was consulted. An abdominal ultrasound was done. She was diagnosed with a high grade small bowel obstruction. She was managed conservatively with NPO, IVF, NGT (placed on post-partum day 1), IV anti-emetics and IV pain medications, with gradual improvement noted in her symptoms and abdominal exam. On post-partum day 4, her NGT was removed and her diet was slowly advanced. She was transitioned to oral pain medications and anti-emetics. By post-partum day 7, she was able to tolerate a regular diet. Her blood counts and electrolytes were monitored closely throughout her post-partum course. Her bandemia of unclear etiology resolved. A C diff culture was negative. She was discharged home on ___, post-partum day ___, in stable condition on a standing PO anti-emetic regimen (zofran, reglan, compazine). She had close outpatient follow-up scheduled.
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11326215-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / animal dander <ATTENDING> ___. <CHIEF COMPLAINT> Metastatic mullerian adenocarcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, optimal cytoreductive surgery including radical abdominal hysterectomy, bilateral salpingo-oophrectomy, omentectomy, splenectomy, partial liver and diaphragm resections, and removal of peritoneal nodules <HISTORY OF PRESENT ILLNESS> ___ is a ___ y/o G6P1 woman with stage IVB adenocarcinoma of mullerian origin with widespread lymphadenopathy and possible bony metastasis to sternum s/p 6 cycles of carbotaxol. She was originally referred to gynecologic oncology for evaluation of new finding of pelvic mass on evaluation for anorexia, weight loss, abdominal pain and bloating. She has noted these symptoms for several months with worsening early satiety and now poor appetite. Reports nausea if tries to eat any more than a few bites. Has lost 20 pounds unintentionally over the past few months. She has also noted worsening fatigue. Mild constipation which is not new for her. For the past several days has noted some increased burping and GERD symptoms. Also has had mid chest sub-sternal pain for 2 months. Reports has had multiple EKGs and workup with PCP has not been concerning for cardiac etiology. She regularly exercises with swimming several times a week and has not noted a decreased ability to do this. On ___, she underwent TAH/BSO, resection of pelvic mass, splenectomy, omentectomy, partial liver resection, partial R diaphragm resection and repair ___ transferred to FICU post-operatively. She was not extubated due to lengthy extensive surgery, but is otherwise hemodynamically stable off pressors. OR course: ~12 hours, EBL ___ ml. Received 5 units pRBCs, 1 unit FFP, 1 bag platelets, 600g albumin, ___ crystalloid. JP drain in place LUQ, epidural in place and running. On arrival to the ICU, she is intubated and sedated REVIEW OF SYSTEMS: - Unable to obtain on arrival <PAST MEDICAL HISTORY> PMH: - Metastatic adenocarcinoma of mullerian origin diagnosed ___ s/p 6 cycles carbotaxol - Hypothyroidism - Allergic asthma - Endometriosis - Migraine headaches - Osteoarthritis (bilateral hips) s/p bilateral THA - Infertility PSH: - ___ R hip THA - ___ L hip THA - ___ R ovarian cystectomy - ___ R endometrioma resection - ___ Benign R breast bx - ___ R endometrioma resection - ___ lap chole->emergent ex-lap for hemorrhage, 4u pRBC - ___ Right ovarian cystectomy, L ovarian endometrioma resection with incidental appy HCM: Last mammogram: ___ Last colonoscopy: none prior Last bone density scan: none prior POBHx: G6P1(1) + one living adopted child SVD 40 week fetal demise SVD term no complications SAB x4, D&C x3 PGYNHx: LMP: ___ Denies PMB. Fibroids: unsure if history of fibroids Cysts: has extensive endometriosis hx, see PSH STIs: reports hx genital warts Sexually active: yes, monogamous with male partner, denies sexual dysfunction Dyspareunia: no Contraception: n/a ___: unknown Last pap: ___ normal, reports remote history of abnormal. recently UTD and normal. <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Denies history of gyn or colon cancer, bleeding or clotting disorder. - Significant for father with CVD, deceased of MI at age ___. - Mother with sick sinus syndrome with pacemaker, spinal stenosis, ___ disease. - Brother with MS. ___ Exam: ICU ADMISSION PHYSICAL EXAM: VITALS: T 98.7, HR 98, BP 130/82, RR 12 O2 100% on PSV ___, FiO2 .50 GENERAL: Intubated and sedated, arousable to voice HEENT: PERRL, anicteric sclera NECK: No JVD appreciated CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi ABDOMEN: Midline incision covered with clean/dry bandage. JP drain in LUQ with serosanguinous discharge. Abdomen soft, non-distended EXTREMITIES: Wwp, no ___ edema PULSES: 2+ DP pulses bilaterally NEURO: Sedated, arousable to voice 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> _______________________ ADMISSION LABS: ___ 06: 40AM BLOOD WBC-2.7*# RBC-2.75*# Hgb-9.4* Hct-29.1*# MCV-106*# MCH-34.2*# MCHC-32.3 RDW-16.9* RDWSD-65.0* Plt ___ ___ 06: 40AM BLOOD ___ PTT-35.9 ___ ___ 08: 50PM BLOOD Glucose-216* UreaN-11 Creat-0.8 Na-138 K-4.6 Cl-103 HCO3-21* AnGap-19 ___ 08: 50PM BLOOD ALT-240* AST-344* AlkPhos-44 TotBili-6.7* ___ 08: 50PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.6 ___ 01: 58PM BLOOD ___ pH-7.32* Intubat-INTUBATED Vent-CONTROLLED ___ 12: 09PM BLOOD Na-135 K-4.4 Cl-105 ___ 12: 09PM BLOOD Hgb-9.5* calcHCT-29 ___ 01: 58PM BLOOD freeCa-1.06* <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ondansetron ___ mg PO Q8H: PRN nausea 2. Prochlorperazine 10 mg PO Q6H: PRN nausea 3. LORazepam 0.5-1 mg PO Q4H: PRN nausea/anxiety/insomnia 4. Multivitamins 1 TAB PO DAILY 5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 6. Cetirizine 10 mg PO DAILY 7. Albuterol Inhaler 2 PUFF IH Q4H: PRN wheezing 8. Sumatriptan Succinate 100 mg PO ONCE: PRN headache 9. Levothyroxine Sodium 100 mcg PO DAILY 10. Cyanocobalamin Dose is Unknown PO DAILY 11. Vitamin D 1000 UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4,000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time Take this medication for a total of 28 days after your surgery, ending on ___. RX *enoxaparin 40 mg/0.4 mL 40 mg sc DAILY Disp #*22 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Take with food or milk. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Do not drink alcohol or drive. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 6. Cyanocobalamin 100 mcg PO DAILY ** dosage unknown ** 7. Albuterol Inhaler 2 PUFF IH Q4H: PRN wheezing 8. Cetirizine 10 mg PO DAILY 9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 10. Levothyroxine Sodium 100 mcg PO DAILY 11. LORazepam 0.5-1 mg PO Q4H: PRN nausea/anxiety/insomnia 12. Multivitamins 1 TAB PO DAILY 13. Ondansetron ___ mg PO Q8H: PRN nausea 14. Prochlorperazine 10 mg PO Q6H: PRN nausea 15. Sumatriptan Succinate 100 mg PO ONCE: PRN headache 16. Vitamin D 1000 UNIT PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> stage IVB adenocarcinoma of Mullerian origin ** final pathology pending ** <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. * Do not put anything in the rectum (suppository, enema, etc) for 6 months, unless advised otherwise by your doctor. . 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
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___ COURSE ___ - ___ Ms. ___ is a ___ y/o G6P1 woman with stage IVB adenocarcinoma of mullerian origin with widespread lymphadenopathy and possible bony metastasis to sternum s/p 6 cycles of carbotaxol who underwent TAH/BSO, resection of pelvic mass, splenectomy, omentectomy, partial liver resection, partial R diaphragm resection and repair ___ transferred to ___ post-operatively still intubated. Please see the operative report for full details. She did not require pressors while in the ICU. Her blood pressures were maintained with crystalloid and colloid products (LR, albumin, and pRBCs). She was successfully extubated ___ AM, and then transferred to the floor. On ___ (post-operative day 1), she was admitted to the gynecologic oncology service. Her pain was controlled with epidural and dilaudid PCA. The prophylactic NG tube she had in place in the ICU was self-discharged on post-operative day 2 and her diet was slowly advanced to clear liquids, which she tolerated well. She had no nausea or vomiting. On post-operative day 4, her diet was further advanced without difficulty. Her epidural was removed and she was transitioned to oral oxycodone, acetaminophen, ibuprofen(pain meds). Her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Her JP drain was output had decreased and was removed without incident. 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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11328899-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Indomethacin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) <ATTENDING> ___ <CHIEF COMPLAINT> Left lower quadrant abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms ___ is ___ year old G5P2 with PMH notable for SLE on hydroxychloroquine and MMF, lupus nephritis (in remission), and h/o of left pyosalpinx (___) presenting with acute LLQ pain since ___. She initially presented to her PCP, who after discussion with patient's primary OB/GYN provider, referred her to triage for expedited work up. Patient reports that her pain is similar to her pain with prior pyosalpinx. Her pain is left sided, sharp and does not improve with Tylenol. Previously, she was afebrile during presentation due to her prior diagnosis and her pyosalpinx was treated with IV antibiotics. Currently patient reports no fevers, chills, cp, sob, n/v. No urinary symptoms. Regarding her prior infection, there was no clear etiology in first occurrence of pyosalpinx; she is monogamous with her husband and does not use a form of birth control. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Possible diagnosis of lupus in ___, positive ___ and positive beta 2 glycoprotein. 2. Recent diagnosis of anemia of HgB 11. 3. Miscarriage x2 (___) 4. Recent diagnosis of atypical migraines and some facial paresthesias and scintillating scotomata. 5. Headaches related to vision impairment that have improved with glasses. Past Surgical History: 1. ___ C-section. 2. ___ D&C. 3. ___ C-section. <SOCIAL HISTORY> ___ <FAMILY HISTORY> The patient does not have a history of rheumatoid arthritis, lupus, Sjogren's disease or scleroderma in her family. Her mother has osteoarthritis and her uncle has diabetes. <PHYSICAL EXAM> On admission: Vitals: T 98.5 HR 67 BP 112/80 RR18 Gen: A&O, tearful but NAD CV: RRR Resp: CTAB Abd: soft, no rebound or guarding, + LLQ pain on deep palpation Spec: normal external genitalia, clear green discharge, able to visualize anterior aspect of cervix but exam limited due to patient discomfort. Pelvic: No cervical motion tenderness. No adnexal masses palpated. pain on deep palpation of left adnexa Ext: calves nontender bilaterally, no c/c/e On discharge: Vitals: 24 HR Data (last updated ___ @ 100) Temp: 98.4 (Tm 98.4), BP: 118/74, HR: 56, RR: 16, O2 sat: 100%, O2 delivery: ra PE: Gen: NAD, resting comfortably in hospital bed. CV: RRR Pulm: LCTAB Abd: nondistended, positive bowel sounds, tender to palpation on LLQ near left cesarean section incision. Ext: BLE nontender, nonedematous <PERTINENT RESULTS> <PERTINENT RESULTS> ___ 05: 30PM BLOOD WBC-4.0 RBC-4.33 Hgb-13.7 Hct-40.7 MCV-94 MCH-31.6 MCHC-33.7 RDW-11.8 RDWSD-40.5 Plt ___ ___ 05: 30PM BLOOD Neuts-43.5 ___ Monos-11.8 Eos-0.5* Baso-0.3 Im ___ AbsNeut-1.74 AbsLymp-1.74 AbsMono-0.47 AbsEos-0.02* AbsBaso-0.01 ___ 01: 04AM BLOOD Glucose-87 UreaN-6 Creat-0.5 Na-139 K-3.7 Cl-105 HCO3-25 AnGap-9* ___ 05: 30PM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-138 K-5.9* Cl-102 HCO3-25 AnGap-11 ___ 05: 30PM BLOOD Calcium-10.0 Phos-3.0 Mg-2.1 ___ 05: 30PM URINE Color-Straw Appear-Clear Sp ___ ___ 05: 30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 05: 30PM URINE UCG-NEGATIVE ___ 05: 09PM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG CT A/P ___ IMPRESSION: No evidence of acute abdominopelvic pathology. Mildly prominent stool content along the colon. Pelvis US ___ IMPRESSION: 1. No evidence of ovarian torsion. 2. Resolved left pyosalpinx or hematosalpinx. 3. Possibility of endometrial polyp based on vascular structure lying within the fundal endometrium or perhaps immediately adjacent. <MEDICATIONS ON ADMISSION> Cellcept Plaquenil <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H Do not exceed 4000mg in a day RX *acetaminophen 500 mg 1 tablet(s) by mouth Q6H PRN Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *1 3. OxyCODONE (Immediate Release) 5 mg PO ONCE Duration: 1 Dose Do not drink alcohol or drive when taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Left lower quadrant abdominal 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 gynecology service for evaluation and pain control for your left sided abdominal pain. We obtained imaging (ultrasound and CT scan) which showed no evidence of infection or other acute gynecologic or gastroenterologic process. At this time, we feel that it is safe for you to be discharged home. Discharge instructions: * Your left lower quadrant abdominal pain may be from a kidney stone although your urinalysis did not note blood in your urine. Please strain your urine for the next several days. * 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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Ms. ___ is a ___ year old G5P2 with a history of systemic lupus erythematous, lupus nephritis (in remission), and history of left sided pyosalpinx (___) who presented on ___ with left lower quadrant abdominal pain. For her left lower quadrant abdominal pain, she had no rebound tenderness or guarding. A pelvic ultrasound returned negative. She received IV dilaudid for pain. A urine hcg was negative. Her labs were normal with no evidence of infection. Her urinalysis was negative. A gonorrhea, chlamydia and trichomonas swab were sent. Urine cultures were sent. Given low concern for ovarian pathology or infectious process, patient was admitted to the gynecology service for pain management. On hospital day 2, ___, patient continued to have left lower quadrant pain which she described as sharp and throbbing. This was relieved by Tylenol and oxycodone. Given the character of the pain, the differential diagnosis was of musculoskeletal origin or possibly related to a small kidney stone (although UA neg, CT A/P wnl). She was thus discharged to home with plan to monitor pain and call back in 2 days if symptoms do not resolve.
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11329631-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Vaginal discharge, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p total abdominal hysterectomy in ___ presents with 4 days of pelvic pain and 1 day of vaginal discharge. She reports she was in her usual state of health until ___ when she developed midline pressure-like pelvic pain radiating to the vagina. The pain was worse in the morning but resolved after a bowel movement. The pain returned in the morning of ___ then but then again resolved spontaneously, often after a bowel movement. Today, however the pain worsened despite a bowel movement and she noticed a wet feeling in her underwear and discovered a ___ cup of green mucous discharge" in her underwear. Since then the pain has completely resolved but she has continued to leak scant yellow-green purulent discharge. She did not feel a "pop" sensation. She denies fevers or chills, N/V, diarrhea. She is not sexually active and denies inserting anything in her vagina. She has had regular well formed bowel movements without blood or mucous. <PAST MEDICAL HISTORY> PMH: - borderline chronic hypertension, never started on antihypertensive medications - stable right kidney cyst followed by Dr ___. First seen in ___ - osteopenia, last DEXA ___ - OA - diverticulosis, no h/o diverticulitis. Diverticulosis first seen on diagnostic laparoscopy in ___ per pt, seen on colonoscopy in ___ PSH: -___ Tonsillectomy and adenoidectomy - ___ Low transverse C-section - ___ repeat low transverse C-section - ___ total abdominal hysterectomy for fibroids at ___ - ___ Laparotomy with left salpingo-oophorectomy for benign cyst - ___ breast biopsy for benign mass - ___ right rotator cuff repair POB/GYN: G2P2, LTCS x 2. open Left salpingo oopherectomy as above. Surgical menopause in ___. Believes went through menopause at age ___. Not sexually active. Denies STIs. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies any family history of uterine, ovarian or breast cancer. Maternal aunt had colon cancer. <PHYSICAL EXAM> On admission: Vital signs: 98.6 °F, Pulse: 115 (s/p 1L IVF), RR: 18, BP: 160/97, O2: 99 GEN: no acute distress, well appearing CV: tachycardia with regular rhythm Resp: Clear to auscultation bilaterally back: no costovertebral angle tenderness Abd: soft, non-distended. Non tender to palpation, no rebound or guarding. No masses. + normal bowel sounds BME: exquisitely tender to palpation along cuff with greatest TTP on L apex of cuff. Cuff feels to be intact but unable to palpate L apex of cuff secondary to patient discomfort speculum exam: speculum inserted and 15cc's of mucopurulent material filled speculum. Unable to open speculum due to patient discomfort and positioning. Cuff culture collected Ext: non-tender On discharge: Afebrile, vital signs stable Gen: No acute distress CV: regular rate and rhythm Pulm: Clear to auscultation bilaterally Abd; soft, nontender, non distended, no rebound/guarding Extr: Nontender/nonedematous <PERTINENT RESULTS> LABS: ___ 05: 56AM BLOOD WBC-5.9 RBC-4.14* Hgb-11.1* Hct-34.1* MCV-82 MCH-26.9* MCHC-32.6 RDW-13.6 Plt ___ ___ 06: 10AM BLOOD WBC-7.5 RBC-4.15* Hgb-10.8* Hct-34.6* MCV-83 MCH-26.0* MCHC-31.2 RDW-14.2 Plt ___ ___ 05: 40PM BLOOD WBC-7.2 RBC-4.25 Hgb-11.0* Hct-35.7* MCV-84 MCH-25.9* MCHC-30.8*# RDW-14.2 Plt ___ ___ 02: 30AM BLOOD WBC-12.0* RBC-4.24 Hgb-11.7* Hct-34.1* MCV-80* MCH-27.7 MCHC-34.4 RDW-13.8 Plt ___ ___ 05: 35PM BLOOD WBC-13.6*# RBC-4.21 Hgb-11.7* Hct-33.8* MCV-80* MCH-27.8 MCHC-34.6 RDW-14.1 Plt ___ ___ 05: 56AM BLOOD Glucose-108* UreaN-10 Creat-0.6 Na-142 K-3.4 Cl-104 HCO3-28 AnGap-13 ___ 06: 10AM BLOOD Glucose-90 UreaN-9 Creat-0.6 Na-142 K-3.9 Cl-104 HCO3-26 AnGap-16 ___ 05: 40PM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-140 K-4.2 Cl-102 HCO3-25 AnGap-17 ___ 02: 30AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-141 K-3.9 Cl-105 HCO3-22 AnGap-18 ___ 05: 35PM BLOOD Glucose-101* UreaN-20 Creat-0.6 Na-139 K-3.8 Cl-99 HCO3-26 AnGap-18 ___ 05: 35PM BLOOD CEA-1.2 CA125-14 ___ 02: 30AM BLOOD TSH-3.5 IMAGING: CT Abd/pelvis ___: ABDOMEN: The lung bases are clear. No pleural or pericardial effusion is seen. The liver, spleen, pancreas, gallbladder, adrenal glands, stomach, and small bowel are within normal limits. A 5-cm right renal hypodensity measures slightly higher density than fluid and most likely represents a hemorrhagic cyst but is incompletely evaluated. Additional bilateral renal hypodensities are too small to characterize. No free intraperitoneal air or ascites is detected. Arterial atherosclerotic calcifications are noted. PELVIS: Extensive sigmoid diverticulosis is present with peisigmoid fascial thickening and mild fat stranding. Loss of fat plane between the sigmoid colon and the vaginal cuff noted with hypodense fluid and gas localized at the vaginal cuff on series 601b, images ___ raising concern for colovaginal fistula. No drainable fluid collection is seen. There is a 4.9 x 4.3 x 3.5 cm right adnexam complex cyst with internal septations. Patient s/p left oophorectomy. The bladder is unremarkable. BONES: No concerning lytic or sclerotic osseous lesions are detected. Degenerative changes are seen in the spine and hips. IMPRESSION: 1. Probable colovaginal fistula, likely the complication of chronic sigmoid diverticulitis. 2. Complex right adnexal cyst measuring 4.9 x 4.3 x 3.5 cm, concerning for ovarian neoplasm. Gynecologic surgical consult is recommended. MRI pelvis ___: There is extensive diverticulosis noted of the long segment of sigmoid colon extending over a distance of approximately 8.8 cm. There is associated circumferential bowel wall thickening, edema, and pericolonic stranding consistent with active diverticulitis. An inflammatory mass measuring approximately 3.5 x 3.9 cm is seen arising from the inferior portion of the mid sigmoid colon with an active fistulous tract seen between this and the cuff of the remaining vagina, (note is made of a previous hysterectomy). Findings are concerning for a colovaginal fistula (series 3, image 18, series 4, image 19, and series 1102, image 53). The remainder of the proximal sigmoid colon demonstrate multiple diverticula. The bladder is intact with no associated bladder wall thickening. There is no MR evidence for ___ fistula. Within the anterior dome of the bladder, a 7-mm cystic lesion is identified which is minimally hyperintense relative to adjacent bladder wall on T1-weighted imaging consistent with some internal proteinaceous content (series 9, image 50) with a urachal cyst remnant. There has been a previous left oophorectomy and salpingectomy. In the right adnexa, a 4.4 x 4.7 x 4.2 cm lesion is identified which is hyperintense relative to adjacent ovarian parenchyma on T2-weighted imaging (series 4, image 13), hypointense on T1-weighted imaging (series 9, image 50), does not demonstrate intravoxel or bulk fat, and demonstrates only mild thin septal and wall enhancement post-contrast (series 1102, image 48). There is no evidence for a thickened irregular wall or solid mural component. Tiny trace of free fluid is noted within the pelvis. There is no pelvic adenopathy. Bone marrow signal is normal. There are no osseous destructive lesions. Subchondral cystic degenerative change noted in relation to both hip joints. IMPRESSION: 1. Colovaginal fistula demonstrated between the mid sigmoid colon and the upper cuff of the remaining vagina (patient is status post hysterectomy in ___ secondary to diverticulitis. 2. Minimally complex 4.4 x 4.7 x 4.2 cm cystic lesion in the right adnexa, likely ovarian in origin. 3. Urachal cyst remnant noted at the dome of the bladder. <DISCHARGE INSTRUCTIONS> Ms. ___, you were admitted for further evaluation of a colovaginal fistula. An MRI and CT scan have confimed this diagnosis as well as diverticulitis and a right ovarian cyst. You will need to take two antibiotics (ciprofloxacin and flagyl) for the next ___ days. Please follow up with Dr. ___ to plan for surgical management of this fistula. You will also follow up in ___ clinic for surgical planning of a right ovarian mass seen on imaging. Please call for an earlier appointment if your surgery date with ___ is before ___. You were also started on medication for your hypertension during this admission. Please continue taking metoprolol as prescribed and follow up with your primary care physician as soon as possible to adjust this regimen as needed. You may take tylenol as needed for your pain (do not exceed 4000mg in 24 hours)
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Ms. ___ was admitted to the GYN service for further evaluation of a possible enterovaginal fistula diagnosed on CT scan in the ED. Due to an elevated WBC and evidence of diverticulitis on imaging, the patient was started on IV ciprofloxacin, flagyl, and ampicillin. She chose to have IV tylenol for pain control. She was made NPO in case she required surgical intervention as well as to minimze PO intake in the setting of acute diverticulitis. She was afebrile throughout her stay. An MRI was performed to further evaluate the fistula as well as a right adnexal mass seen on CT (patient not able to tolerate transvaginal ultrasound due to cuff pain). MRI confirmed a midsigmoid-vaginal fistula as well as a minimally complex 4.4 x 4.7 x 4.2 cm cystic lesion in the right ovary. Colorectal was consulted on admission. The colorectal team recommended outpatient antibiotic therapy for 2 weeks with outpatient followup for surgical planning of fistula repair. She was seen by anesthesia for preoperative testing and was also seen by the ostomy nurse for site marking. On admission, Ms. ___ was noted to be tachycardic, with a heart ranging from 110s-120s. An EKG showed sinus tachycardia but no other abnormalities. A TSH was within normal limits and a hematocrit was stable. She had no evidence of sepsis. Her tachycardia was attributed to both infection and anxiety. Her tachycardia spontaneously resolved to a heart rate in the ___ on discharge. Ms. ___ WBC trended down and was 7.2 on discharge. She was advanced to a regular diet on hospital day#2 which she tolerated well. Ms. ___ admission blood pressures were elvated at a range of 160s-180s/90-100s. She reported a history of hypertension but was not on any medication for this. While NPO, she was given IV metoprolol 5mg BID which adequately controlled her pressures. When advanced to a regular diet, she was transitioned to PO metoprolol 12.5mg BID with adequate, although not idea, blood pressure control. The patient refused further titration of her blood pressure medications and chose to follow up with her PCP for titration of the metoprolol. On discharge her blood pressures mainly ranged 130s-160/80-90s. Ms. ___ will follow up in chief GYN surgery clinic in order to plan a concominant adnexal cyst removal at time of her colorectal surgery. A CA-125 and CEA were within normal limits. Ms. ___ was discharged home in stable condition on hospital day #3 with 2 weeks of PO antibiotics. Discharge Medications: 1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Colovaginal fistula, right adnexal cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11331147-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> -term pregnancy, desires elective repeat cesarean section <MAJOR SURGICAL OR INVASIVE PROCEDURE> - repeat low transverse cesarean section, supracervical hysterectomy, exploratory laparotomy, left salpingoophorectomy, abdominal packing removal, abdominal wall closure and normal cystoscopy. <HISTORY OF PRESENT ILLNESS> On admission to L&D: Patient is a ___ G4___ @ 39+wks with h/o LTCS presents for elective repeat cesarean. Active FM. No LOF, VB, ctxns. Declines TOL, wants rpt LTCS. On Admission to ICU: ___ with h/o postpartum hemorrhage with previous cesarean (hct nadired to 16 on pod#1 and pt received 2u PRBC), who underwent elective repeat low transverse cesarean on ___ which was complicated by atony of her uterine fundus and massive post partum hemorrhage, with labs concerning for DIC. . The pt underwent Csection and had uterine atony which was addressed with multiple different appropriate medications with some response. No oozine of her abdomen was noted at that time, however there was a good amount of bleeding noted under her drapes. EBL during procedure estimated 2L. . She was then transferred to PACU, and her course there was significant for worsening mentation, bleeding from her mouth. BP's in the PACU were noted to be low (unclear exactly how low) and she got some boluses of Neo in PACU and subsequently during ___ trip to OR. She was taken back to the OR where she had 1L of blood in her abdomen. They were unable to find an active bleeder. Trauma, Gyn-Onc were on board at that time, and unable to find any bleeding source in her abdomen either. . Through this, she eventually required 20u PRBC, ___ FFP, 2 cryo, 4 plts, 4L crystalloid, then 500cc colloid. She tamponaded off eventually. Her abdomen was packed with 4 lap pads, 3 blue towels wrapped in Ioban, and a full Kerlex roll; all wrapped in plastic dressing and put to NGT suction, which is draining serosanguinous fluid. Her abdomen is noted to be edematous. She also got 2 doses of Ancef, once pre Csection and intra-op . Through this, her labs have been concerning for DIC: an acute platelet drop from 131 to 49, acute Hct drop from 35.7 to 17.2, coags 18.6 / >150 / 1.7, fibrinogen 141 (<300 in pregnancy is abnml), FDP >1280. Her Ddimer is pending x2, other labs of note include lactate that continues to rise and currently at 6.2. <PAST MEDICAL HISTORY> pnc: 1. Dating: lmp ___, edc ___ 2. Labs: O+, Ab neg, RPR nr, RI, HbsAg neg, HIV neg, GBS positive 3. Normal FFS 4. AMA: declined amnio pobhx: ___ missed AB s/p D&C ___ primary elective LTCS @ 40wks (known 7cm LUS fibroid) -- complicated by uterine atony, requiring uterotonics. s/p 2 units pRBC on pod#1. ___ SAB 7wks pgynhx: reg menses. no abnl paps. no stds. h/o fibroid (largest 3cm in ___ but none noted during pregnancy on ultrasound) pmh/psh: h/o +PPD s/p 6 months INH, D&C, cesarean, h/o transfusion, h/o fibroid (though not noted on recent pregnancy ultrasounds) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Preop <PHYSICAL EXAM> pe: avss Gen: NAD CV: RRR Resp: CTA bilaterally Abd: soft NT gravid EFW by ___ ___ Ext: no c/c/e FHT: 140s Transfer to ICU <PHYSICAL EXAM> Tm: 100.9, Tc: 98.2, BP: 136/90, HR: 106, RR: 16, SO2: 100% GEN: Intubated, sedated female who appears comfortable, no grimacing or bucking the vent. Dried crusted blood around her nostrils NEENT: No JVD RESP: CTAB, no w/c/r/r CV: RRR, no m/r/g, PMI not displaced ABD: Abd with vacuum suction applied to midline open wound but appears c/d/i, draining bloody fluid EXT: No BLE edema noted, no hives noted on BLE's, bilateral hands and feet are cool to touch <PERTINENT RESULTS> ICU Admission Results: . ___ 10: 14AM BLOOD WBC-5.6 RBC-3.75* Hgb-12.1 Hct-35.7* MCV-95 MCH-32.4*# MCHC-34.0 RDW-13.3 Plt ___ ___ 02: 38PM BLOOD ___ PTT->150* ___ ___ 03: 00PM BLOOD FDP->1280* ___ 10: 20PM BLOOD Glucose-138* UreaN-12 Creat-0.7 Na-151* K-2.9* Cl-117* HCO3-22 AnGap-15 ___ 10: 20PM BLOOD LD(LDH)-257* ___ 10: 20PM BLOOD Calcium-8.3* Phos-5.4* Mg-1.0* ___ 06: 34PM BLOOD ___ ___ 04: 35PM BLOOD Type-ART pO2-315* pCO2-42 pH-7.20* calTCO2-17* Base XS--10 Intubat-INTUBATED ___ 04: 35PM BLOOD Glucose-231* Lactate-4.5* Na-139 K-4.9 Cl-106 ___ 04: 35PM BLOOD Hgb-12.0 calcHCT-36 O2 Sat-98 COHgb-1 ICU Discharge Results: ___ 03: 07PM BLOOD Glucose-161* UreaN-12 Creat-0.6 Na-139 K-3.5 Cl-102 HCO3-27 AnGap-14 ___ 04: 45AM BLOOD WBC-11.1* RBC-3.41* Hgb-10.0* Hct-29.0* MCV-85 MCH-29.4 MCHC-34.6 RDW-15.7* Plt ___ ___ 04: 45AM BLOOD ___ PTT-25.6 ___ CTA ___: IMPRESSION: 1. No pulmonary embolism. 2. Stable large bilateral pleural effusions associated with bibasilar atelectasis. 3. Findings suggestive of pulmonary edema. 4. Trace free fluid in perihepatic location. 5. 3-mm lingular nodule, without short interval change. Per ___ guidelines, in the absence of risk factors for intrathoracic malignancy such as smoking, no further followup for this is necessary. Otherwise, a followup chest CT in 12 months is suggested. ECHO ___ left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) with global near akinesis (the basal inferior and lateral segments move best). RV not well seen but appears to have normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. <MEDICATIONS ON ADMISSION> prenatal vitamin <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *30 Tablet(s)* Refills: *2* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 4. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp: *30 Tablet Sustained Release 24 hr(s)* Refills: *2* 5. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* 6. Prenatal Plus ___ mg Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> - s/p repeat cesarean, supracervical hysterectomy for massive postpartum hemorrhage, uterine atony, coagulopathy. - s/p exploratory lapartomy, left salpingoophorectomy. - s/p abdominal packing removal, abdominal wall closure and normal cystoscopy. - s/p 23 units pRBCs, s/p ___ FFP, 4 platelets. - cardiomyopathy (EF ___ <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <DISCHARGE INSTRUCTIONS> see nursing sheets *) Given new diagnose of cardiomyopathy: -please weight yourself once daily, if gain more than 2 lbs in 2 consective days, please call your physician -___ you have shortness of breath with walking or min. activities, or unable to sleep/lay down flat, please call your physician ___: ___
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*Labor and Delivery Course: Ms. ___ was admitted to labor and delivery for a scheduled repeat cesarean. She underwent a repeat low transverse cesarean section on ___ complicated by fundal uterine atony and hemorrhage with an EBL of 2000cc. Uterine tone improved with improved hemostasis achieved after uterine massage and administration of uterotonics. Patient was then transferred to the PACU with plan to transfuse blood there. However, in the PACU the patient was urgently taken back to the operating room due to continued uterine atony and suspected coagulopathy given thrombocytopenia, low fibrinogen and bleeding from the gums. The patient underwent exploratory laparotomy, supracervical hysterectomy, and packing of the abdomen with the assistance of Trauma Surgery and Gyn Oncology. The patient was then transfered to the ICU for further monitoring. Please see details below. *ICU Course: ___ with h/o previous cesarean complicated by post-partum hemorrhage, admitted to ___ s/p repeat cesarean complicated by massive post-partum hemorrhage and evolving DIC picture. . 1. Post-partum hemorrhage: Presented to the FICU after suspicion of DIC given labs and post partum history. The pt underwent cesarean and had uterine atony which was addressed with multiple different appropriate medications with some response. No oozing of her abdomen was noted at that time, however there was a good amount of bleeding noted under her drapes which appeared to respond to uterotonics and massage. EBL during procedure was 2L. . She was then transferred to PACU, and her course there was significant for worsening mentation, bleeding from her mouth. BP's in the PACU were noted to be low. She got some boluses of Neo in the PACU and during ___ trip to OR. She was taken back to the OR where she had 1L of blood in her abdomen. Supracervical hysterectomy was performed (see operative notes for full details); however, still a good amount of ongoing blood loss was noted. There was difficulty in visualizing the source of the ongoing blood loss, thus trauma surgery and gyn onc were consulted. Upper abdomen was found to be intact and no single active bleeding source could be identified. Pelvis in general had several oozing sites. Ultimately, electrosurgery to bleeding peritoneal sites and pelvic pressure was applied. Patient was massively resuscitated thus decision was made to leave the abdomen open with the abdominal packing. . Total requirements during this time were 20u PRBC, ___ FFP, 2 cryo, 4 plts, 4L crystalloid, then 500cc colloid. Her abdomen was packed with 4 lap pads, 3 blue towels wrapped in Ioban, and a full Kerlex roll; all wrapped in plastic dressing and put to NGT suction . Through this, her labs were concerning for DIC: an acute platelet drop from 131 to 49, acute Hct drop from 35.7 to 17.2, coags 18.6 / >150 / 1.7, fibrinogen 141 (<300 in pregnancy is abnml), FDP >1280. Lactate at that time was 6.2. . In the FICU, labs were serially checked. In total she received an additional 3 units of pRBCs and HCT stabilized thereafter. Patient had a large amount of blood draining of her abdominal drains and thus she returned to the OR on pod#1 (___) to ensure no ongoing blood loss. Only small amount of oozing seen from the left adnexal pedicle and left salpingoophorectomy was performed and abdomen was once again repacked but left open. . 2. Abdominal wound: Patient returned to the OR on ___ for nearly complete abdominal wound closure with staples. Also underwent normal cystoscopy at this same time. Wound was packed twice daily. Patient was placed on Amp/Gent/Clindamycin originally after first surgery. Abx's were discontinued, but by ___ Ob/Gyn requested Abx's again with Vanc/Zosyn for broad coverage of possible abdominal/GU infection. Extubated on ___ without complications. Patient had a few LGF's, but was afebrile for >36hrs at time of DC from ICU. Had low white count, but went from 7 to 11 by ICU #4. Differential originally had 10% bandemia, but by ICU day#4 no bands, only 90%PMN's. Continued to treat broadly, as had SIRS criteria with tachycardia and sporadic fevers. Pain control with Hydromorphone 0.5-1.0. . 3. Tachycardia/Tachypnea: As above. Extubated after ___ surgery. Had tachycardia for several days prior to extubation, and after extubation found to have tachycardia and tachypnea. Had chest xray which showed significant pleural effusions, as patient was +>12L for length of stay. Diuresed with 2 doses of 20mg IV lasix, with about 4 Liter output. Tachycardia modestly improved. Would continue to check fluid status and diurese, as patient was >10 L positive by ICU #4. With tachycardia, concern for PE or ACS. Had CTAP which was negative for PE. Had EKG which was not consisten with STEMI/Ischemic changed. Had cardiac enzymes performed which were CK-MB 8.0, and troponin 0.15 with follow up CK-MB 6.0 and troponin 0.12. Elevated troponins thought to be due to strain in presence of persistent tachycardia, but recommend stress test to ID risk of ACS. . *Postpartum Course: Ms. ___ was transfered to the post-partum floor in stable condition on ___. Postpartum issues included: *) Cardiomyopathy - the pt was persistently tachycardic on the postpartum floor. She underwent a second CTA which was negative for pulmonary embolism but did show persistent bilateral pleural effusions, pulmonary edema and atelectasis. Cardiology was consulted and the pt underwent an echocardiogram on ___ which showed cardiomyopathy with a left ventricular ejection fraction of ___. The patient was started on Metoprolol, Lasix and Lisinopril. Cardiology continued to follow her throughout her stay and she will follow up as an outpatient with Dr. ___ ___ cardiology. *) Pulm: the patient had a persistent oxygen requirement and was found to have pulmonary edema on imaging. Her CTA was negative for PE. She received lasix and her O2 sats improved with diuresis. Her oxygen requirement resolved and she was discharged home with good O2 saturation on room air and no pulmonary symptoms. . *) Anemia: acute blood loss anemia and DIC. The patient received large amounts of blood products as documented above, however, her coagulation labs normalized and on the postpartum floor her Hct was stable. . *) Wound: the patient underwent wound closure on ___ (a portion of the incision at the trisection point between vertical and horizontal incisions was left open and packed). Post-operatively, an additional limited section of the wound was opened and the patient had dressing changes twice a day. The patient was evaluated by the wound care service. The wound did not show any sign of infection. The patient was discharged home with ___ services. . *) ID:the patient received vancomycin and zosyn for 72h afebrile and did not show further signs of infection (abx initiated in the ICU for rise in WBC, bandemia, fevers). . *) FEN/GI: the patient's diet was advanced and she was discharged home eating a regular diet. She was seen by nutrition and encouraged to eat a diet rich in protein as her albumin was found to be low at 2.5. The patient's electrolytes were monitored daily once she started on Lasix and were repleted as needed. She will follow up in approximately 1 week after discharge for lab work/electrolyte monitoring. The patient was discharged home on postoperative day #11 from her cesarean and hysterectomy and post-operative day #9 from her wound closure in stable condition, pain well controlled on oral meds, ambulating, voiding spontaneously, and eating a regular diet with follow up appointments scheduled.
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11331335-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ultram <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 2, para 2, whose last menstrual period was on ___, who has a long history of symptomatic uterine fibroids. Her last imaging study was on ___, when she underwent an MRI of her pelvis in order to be evaluated for possible uterine fibroid embolization. The MRI of her pelvis showed multiple intramural and subserosal fibroids. The largest intramural fibroid was identified posteriorly in the uterine fundus and measured 3.9 x 4.1 cm and in the lower uterine body on the left side there was a fibroid that measured 3.1 x 3.2 cm. There were also a few subserosal fibroids, the largest measuring 1.6 x 1.5 cm arising from the anterior portion of the fundus at the uterus. These fibroids were all hypointense, relative to the uterine myometrium with the larger fibroids hypo-enhancing relative to the uterine myometrium. There was a possibility of 4 mm submucosal fibroid identified too. The ovaries were visualized bilaterally with normal dominant physiologic follicles. Endometrial biopsy was performed on ___, and showed secretory endometrium, day 24. The patient's last Pap was on ___, negative for dysplasia or malignancy. The patient presents today to discuss uterine fibroid management. <PAST MEDICAL HISTORY> OB-GYN HISTORY: Menarche uncertain. She bleeds monthly, often with increased bleeding during her period. She has been ingesting iron-rich foods. Her last hematocrit was on ___, and was nearly 42%. She denies sexual activity at present, she prefers men. She has had two full-term cesarean deliveries. She denies any history of abnormal Pap smears or sexually transmitted infections. Of note, she is status post right mastectomy with reconstruction in ___, she declined postoperative tamoxifen. PAST MEDICAL HISTORY: Hypertension, anxiety, depression, history of positive PPD in the past with negative chest x-rays, trochanteric bursitis, hemorrhoids, as above history of right breast cancer, symptomatic uterine fibroids. OPERATIVE HISTORY: ___ appendectomy; cesarean deliveries at term x 2 ; ___ right mastectomy with reconstruction, hysteroscopic myomectomy (pedunculated fibroid into the cavity). <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for any female cancers. <PHYSICAL EXAM> INITIAL (PRE-OP) PHYSICAL EXAMINATION: GENERAL: This is a well-developed, well-nourished woman in no apparent distress. VITAL SIGNS: Blood pressure 118/80, weight 152. HEENT: Normocephalic, atraumatic. NECK: Supple, without increased thyroid, without lymphadenopathy. BREASTS: Left breast, without masses or tenderness, or nipple discharge. Right breast, again the patient is status post mastectomy with reconstruction. She is concerned that the nipple has retracted. ABDOMEN: Soft, nondistended, nontender. There was a palpable mass approximately 2 fingerbreadths below the umbilicus consistent with an irregularly contoured fibroid uterus. PELVIC: Normal female external genitalia. Bartholin, urethral, and Skene's glands were normal. The vaginal vault had a normal-appearing discharge, there were no lesions. The cervix was without cervical motion tenderness, and no lesions. Uterus approximately 14 to 16 cm in maximum vertical dimension; mobile, firm, and nontender. Adnexa, impossible to evaluate secondary to this large pelvic abdominal mass. DISCHARGE PHYSICAL EXAM VSS and wnl General: NAD, comfortable CV: RRR Lungs: CTAB Abd: soft, non-tender, non-distended Incision: c/d/i GU: vaginal bleeding c/w menses Ext: no edema, no tenderness, no erythema <PERTINENT RESULTS> ___: 00AM BLOOD WBC-7.0# RBC-2.26*# Hgb-6.8*# Hct-21.3*# MCV-95 MCH-30.1 MCHC-31.8 RDW-14.9 Plt ___ <MEDICATIONS ON ADMISSION> amlodipine 5', lorazepam ___ HS, gabapentin 100-200 HS, ibuprofen 800''' prn, percocet''' prn, lidoderm 7% to low back, melatonin 3 HS, miralax', senna'' prn, loratadine 10', fish oil <DISCHARGE MEDICATIONS> 1. Amlodipine 5 mg PO DAILY 2. Gabapentin 200 mg PO HS 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 4. Lidocaine 5% Patch 1 PTCH TD DAILY 5. Lorazepam 0.5-1 mg PO Q8H: PRN anxiety 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not drive on this medication. Do not take more than 12 pills in 24 hr. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 7. Docusate Sodium 100 mg PO BID Take to prevent constipation while taking narcotics. Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 8. Ferrous Sulfate 325 mg PO TID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills: *1 9. Senna 1 TAB PO BID: PRN constipation <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic uterine fibroids blood loss anemia <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 undergoing the procedures listed below. Your blood count was low, but you did not want a blood transfusion and received IV iron instead. You have recovered well and the team feels you are safe for discharge home. 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 >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 abdominal myomectomy. Please see the operative report for full details. Immediately post-op, her pain was controlled with a Dilaudid PCA and IV acetaminophen. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO percocet and motrin. Her home medications were restarted. Her post-operative course was complicated by tachycardia. On post-operative day 1, she was noted to have a HR to 124 when standing and patient was complaining of lightheadedness and dizziness. Orthostatics were negative by blood pressure. Repeat CBC was obtained with hematocrit 21.3 down from pre-operative hematocrit (___) 38.5. Exam was benign, although patient was having heavy menses consistent with her usual menses. Given acute blood loss anemia, patient was offered transfusion, which she declined. Patient was offered transfusion on numerous occasions, all of which she declined. She ultimately was accepting of an iron transfusion, which was given on post-operative day 1. Tachycardia improved without further intervention and patient's symptoms also improved. 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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11331400-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> small bowel obstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ s/p ex-lap, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy, and tumor debulking on ___ followed by pelvic radiation for grade 1 endometrioid adenocarcinoma. Her postoperative course has been complicated by a multiple episode of adhesive partial small bowel obstructions all successfully managed with conservative treatment. No surgery required. She was transferred from ___ after presenting with abdominal pain, nausea and vomiting concerning for a repeat small bowel obstruction. Patient states that starting on ___ she began feeling significant abdominal pain, cramping, and bloating that was followed by approximately 12 episodes of emesis. The pain is similar to the pain she typically feels with her obstructions. She was driving to ___ but instead presented to ___ because she felt she was too ill to travel to ___. Upon arrival at ___, she was mildly tachycardic but she was afebrile, hemodynamically stable, normotensive, with normal arterial oxygenation. On exam she was moderately distended with generalized tenderness. She continued to have emesis at ___ where an NGT was placed. Labs were done that were significant for a leukocytosis of 12,000 with a left shift and hematocrit of 40. A CT scan was done that showed the presence of a high-grade, small bowel obstruction with possible fecalization of the small bowel and transition zone down in the pelvis. There was no evidence of pneumatosis intestinalis or other secondary signs of strangulation or obstruction. She reports a normal bowel movement on ___. She is passing a little flatus, one time at ___ and 2x since arriving to ___. There has been approximately 70cc output from the NGT. She denies any fevers or chills, constipation or diarrhea, abdominal pain, dysuria or hematuria, abnormal vaginal bleeding or unusual vaginal discharge. ROS: 10 point review of systems is otherwise negative except as mentioned above <PAST MEDICAL HISTORY> Oncologic history: - ___: found to have large pelvic mass with pain. - ___: CA-125 drawn there was 4832 - ___: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy and tumor debulking with no gross residual disease. grade 1 endometrioid adenocarcinoma. Required 2 units PRBC. - ___: Completed pelvic radiation therapy - ___: Hospitalized for small bowel obstruction, ACS service, managed conservatively with NGT/IVF/NPO. CA-125 3.6. - ___: Hospitalized for small bowel obstruction, GYN ONC service, managed conservatively. CA-125 3.8. - ___: MR enterography was done which was normal - ___: CA-125 3.1. - ___: SBO, managed conservatively, followed by Dr. ___ ___: - G0 - Menopause age ___ PMH: - H/O SBO x 3, ___ managed conservatively, likely secondary to pelvic adhesions and radiation therapy. - MVP - osteopenia - hyperlipidemia - Denies h/o HTN, DM and thromboembolic disorder PSH: - TAH, BSO, PLND, omentectomy and debulking, ___, as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian, endometrial and colon cancers. <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, no rebound/guarding ___: nontender, nonedematous <MEDICATIONS ON ADMISSION> atorvastatin, aspirin, Vitamin D3, calcium carbonate <DISCHARGE MEDICATIONS> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> small bowel obstruction <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service for a small bowel obstruction. You have recovered well and the team feels that you are safe to be discharged home. Please follow these instructions: . Please make sure to eat small meals and focus on soft foods that are easy to digest. Stay hydrated . 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 transferred from ___ ___ and admitted to the Gynecologic Oncology service for a small bowel obstruction. She had an NGT placed at the outside hospital, which was kept in place and she was maintained on IV fluids and kept NPO. Abdominal x-ray demonstrated no evidence of small bowel obstruction, with NGT ending just below the GE junction. On hospital day 1 her NGT output had decreased, so it was clamped. She had no symptoms of nausea or vomiting during this clamp trial, so her diet was advanced to sips. On hospital day 2, she had some dry heaving and nausea, so her diet was backed down to NPO. Her NGT was advanced to assure that it was in the correct position, which was confirmed with Xray showing NGT ending at in the distal stomach. For her pain, she was given IV tylenol, dilaudid and ativan and for her nausea she was given IV zofran. Her electrolytes were drawn daily and repleted as necessary. During her admission, Colorectal surgery was consulted and provided recommendations. On hospital day 3, her NGT was clamped and her diet was advanced to clear liquids. Her symptoms improved and she had no nausea or vomiting. On hospital day 4, she continued to improve and her NGT was removed. By hospital day 4, she was tolerating a regular diet and she had clinically improved. She was discharged home in stable condition with outpatient follow-up as scheduled.
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11331400-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> small bowel obstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ s/p ex-lap, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy, and tumor debulking on ___ followed by pelvic radiation for grade IIB endometrioid adenocarcinoma of the ovary. Her postoperative course has been complicated by a multiple episodes of adhesive partial small bowel obstructions all successfully managed with conservative treatment without surgery. She was transferred from ___ after presenting with epigastric abdominal pain, nausea and vomiting starting ___ ___ concerning for a repeat small bowel obstruction. The pain is similar to the pain she typically feels with her obstructions. It was constant, more in epigastric region and initially ___. She continued to have emesis at ___. She was treated with IVF and morphine with significant improvement in abd pain. She had CT which showed: 1. High-grade small bowel obstruction with transition point in the pelvis. There is associated fat stranding and small volume free fluid. 2. Diverticulosis. Labs were done with wbc 9.4, HCT 36.4 , chemistry wnl. She reports a normal bowel movement on ___. She is passing a little flatus. She denies any fevers or chills, constipation or diarrhea, dysuria or hematuria, abnormal vaginal bleeding or unusual vaginal discharge. Currently with mild epigastric pain and comfortable. No current nausea or emesis. <PAST MEDICAL HISTORY> Oncologic history: - ___: found to have large pelvic mass with pain. - ___: CA-125 drawn there was 4832 - ___: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy and tumor debulking with no gross residual disease. grade IIB endometrioid adenocarcinoma of the ovary. Required 2 units PRBC. - ___: Completed pelvic radiation therapy - ___: Hospitalized for small bowel obstruction, ACS service, managed conservatively with NGT/IVF/NPO. CA-125 3.6. - ___: Hospitalized for small bowel obstruction, GYN ONC service, managed conservatively. CA-125 3.8. - ___: MR enterography was done which was normal - ___: CA-125 3.1. - ___: SBO, managed conservatively, followed by Dr. ___ - ___: SBO, managed conservatively POB/GYNH: - G0 - Menopause age ___ PMH: - H/O SBO x 3, ___ managed conservatively, likely secondary to pelvic adhesions and radiation therapy. - MVP - osteopenia - hyperlipidemia PSH: - TAH, BSO, PLND, omentectomy and debulking, ___, as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian, endometrial and colon cancers. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, non tender, nondistended, normoactive bowel sounds, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 08: 17AM BLOOD WBC-7.0 RBC-3.85* Hgb-12.4 Hct-37.9 MCV-98 MCH-32.2* MCHC-32.7 RDW-13.1 RDWSD-47.4* Plt ___ ___ 06: 15AM BLOOD WBC-7.5 RBC-3.40* Hgb-10.8* Hct-33.5* MCV-99* MCH-31.8 MCHC-32.2 RDW-13.2 RDWSD-47.4* Plt ___ ___ 07: 25AM BLOOD WBC-8.5 RBC-3.48* Hgb-11.3 Hct-33.9* MCV-97 MCH-32.5* MCHC-33.3 RDW-13.2 RDWSD-47.5* Plt ___ ___ 07: 32AM BLOOD WBC-10.5* RBC-3.48* Hgb-11.2 Hct-34.3 MCV-99* MCH-32.2* MCHC-32.7 RDW-13.2 RDWSD-47.1* Plt ___ ___ 04: 50AM BLOOD WBC-11.6*# RBC-4.17 Hgb-13.2 Hct-40.6 MCV-97 MCH-31.7 MCHC-32.5 RDW-12.9 RDWSD-46.2 Plt ___ ___ 08: 17AM BLOOD Neuts-73.2* Lymphs-12.7* Monos-9.4 Eos-3.6 Baso-0.7 Im ___ AbsNeut-5.09 AbsLymp-0.88* AbsMono-0.65 AbsEos-0.25 AbsBaso-0.05 ___ 06: 15AM BLOOD Neuts-73.2* Lymphs-12.1* Monos-11.9 Eos-2.1 Baso-0.4 Im ___ AbsNeut-5.49 AbsLymp-0.91* AbsMono-0.89* AbsEos-0.16 AbsBaso-0.03 ___ 07: 25AM BLOOD Neuts-78.2* Lymphs-9.8* Monos-10.3 Eos-1.1 Baso-0.2 Im ___ AbsNeut-6.61* AbsLymp-0.83* AbsMono-0.87* AbsEos-0.09 AbsBaso-0.02 ___ 04: 50AM BLOOD Neuts-90.6* Lymphs-4.0* Monos-4.6* Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.53* AbsLymp-0.46* AbsMono-0.54 AbsEos-0.01* AbsBaso-0.04 ___ 08: 17AM BLOOD Glucose-106* UreaN-5* Creat-0.7 Na-137 K-4.4 Cl-98 HCO3-25 AnGap-18 ___ 06: 15AM BLOOD Glucose-123* UreaN-3* Creat-0.6 Na-141 K-4.0 Cl-106 HCO3-23 AnGap-16 ___ 07: 25AM BLOOD Glucose-115* UreaN-4* Creat-0.6 Na-141 K-3.8 Cl-106 HCO3-26 AnGap-13 ___ 07: 32AM BLOOD Glucose-150* UreaN-7 Creat-0.6 Na-133 K-4.0 Cl-104 HCO3-22 AnGap-11 ___ 04: 50AM BLOOD Glucose-172* UreaN-15 Creat-0.8 Na-136 K-4.8 Cl-102 HCO3-20* AnGap-19 ___ 04: 00PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 04: 50AM BLOOD cTropnT-<0.01 ___ 01: 20AM BLOOD cTropnT-<0.01 ___ 08: 17AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.2 ___ 06: 15AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.3 ___ 07: 25AM BLOOD Calcium-7.8* Phos-2.1* Mg-2.3 ___ 07: 32AM BLOOD Calcium-7.4* Phos-1.6* Mg-1.8 ___ 04: 54AM BLOOD Lactate-1.5 <MEDICATIONS ON ADMISSION> - atorvastatin - APAP prn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> small bowel obstruction <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service with a small bowel obstruction. Your symptoms improved with placement of a NG tube and with backing down on your diet. Your diet was gradually advanced, which you tolerated well, and the team feels that you are safe to be discharged home. Please follow these instructions: . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ is a ___ y/o s/p exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy, and tumor debulking on ___ and s/p pelvic radiation for grade IIB endometrioid adenocarcinoma of the ovary with history of multiple small bowel obstructions, who was admitted for management of a small bowel obstruction. Her CT abdomen and pelvis from ___ was notable for a high grade small bowel obstruction with a transition point in the pelvis. She was made NPO and kept on IV fluids. She had a NG tube placed in the emergency department. She was still reporting nausea on ___, and had had some episodes of dry heaving in the days prior, so a CT scan of her abdomen was repeated and found to be notable for an improved partial small bowel obstruction. Her NG tube was discontinued on ___ after a clamp trial showed no residual, and her diet was gradually advanced, which she tolerated well. In the emergency department, she was noted on EKG to have some T wave flattening in V4-V6 compared to her EKG 1 week ago. She was asymptomatic, but troponins were trended x3 and were negative. She was monitored on telemetry without any evidence of cardiac dysfunction. Repeat EKG on ___ was evaluated by cardiology and found to be reassuring, so telemetry was discontinued. She developed some upper respiratory congestion on ___, which was improved with albuterol nebulizer treatments. Chest XR showed mild pleural effusions, but stability from her ED CXR. She was saturating well on RA throughout this time. She had a CT chest on ___ which was negative for pulmonary embolism and also negative for any acute pulmonary pathology that could be contributing to her symptoms. By ___, symptoms improved. She received heparin for DVT prophylaxis as well as a H2 blocker while she was NPO. By ___, she was tolerating a regular diet without nausea or vomiting. She was also passing flatus. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11331400-DS-6
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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, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy, tumor debulking, washings Blood transfusion <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G0 who presented to the ED at ___ ___ with complaints of severe abdominal pain, nausea and vomiting on ___. CT scan revealed a 9.3 cm pelvic mass with heterogeneous enhancement posterior to the uterus. Also noted were abdominal ascites, bowel wall thickening, and bilateral small pleural effusions. Subsequent CA-125 drawn there was 4832 on ___. The patient denies a history of previous abdominal pain, bloating, bleeding, discharge, GI symptoms and urinary symptoms. She notes a ___ pound weight loss over one month. <PAST MEDICAL HISTORY> PMH: MVP, osteopenia, hyperlipidemia. Denies h/o HTN, DM and thromboembolic disorder. PSH: Denies. OB: G0. GYN: Menarche age ___, menopause age ___, regular cycles, bleeding x4 days. Previous history of asymptomatic fibroids. H/O ovarian cyst in ___ that resembled a 3 cm endometrioma. Follow up showed a decrease in size, and she has had no further follow up. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian, endometrial and colon cancers. <PHYSICAL EXAM> On admission: A&Ox3 NAD Abd soft, NT, ND Extrem nontender, no edema Pelvic exam reveals normal external genitalia. The vaginal walls are smooth, and the cervix is normal appearing. Manual exam reveals a mobile, nontender uterus and no CMT. Pelvic mass palpable posterior to the uterus. Rectovaginal exam confirms the mass is present in the cul-de-sac. There is no nodularity. <MEDICATIONS ON ADMISSION> ___ 600 mg PO BID <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 2. Gemfibrozil 600 mg PO BID 3. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *2 4. HYDROmorphone (Dilaudid) 2 mg PO Q3H: PRN Pain RX *hydromorphone 2 mg 1 tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 5. Lorazepam 0.5 mg PO Q4H: PRN nausea RX *lorazepam 0.5 mg 1 tablet by mouth every 4 hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ovarian cancer, final pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 12 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. * 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 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 gyn oncology service post-operatively. Please see operative note for full details of her procedure. An epidural was placed for pain control pre-operatively and removed on post-op day 2. She received two units of packed red blood cells in the operating room as the pelvic mass was quite friable. Her hematocrit was stable post-operatively and she did not require further transfusion. Her diet was advanced slowly as she had some persistent nausea. She did overall well and was discharged home on post-op day 6.
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11331400-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Nausea, vomiting, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year old with hx of stage IIC endometrioid type ovarian cancer versus multifocal endometrioid adenocarcinoma arising from endometriosis s/p TAH, BSO, pelvic lymphadenectomy and tumor debulking in ___ followed by pelvic radiation who is currently hospitalized for a small bowel obstruction. . She woke up with nausea, vomiting and abdominal pain on ___ and presented to an OSH where CT scan was suspicious for SBO. She was then transferred to ___ and admitted to general surgery. She reports feeling well up until ___. She had been tolerating a regular diet and denies feeling bloated. She was previously having daily bowel movements and denies recent weight changes. <PAST MEDICAL HISTORY> Oncologic history: - ___: found to have large pelvic mass with pain. - ___: CA-125 drawn there was 4832 - ___: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy and tumor debulking with no gross residual disease. Required 2 units PRBC. - ___: Completed pelvid radiation therapy . POB/GYNH: - G0 - Menopause age ___ . PMH: MVP, osteopenia, hyperlipidemia. Denies h/o HTN, DM and thromboembolic disorder . PSURGH: - TAH, BSO, PLND, omentectomy and debulking, as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian, endometrial and colon cancers. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, non tender, nondistended ___: nontender, nonedematous <PERTINENT RESULTS> ADMISSION LABS: ___ 01: 01PM BLOOD WBC-12.9*# RBC-3.88* Hgb-12.2 Hct-36.3 MCV-94 MCH-31.4 MCHC-33.5 RDW-13.5 Plt ___ ___ 01: 01PM BLOOD Neuts-92.1* Lymphs-2.0* Monos-5.3 Eos-0.6 Baso-0.1 ___ 01: 01PM BLOOD ___ PTT-30.2 ___ ___ 01: 01PM BLOOD Glucose-117* UreaN-28* Creat-0.8 Na-140 K-3.4 Cl-106 HCO3-18* AnGap-19 ___ 01: 01PM BLOOD ALT-14 AST-27 AlkPhos-86 TotBili-0.5 ___ 01: 01PM BLOOD Lipase-27 ___ 01: 01PM BLOOD Albumin-4.2 Calcium-8.1* Phos-2.8 Mg-1.8 ___ 01: 07PM BLOOD Lactate-1.2 ----- ___ 07: 30AM BLOOD CA125-3.6 ----- DISCHARGE LABS: ___ 07: 05AM BLOOD WBC-3.5* RBC-3.35* Hgb-10.7* Hct-31.9* MCV-95 MCH-32.0 MCHC-33.5 RDW-13.2 Plt ___ ___ 07: 05AM BLOOD Neuts-56.9 ___ Monos-9.7 Eos-7.9* Baso-0.6 ___ 07: 05AM BLOOD Glucose-102* UreaN-7 Creat-0.8 Na-143 K-4.5 Cl-109* HCO3-24 AnGap-15 ___ 07: 05AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.1 <MEDICATIONS ON ADMISSION> Aspirin 81', calcium 600-400', VitD3 1000', MVI <DISCHARGE MEDICATIONS> No change to home medications, no new medications. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Small bowel obstruction <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service for a small bowel obstruction. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: * You should eat a simple diet and continue to drink a lot of fluids. * Call the office with any concerning symptoms, such as nausea, vomiting, or abdominal pain. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was initially admitted to the Acute Care Surgery after being transferred from an outside hospital. She was then transferred to the Gynecologic Oncology service for treatment of a small bowel obstruction. . She had a nasogastric tube placed by the ___ team and was made NPO on admission. Her nausea was controlled with IV zofran and her pain was controlled with IV toradol and one dose of IV morphine. Her NGT was removed on hospital day 4 and her diet was slowly advanced without difficulty. . By hospital day 6, she was tolerating a regular diet and her nausea and abdominal pain had resolved. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11331400-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> small bowel obstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> nasogastric tube <HISTORY OF PRESENT ILLNESS> ___ year old with hx of stage IIC endometrioid type ovarian cancer versus multifocal endometrioid adenocarcinoma arising from endometriosis s/p TAH, BSO, pelvic lymphadenectomy and tumor debulking in ___ followed by pelvic radiation who presents to the ED with abdominal pain. Patient reports several hours of gradually increasing severe crampy abdominal pain and nausea and vomiting after eating lunch today. No bowel movement since yesterday. Still having flatus. Denies fevers or chills. No chest pain or shortness of breath. In the ED, she underwent KUB consistent with small bowel obstruction. An NGT was placed and symptoms improved. She then underwent CT abdomen/pelvic with oral contrast. Read is pending. Patient was recently admitted in ___ for small bowel obstruction and reports that her symptoms are identical to this prior episode. Her CA-125 was 3.6 at that time. There was no evidence of disease recurrence and obstruction was thought likely due to pelvic adhesions and radiation treatment. Oncologic history: - ___: found to have large pelvic mass with pain. - ___: CA-125 drawn there was 4832 - ___: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy and tumor debulking with no gross residual disease. Required 2 units PRBC. - ___: Completed pelvic radiation therapy <PAST MEDICAL HISTORY> Oncologic history: - ___: found to have large pelvic mass with pain. - ___: CA-125 drawn there was 4832 - ___: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy and tumor debulking with no gross residual disease. Required 2 units PRBC. - ___: Completed pelvid radiation therapy . POB/GYNH: - G0 - Menopause age ___ . PMH: MVP, osteopenia, hyperlipidemia. Denies h/o HTN, DM and thromboembolic disorder . PSURGH: - TAH, BSO, PLND, omentectomy and debulking, as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian, endometrial and colon cancers. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, mildly tender, nondistended, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 09: 00AM GLUCOSE-162* UREA N-19 CREAT-0.8 SODIUM-144 POTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-24 ANION GAP-13 ___ 09: 00AM CALCIUM-8.0* PHOSPHATE-3.8 MAGNESIUM-1.8 ___ 09: 00AM CA125-3.8 ___ 09: 00AM WBC-9.2 RBC-3.99* HGB-12.3 HCT-37.3 MCV-93 MCH-30.9 MCHC-33.1 RDW-13.8 ___ 09: 00AM PLT COUNT-244 ___ 04: 55AM GLUCOSE-150* UREA N-21* CREAT-0.9 SODIUM-143 POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-19* ANION GAP-21* ___ 04: 55AM ALT(SGPT)-11 AST(SGOT)-21 ALK PHOS-55 TOT BILI-0.6 ___ 04: 55AM LIPASE-36 ___ 04: 55AM cTropnT-<0.01 ___ 04: 55AM ALBUMIN-4.0 ___ 04: 55AM WBC-14.0*# RBC-4.13* HGB-12.9 HCT-38.7 MCV-94 MCH-31.3 MCHC-33.4 RDW-13.4 ___ 04: 55AM NEUTS-90.3* LYMPHS-3.1* MONOS-5.0 EOS-1.4 BASOS-0.3 ___ 04: 55AM PLT COUNT- ___ KUB: Mild distention of small bowel, measuring up to 4.4 cm with air-fluid levels is concerning for a small bowel obstruction. A CT is recommended for further evaluation. ___ CT Abdomen/Pelvis: IMPRESSION: 1. Small bowel obstruction, with dilated loops of bowel measuring up to 3.6 cm, and a transition point in the mid right pelvis. There is a small amount of ascites. This is likely secondary to adhesions from patient's surgery or radiation therapy. 2. No definite evidence of recurrence of the patient's malignancy, however recommend correlation with CA 125 levels <MEDICATIONS ON ADMISSION> Aspirin 81', calcium 600-400', VitD3 1000', MVI <DISCHARGE MEDICATIONS> 1. Ibuprofen 400 mg PO Q8H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills: *1 2. Acetaminophen 325-650 mg PO Q6H: PRN pain do not exceed 4g in 24 hours RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> small bowel obstruction <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after presenting with likely small bowel obstruction. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * You may eat a regular diet. * It is safe to walk up stairs. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is G0 with h/o stage IIC versus multifocal endometrioid type ovarian adenocarcinoma s/p optimal debulking ___ who was admitted to the gynecologic oncology service after presenting to the ___ ED with abdomnial pain. She was found to have small bowel obstruction which was thought to be likely related to adhesions and radiation. She was made NPO, had an NGT placed and had maintenance IV fluids. She was given IV zofran as needed and written for PPI. Her pain was controlled with toradol On HD#1, her NGT was removed which had 10cc of output since placement. Her pain improved and she did not require any pain meds. Her CA-125 was 3.8. On HD#2, she was advanced to regular diet which she tolerated well. By time of discharge, she was tolerating a regular diet and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up to be scheduled. Plan is to have outpatient MR enterography.
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11331400-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Recurrent small bowel obstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> Nasogastric tube/IVF <HISTORY OF PRESENT ILLNESS> ___ year old with hx of stage IIC endometrioid type ovarian cancer versus multifocal endometrioid adenocarcinoma arising from endometriosis s/p TAH, BSO, pelvic lymphadenectomy and tumor debulking in ___ followed by pelvic radiation completed in ___, complicated by recurrent SBO managed conservatively in ___ and ___, who presents to the ED with acute onset of abdominal pain, nausea and emesis. She was last admitted ___ for SBO. She has been followed closely with outpatient visits and CA-125 levels and was last seen in ___ with no evidence of disease recurrence and a CA-125 level of 3.1. Patient reports onset of mild abdominal pain and cramping at midnight last night. Subsequently awoke at 0300 with more acute pain and nausea and emesis. Has vomited >10 times over past 4 hours, also with lots of dry heaving. Was having flatus up to midnight and had a small bowel movement around 0400 today. Prior to going to bed last night, was generally feeling well with no complaints. She reports that today's symptoms are prior to her prior episodes of SBO. Denies recent travel, ingestion of new or abnormal foods, sick contacts. Denies hematemesis, melena, or hematochezia. Denies chest pain, shortness of breath, diaphoresis, palpitations. ROS also negative for fevers, chills, sweats, abdominal or pelvic pain (prior to last night), pelvic pressure of fullness, weight changes, change in abdominal girth, vaginal bleeding, abnormal discharge. Sexually active with vaginal dryness but denies dyspareunia. In the ED, she underwent KUB that showed a few dilated loops of small bowel with air-fluid levels, concerning for small bowel obstruction. She was given 8mg IV Zofran and 10mg IV Morphine. An NGT was placed; only output was previously given contrast. Symptoms improved with NGT placed. She is awaiting a CT abdomen/pelvis. <PAST MEDICAL HISTORY> Oncologic history: - ___: found to have large pelvic mass with pain. - ___: CA-125 drawn there was 4832 - ___: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, total omentectomy and tumor debulking with no gross residual disease. Required 2 units PRBC. - ___: Completed pelvid radiation therapy POB/GYNH: - G0 - Menopause age ___ PMH: MVP, osteopenia, hyperlipidemia. Denies h/o HTN, DM and thromboembolic disorder PSURGH: - TAH, BSO, PLND, omentectomy and debulking, as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian, endometrial and colon cancers. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, non-tender, nondistended, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 03: 40PM GLUCOSE-99 UREA N-16 CREAT-0.6 SODIUM-139 POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-21* ANION GAP-11 ___ 03: 40PM WBC-8.2 RBC-3.87* HGB-12.3 HCT-37.8 MCV-98 MCH-31.8 MCHC-32.5 RDW-13.4 RDWSD-48.2* ___ 05: 55AM CA125-4.9 <MEDICATIONS ON ADMISSION> Aspirin 81', calcium 600-400', VitD3 1000', MVI <DISCHARGE MEDICATIONS> 1. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth Once daily Disp #*60 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Small bowel obstruction likely secondary to pelvic radiation and 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 gynecologic oncology service for management of recurrent small bowel obstruction likely secondary to pelvic radiation and adhesions. You have recovered well, and the team feels that you are safe to be discharged home. Given the recurrence of your small bowel obstruction, we have referred you to Dr. ___ consultation regarding possible bowel resection to reduce risk of recurrence. Please gradually advance your diet over the next few days. Please call the clinic if you have any concerns or questions. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service for for management of recurrent small bowel obstruction likely secondary to pelvic radiation and adhesions. Emergency Department ___ In the ED, she underwent KUB that showed a few dilated loops of small bowel with air-fluid levels, concerning for small bowel obstruction. She was given IV Zofran and IV Morphine. An NGT was placed; only output was previously given contrast. CT of abdomen and pelvis revealed small bowel obstruction with transition point in the right pelvis, minimal free fluid, and no definite evidence of disease recurrence in the abdomen or pelvis. Patient was then transferred to Gyn-Onc service. Gyn-Onc Service ___ On hospital day #1, shortly after being transferred from ED and having NGT placed, patient had significant improvement of nausea and abdominal pain. Patient provided with IV zofran and IV morphine as needed. On hospital day #2, colorectal surgery was consulted. They recommended outpatient follow up for possible elective procedure for definitive management. On hospital day #3 patient no longer required anti-emetics or pain medication and IV pantoprozole was started. On hospital day #4, NGT output was minimal, it was therefore clamped for several hours with no worsening of symptoms. Later that same day, NGT was removed with no subsequent nausea. On hospital day #4, patient was asymptomatic; no longer complaining of nausea or abdominal pain. Her physical exam was reassuring with significantly improved abdominal distension. She was tolerating PO intake. Patient was discharged home on hospital day #4 in stable condition with outpatient follow-up scheduled.
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11332493-DS-12
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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> Anterior and posterior colporrhaphy, bilateral sacrospinous ligament suspension <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old para 2 with pelvic organ prolapse who decided to proceed with surgical management after failing conservative management. <PAST MEDICAL HISTORY> PMH: HTN, depression, paroxysmal SVT, osteoporosis, lichen sclerosis PSURGH: Bilaterl tubal ligation, left salpingo-oophorectomy, appendectomy, removal of basal cancer on nose OBH/GYN: SVDx2 <SOCIAL HISTORY> Denies T/E/D. <PHYSICAL EXAM> Physical exam on admission: General: NAD CV: RRR Pulm: CTAB Abd: soft, nontender nondistended Ext: nontender <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> 1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). <DISCHARGE MEDICATIONS> 1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). <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 Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ underwent anterior and posterior colporrhaphies, b/l sacrospinous suspension. Please see operative note for full details. She was admitted to the GYN service post-operatively. By POD1 she was ambulating, tolerating a regular diet, controlling her pain with oral pain medications. She underwent UROGYN voiding trial such that after an initial 250 mL of NS was instilled into her bladder she was able to void ___ mL. She was discharged home in good condition on POD1 with follow-up.
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11332558-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> worsening shortness of breath, known pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Paracentesis Chest tube placement and removal <HISTORY OF PRESENT ILLNESS> ___ with T2DM, HTN, ___, h/o breast cancer and known large pelvic mass concerning for ovarian vs fallopian tube malignancy presents as transfer from ___ ED for evaluation of worsening shortness of breath. She has had PND and dyspnea that seems to have worsened over the last 3 days, at its worst this AM. Her dyspnea seems to improve throughout the day and when she is sitting upright. No chest pain. She currently does not feel SOB. She has ___ edema which has not improved with Lasix, which was recently prescribed to her by her PCP. She was referred to the ED but initially brought to ___ where she was told she had "renal failure." She has stable, mild abdominal discomfort. No dysuria. She is making normal volumes of dilute urine. She denies vaginal bleeding. No fevers or chills. No nausea/vomiting. +flatus and regular BMs. At ___, she had labs which showed WBC 10.4, Cr 1.6, trop 0.04, proBNP 1845. CXR showed "elevation of right hemidiaphragm with possible trace right pleural effusion and right basilar atelectasis." Bedside ECHO was performed (images in PACS, but no report available). Abdominal and renal u/s were also performed (images in PACS, but no report available). Had pre-op CXR on ___ that showed mild, right middle lobe atelectasis. No focal consolidation. No pulmonary edema. ___ dopplers at that time also were negative for DVT. Of note, she has also been noted to have worsening ___ over the last several months with baseline Cr 0.9. Most recent Cr 2.2 on ___, presumable due to obstructive uropathy secondary to ureteral compression. ONCOLOGIC WORK-UP: ___: Increasing watery discharge, pelvic mass discovered and surgery recommended ___: MR pelvis 16 x 24 x 22 cm cystic/solid mass with right hydrosalpinx, trace pelvic free fluid, no significant pelvic lymphadenopathy, mild right hydronephrosis, compression of IVC and right common iliac vein without evidence of thrombus REVIEW OF SYSTEMS negative except as above <PAST MEDICAL HISTORY> PMH: - HTN - breast cancer stage IIIA s/p lumpectomy, repeat resection, radiation, hormonal therapy - osteopenia - T2DM: currently diet controlled PSH: - breast lumpectomy, repeat resection - appendectomy age ___ Denies anesthesia complications. HCM: Last mammogram: ___ Last colonoscopy: denies having had in past Last bone density scan: denies, per record review last in ___ showing osteopenia POBHx: G2 P2 SVD x2 No complications PGYNHx: LMP: Age ___ DEnies history of fibroids, cysts, STI. Sexually active: no Dyspareunia: no Contraception: n/a ___: unknown Last pap: "many years ago" denies hx abnormal <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies history of gyn or colon cancer, bleeding or clotting disorder. Significant for mother with diabetes, high blood pressure. <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, mildly distended, no rebound/guarding ___: nontender, 3+ pitting edema bilaterally <PERTINENT RESULTS> ___ 09: 23PM BLOOD WBC-9.2 RBC-3.41* Hgb-8.7* Hct-27.0* MCV-79* MCH-25.5* MCHC-32.2 RDW-15.5 RDWSD-44.5 Plt ___ ___ 06: 40AM BLOOD WBC-9.2 RBC-3.52* Hgb-9.1* Hct-27.9* MCV-79* MCH-25.9* MCHC-32.6 RDW-15.6* RDWSD-45.0 Plt ___ ___ 06: 35AM BLOOD WBC-9.3 RBC-3.62* Hgb-9.5* Hct-28.8* MCV-80* MCH-26.2 MCHC-33.0 RDW-15.7* RDWSD-45.0 Plt ___ ___ 07: 10PM BLOOD WBC-9.0 RBC-3.66* Hgb-9.5* Hct-29.3* MCV-80* MCH-26.0 MCHC-32.4 RDW-15.5 RDWSD-45.1 Plt ___ ___ 06: 27AM BLOOD WBC-8.3 RBC-3.46* Hgb-9.0* Hct-27.7* MCV-80* MCH-26.0 MCHC-32.5 RDW-15.6* RDWSD-45.0 Plt ___ ___ 07: 08AM BLOOD WBC-8.3 RBC-3.55* Hgb-9.1* Hct-28.4* MCV-80* MCH-25.6* MCHC-32.0 RDW-15.7* RDWSD-45.4 Plt ___ ___ 05: 57AM BLOOD WBC-8.8 RBC-3.50* Hgb-9.0* Hct-27.9* MCV-80* MCH-25.7* MCHC-32.3 RDW-15.9* RDWSD-45.8 Plt ___ ___ 06: 05AM BLOOD WBC-7.9 RBC-3.42* Hgb-8.6* Hct-27.1* MCV-79* MCH-25.1* MCHC-31.7* RDW-15.9* RDWSD-45.9 Plt ___ ___ 06: 25AM BLOOD WBC-8.2 RBC-3.37* Hgb-8.5* Hct-26.7* MCV-79* MCH-25.2* MCHC-31.8* RDW-16.1* RDWSD-46.0 Plt ___ ___ 06: 30AM BLOOD WBC-8.4 RBC-3.58* Hgb-9.1* Hct-28.4* MCV-79* MCH-25.4* MCHC-32.0 RDW-16.2* RDWSD-45.5 Plt ___ ___ 06: 43PM BLOOD WBC-13.2*# RBC-3.93 Hgb-10.0* Hct-31.0* MCV-79* MCH-25.4* MCHC-32.3 RDW-16.6* RDWSD-46.3 Plt ___ ___ 05: 00AM BLOOD WBC-10.6* RBC-3.32* Hgb-8.5* Hct-26.4* MCV-80* MCH-25.6* MCHC-32.2 RDW-16.4* RDWSD-46.2 Plt ___ ___ 11: 00PM BLOOD WBC-11.3* RBC-3.14* Hgb-8.1* Hct-25.3* MCV-81* MCH-25.8* MCHC-32.0 RDW-16.8* RDWSD-48.0* Plt ___ ___ 10: 20AM BLOOD WBC-9.5 RBC-3.12* Hgb-8.0* Hct-25.0* MCV-80* MCH-25.6* MCHC-32.0 RDW-16.9* RDWSD-47.8* Plt ___ ___ 07: 22AM BLOOD WBC-8.4 RBC-3.14* Hgb-8.1* Hct-24.8* MCV-79* MCH-25.8* MCHC-32.7 RDW-17.0* RDWSD-47.2* Plt ___ ___ 07: 18AM BLOOD WBC-11.4* RBC-3.21* Hgb-8.3* Hct-25.6* MCV-80* MCH-25.9* MCHC-32.4 RDW-17.1* RDWSD-48.0* Plt ___ ___ 09: 23PM BLOOD Neuts-81.1* Lymphs-6.8* Monos-10.9 Eos-0.7* Baso-0.1 Im ___ AbsNeut-7.48* AbsLymp-0.63* AbsMono-1.01* AbsEos-0.06 AbsBaso-0.01 ___ 06: 43PM BLOOD Neuts-86.6* Lymphs-5.8* Monos-6.2 Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.41*# AbsLymp-0.77* AbsMono-0.82* AbsEos-0.03* AbsBaso-0.03 ___ 05: 00AM BLOOD Neuts-76.0* Lymphs-10.7* Monos-11.4 Eos-1.0 Baso-0.2 Im ___ AbsNeut-8.02* AbsLymp-1.13* AbsMono-1.20* AbsEos-0.11 AbsBaso-0.02 ___ 07: 18AM BLOOD Neuts-84.4* Lymphs-7.5* Monos-7.1 Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.75* AbsLymp-0.86* AbsMono-0.82* AbsEos-0.02* AbsBaso-0.03 ___ 09: 23PM BLOOD Glucose-120* UreaN-48* Creat-1.5* Na-138 K-3.5 Cl-94* HCO3-30 AnGap-18 ___ 06: 40AM BLOOD Glucose-113* UreaN-40* Creat-1.1 Na-137 K-3.3 Cl-96 HCO3-31 AnGap-13 ___ 06: 35AM BLOOD Glucose-131* UreaN-34* Creat-1.0 Na-142 K-3.9 Cl-99 HCO3-33* AnGap-14 ___ 07: 10PM BLOOD Glucose-143* UreaN-33* Creat-1.0 Na-139 K-4.5 Cl-100 HCO3-32 AnGap-12 ___ 06: 27AM BLOOD Glucose-159* UreaN-29* Creat-1.0 Na-140 K-4.0 Cl-99 HCO3-32 AnGap-13 ___ 07: 08AM BLOOD Glucose-119* UreaN-25* Creat-0.8 Na-139 K-4.2 Cl-99 HCO3-33* AnGap-11 ___ 05: 57AM BLOOD Glucose-128* UreaN-27* Creat-0.8 Na-139 K-4.1 Cl-99 HCO3-29 AnGap-15 ___ 06: 05AM BLOOD Glucose-110* UreaN-23* Creat-0.7 Na-139 K-4.2 Cl-100 HCO3-31 AnGap-12 ___ 06: 25AM BLOOD Glucose-111* UreaN-24* Creat-0.8 Na-138 K-4.6 Cl-99 HCO3-31 AnGap-13 ___ 06: 30AM BLOOD Glucose-129* UreaN-26* Creat-0.8 Na-138 K-4.6 Cl-98 HCO3-31 AnGap-14 ___ 12: 07AM BLOOD Glucose-163* UreaN-27* Creat-1.0 Na-135 K-4.7 Cl-94* HCO3-27 AnGap-19 ___ 04: 26AM BLOOD Glucose-141* UreaN-25* Creat-0.9 Na-134 K-4.7 Cl-98 HCO3-27 AnGap-14 ___ 11: 00PM BLOOD Glucose-183* UreaN-21* Creat-0.9 Na-133 K-4.8 Cl-97 HCO3-30 AnGap-11 ___ 10: 20AM BLOOD Glucose-128* UreaN-18 Creat-0.8 Na-134 K-4.6 Cl-96 HCO3-33* AnGap-10 ___ 07: 22AM BLOOD Glucose-125* UreaN-18 Creat-0.7 Na-134 K-4.2 Cl-98 HCO3-28 AnGap-12 ___ 07: 18AM BLOOD Glucose-145* UreaN-18 Creat-0.8 Na-137 K-5.0 Cl-100 HCO3-29 AnGap-13 ___ 09: 23PM BLOOD Albumin-3.0* Calcium-9.1 Phos-2.4* Mg-1.7 ___ 06: 40AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.7 ___ 06: 35AM BLOOD Calcium-9.2 Phos-1.8* Mg-1.7 ___ 07: 10PM BLOOD Calcium-8.7 Phos-1.9* Mg-1.7 ___ 06: 27AM BLOOD TotProt-5.6* Calcium-8.7 Phos-2.3* Mg-1.6 ___ 07: 08AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.5* ___ 05: 57AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.5* ___ 06: 05AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.5* ___ 06: 25AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.7 ___ 06: 30AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9 ___ 12: 07AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9 ___ 04: 26AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.8 ___: 00PM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8 ___ 10: 20AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2 ___ 07: 22AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.0 ___ 07: 18AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.0 ___ 11: 54AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11: 54AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM ___ 11: 54AM URINE RBC-3* WBC-6* Bacteri-FEW Yeast-NONE Epi-0 ___ 06: 56PM PLEURAL WBC-1650* ___ Polys-3* Lymphs-40* Monos-9* Meso-16* Macro-29* Other-3* ___ 12: 49PM PLEURAL Hct,Fl-<2.0% ___ 12: 49PM PLEURAL WBC-583* ___ Polys-34* Lymphs-16* ___ Meso-5* Macro-45* ___ 06: 56PM PLEURAL TotProt-3.5 Glucose-173 Creat-0.7 LD(LDH)-488 Amylase-19 Albumin-1.8 ___ Misc-PRO BNP = ___ 12: 49PM PLEURAL TotProt-3.8 Glucose-135 LD(LDH)-539 Albumin-2.4 ___ Misc-PRO BNP = ___ 08: 08AM ASCITES WBC-6000* ___ Polys-60* Lymphs-6* Monos-14* Mesothe-3* Macroph-17* . Micro: ___ 10: 15 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. CEFTAZIDIME sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . ___ 12: 49 pm PLEURAL FLUID **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. . ___ 6: 12 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. . ___ 6: 43 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. . ___ 8: 20 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. . ___ 4: 42 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. . ___ 8: 08 am PERITONEAL FLUID GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . ___ 6: 26 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . ___ 11: 54 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. . ___ Pleural Fluid NEGATIVE FOR MALIGNANT CELLS. - Reactive mesothelial cells, histiocytes, and lymphocytes. . ___ Echocardiogram The left atrium is elongated. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>60%). There is mild (non-obstructive) focal hypertrophy of the basal septum. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild biatrial enlargement. Normal biventricular chamber size and systolic function. Mild mitral regurgitation. Mild aortic regurgitation. Mild pulmonary hypertension. . ___ CXR In comparison with the study of ___, there again are very low lung volumes which accentuate the prominence of the transverse diameter of the heart. Substantial elevation of the right hemidiaphragm is unchanged. The costophrenic angle is more sharply seen, which could reflect some decrease in pleural fluid and compressive atelectasis, though this appearance may merely be a manifestation of a more upright position of the patient. Left lung is essentially clear and there is no definite vascular congestion. Multiple surgical clips are again seen in the left axilla. . ___HEST W/O CONTRAST . IMPRESSION: Moderate nonhemorrhagic right pleural effusions smaller today than on ___, may account for persistent though improved moderately severe right lower lobe atelectasis. Significant tracheobronchomalacia may also be contributing to right lower lobe atelectasis. No evidence of intrathoracic malignancy. . ___ CXR Comparison to ___. Reaccumulation of the pre-existing right pleural effusion. The extent of the effusion is better visualized on the lateral than on the frontal image. Decrease in lung volumes and mild pulmonary edema is present on the current image. Unchanged size of the cardiac silhouette. Unchanged clips projecting over the left axilla. . ___ CXR The radiograph is improved as compared to ___. The right pleural effusion has decreased. The signs indicative of pulmonary edema have also decreased in severity. The edema is now mild. Paratracheal calcified lymph node is better appreciated than on the previous images. Moderate cardiomegaly persists. . ___ Imaging ___ DUP EXTEXT BIL (MAP IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Extensive edema noted in the bilateral calves. . ___ KUB 1. No evidence of obstruction or intraperitoneal free air. 2. Radiodense material in the right lower quadrant of the patient, possibly external. Correlation with physical exam of the area is recommended. . ___BD & PELVIS WITH CO IMPRESSION: 1. Although there is apparent interval decrease in the size of the large pelvic mass, which now measures up to 16.6 cm, previously measuring up to 24 cm, there appears to be an interval increase in the extent of the solid component of this mass and a decrease in the cystic component. There appears to be local invasion, inseparable from the uterus as well as contact with small and large bowel and bladder. An MRI of the pelvis may be helpful for further detailed evaluation. 2. Interval increase in the extensive moderate ascites, with subtle peritoneal thickening, may be secondary to peritonitis. 3. Mild to moderate right hydroureteronephrosis, secondary to mass effect compressing against the distal right ureter. 4. Stable nodularity of the adrenal glands bilaterally. 5. Compression of the IVC and bilateral common iliac veins, however no definite evidence of thrombus. 6. Interval increase in moderate right pleural effusion with adjacent consolidation which may be secondary to atelectasis, however a superimposed infection cannot be excluded. . ___ Imaging CT LOWER EXT W/C RIGHT Extensive subcutaneous edema of the right calf. No abscess and no findings suggestive of osteomyelitis identified. . ___ CXR In comparison with the study of ___, with the patient supine there has been posterior layering of the substantial right pleural effusion with underlying compressive atelectasis. Cardiac silhouette is stable. Indistinctness of pulmonary vessels suggests some elevation in pulmonary venous pressure. Surgical clips are again seen in the left axillary region, soft tissue opacification along the left lateral chest wall most likely represents an overlying artifact. . ___ CXR Comparison to ___. Unchanged moderate right pleural effusion. Mild to moderate pulmonary edema. Mild cardiomegaly. The soft tissue structures that projected over the lateral left chest wall are no longer visible. . ___ CXR Comparison to ___, 15: 24. As compared to the previous image, the patient has received a right -sided chest tube. The right effusion has completely drained. Elevation of the right hemidiaphragm. No pneumothorax. Mild cardiomegaly and elongation of the descending aorta. <MEDICATIONS ON ADMISSION> Lasix 20mg qAM Femara 2.5mg qD simvastatin 20mg qD Tylenol prn potassium <DISCHARGE MEDICATIONS> 1. Simvastatin 20 mg PO QPM 2. Bisacodyl ___AILY: PRN constipation RX *bisacodyl [Dulcolax (bisacodyl)] 10 mg 1 suppository(s) rectally once a day Disp #*30 Suppository Refills: *3 3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*18 Tablet Refills: *0 4. Docusate Sodium 200 mg PO BID RX *docusate sodium [Colace] 100 mg ___ capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 5. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 10 Days RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*27 Tablet Refills: *0 6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours Disp #*60 Tablet Refills: *0 7. Polyethylene Glycol 17 g PO DAILY: PRN constipation RX *polyethylene glycol 3350 [HealthyLax] 17 gram 1 powder(s) by mouth once a day Disp #*30 Packet Refills: *3 8. Senna 8.6 mg PO BID: PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills: *3 9. Letrozole 2.5 mg PO DAILY 10. Furosemide 20 mg PO DAILY <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> pelvic mass concerning for ovarian malignancy pleural effusions secondary bacterial peritonitis type 2 diabetes mellitus lower extremity edema <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 due to worsening symptoms from your pelvic mass. The team feels that you are safe to be discharged to rehabilitation/skilled nursing. 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. * You may eat a regular diet. * It is safe to walk up 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 gynecologic oncology service for worsening dyspnea with known pelvic mass concerning for ovarian malignancy. In terms of her dyspnea, she had no hypoxia or evidence of infection on presentation. She had a chest x-ray showing pleural effusion, and lower extremity dopplers that were negative. She had a CTA chest showing no evidence of pulmonary embolism, moderate to large pleural effusion. On ___, she underwent thoracentesis by interventional pulmonology with 900cc of serosanguious fluid, which was sent for fluid analysis including micro and cytology. Cytology returned negative for malignancy. She initially required supplemental oxygen, which was weaned off. She was found to have elevated troponin that was stable with ECG without ST changes. Medicine was consulted and recommended echocardiogram, which showed normal ventricular sizes and functions, mild mitral and aortic regurgitation, and mild pulmonary hypertension. Medicine cleared her for surgery. She had acute kidney injury with creatinine increased to 1.5 from baseline of 0.7, likely due to obstructive uropathy. She was given aggressive IV hydration with creatinine improving to baseline. She was also found to have a urinary tract infection growing E Coli sensistive to ciprofloxacin, and was initially given ceftriaxone once before transitioning to ciprofloxacin for a total of 5 days of antibiotics (completed on ___. . Wound care was consulted for bilateral lower extremity edema and skin changes and recommended the following: . Pressure relief per pressure ulcer guidelines . Turn and reposition every ___ hours and prn off affected area Heels off bed surface at all times w/ Pillow or Waffle Boots (x) Sit on a pressure redistribution cushion- Standard Air ( x ) Elevate ___ while sitting. Moisturize B/L ___ and feet BID with Moisture Barrier . Cleanse ___ with warm water and foam cleanser, pat the tissue dry 1.Apply Soothe and ___ Barrier to bilat LLE 2x daily. 2.Would manage conservatively with elevation only, as bullae are increasing in size and Ace wraps at this point could make that worse. . Recommendation for opening Blisters: If legs become weepy and blisters open/unroof: Apply Xeroform Gauze, gently wrap with kling, secure with medipore tape. **AVOID Compression Dressing.* . Support nutrition and hydration. . She was given 10mg IV Lasix on ___ for symptomatic management and overall fluid status. She was originally planned for the OR on ___ for her pelvic mass, which was placed on hold due to her worsening dyspnea on presentation. She was evaluated by medicine and anesthesia and both found her risks for surgery acceptable. She was then scheduled for the OR on ___. On ___, she had increased tachypnea that resolved, and chest x-ray showed reaccumulation of right pleural effusion. Overnight on ___, she had tachycardia with heart rate up to 150s, with temperature of 101.1 F, leukocytosis of 13.5, lactate of 3.5. She was transferred to the FICU due to her respiratory and cardiovascular status. Her urinalysis was concerning for possible urinary tract infection. Her right lower extremity edema and erythema was concerning for cellulitis. She was given ceftriaxone once, and was started on vancomycin, cefepime, and flagyl on ___. Her repeat CT abdomen/pelvis showed worsened disease burden. CT of the right lower extremity showed no evidence of abscess. Her respiratory and cardiovascular status improved and she was called out of the FICU on ___. Work-up for her sepsis continued and infectious disease was consulted. They recommended diagnostic paracentesis and thoracentesis. On ___, she underwent diagnostic paracentesis that showed evidence for secondary bacterial peritonitis. She underwent chest tube insertion on ___, which was removed on ___, with pleural fluid analyses indicating transudative pleural effusion. Infectious disease recommended discontinuing the vancomycin and transitioning the patient to oral ciprofloxacin and flagyl to complete 14 days course. She was transitioned to PO antibiotics on ___. Medical oncology recommended that chemotherapy would not be appropriate given the patient's functional and health status. Surgery was also felt to unlikely be palliative at this time given her high surgical risk of complications. In addition, repeat imaging via CT scan on ___ showed interval rupture of the cystic pelvic mass. There was not significant fluid remaining to be drained with surgery for palliation of symptoms. She was evaluated by physical therapy who recommended rehab upon discharge. She was also seen by palliative care, who recommended pain control with narcotic medications if needed and discussed hospice care and palliative care with the patient and family members. On ___, a family and team meeting was held with the patient, the patient's daughter and daughter-in-law, gynecological oncology, palliative care, medicine, social work to discuss goals of care. It was agreed that surgery and chemotherapy were not viable options for treatment or palliation of symptoms and focus should be on symptomatic management and improving her functional status. During her hospital stay, she was given subcutaneous heparin, pneumaboots, and incentive spirometry for prophylaxis. She was continued on diabetic diet for diet controlled type 2 diabetes mellitus and fingerstick blood glucose levels remained appropriate. At the family meeting, the decision was made to no longer check fingerstick glucose levels. On ___, she was discharged to ___ in ___ in stable condition with outpatient follow-up scheduled.
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11333846-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ruptured membranes <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ ___ yrs. G1, P0, Term0, Preterm0, Abt0, Sab0, Tab0, Ect0, Live0 at 18w4d presented to ___ for evaluation of ruptured membranes. HPI: She complains of gush of fluid starting 10: 40 am today when she was in the shower, had burst of vaginal fluid, and mucus Pt having occ cxs, still leaking, no fever/chills, no bleeding Pt here in triage with her partner, still some leaking Rubella ___ B surf antigen Neg/Syphilis Neg/HIV Neg/ B positive Relevant Review of Systems: Constitutional: no symptoms Allergy: no symptoms Endocrine: no symptoms Dermatologic: no symptoms Cardiovascular: no symptoms Respiratory: no symptoms Gastrointestinal: no symptoms Gynecologic: negative except as noted in CC/HPI Urologic: negative except as noted in HPI Neurological: no symptoms Psychiatric: no symptoms Other: None Maternal Medical Issues: 1) di/di twins, spontaneous 2) scleroderma 3) Face Vitiligo 4) was hospitalized ___ ___ for presumed nephrolithiasis, constipation, d/c diagnosis musculoskeletal etiology <PAST MEDICAL HISTORY> GYN Hx: abnl pap and colpo OBHx: G1P0, twin gestation PMH: MS, scleroderma, asthma PSH: h/o r lung collapse requiring chest tube placement Meds: PNV, albuterol NKA <PAST MEDICAL HISTORY> DiagnosisDate -Anemia low iron -Asthma -Chickenpox -Elevated blood pressure ___ Last 5 Blood Pressures: Normalized with weight loss -Migraine 1x/week (usually resolves with Ibuprofen), no aura -MS ___ ___ -Pneumonia, organism ___ Converted Data -Pneumothorax on right___ Chest tube Past Surgical History: ProcedureLateralityDate -THORACENTESIS,INSRT CHEST TUBE,PTX2015 right sided spontaneous pneumothorax -TONSILLECTOMY & ADENOIDECTOMY <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Relevant PE: Constitutional: Gravid well developed, well nourished female, appearing in no acute distress, normal hair distribution, appropriately sad and concerned Vitals: Within normal limits, ___ 11: 27Temp.: 99.0°F ___ 11: 28BP: 127/54 (69) ___ ___: 83 Abdomen: no tenderness, no masses, no palpable organomegaly and no hernia Fundus: size equals dates, nontender EFW: Average Sterile speculum exam-: + small amt pooling of clear to light pink fluid, yellow mucous from os with streak of blood in it, entire vagina with wet shiny sheen as well as labia, cervix appears long and closed. Nitrizine +, Ferns +, Amnisure +. VE- deferred Bedside u/s with MFM (Dr. ___ Dr. ___ Twin A confirmed oligo, very low in pelvis so difficulty clearly visuaizing, no fhr seen Twin B appears normal, nomal fhr, and normal fluid see ___ notes for details Repeat speculum exam with MFM (twin A so low, wanted to confirm that she was not delivering) Os closed, no fetal parts noted, pooling Labs: CBC pending <PERTINENT RESULTS> ___ 06: 45PM WBC-9.7 RBC-2.83* HGB-8.3* HCT-26.8* MCV-95 MCH-29.3 MCHC-31.0* RDW-14.9 RDWSD-51.5* ___ 06: 45PM PLT COUNT-358 ___ 12: 42PM URINE HOURS-RANDOM ___: 42PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 12: 42PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12: 42PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-80* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR* ___ 12: 42PM URINE RBC-5* WBC-5 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 12: 42PM URINE MUCOUS-RARE* ___ 12: 41PM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG <MEDICATIONS ON ADMISSION> pnv <DISCHARGE MEDICATIONS> ibuprofen tylenol <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ___ trimester spontaneous abortion pprom di/di twins <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> call for fever, chills, nausea vomiting increased pain
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Relevant PE: Constitutional: Gravid well developed, well nourished female, appearing in no acute distress, normal hair distribution, appropriately sad and concerned Vitals: Within normal limits, ___ 11:27Temp.: 99.0°F ___ 11:28BP: 127/54 (69) ___ ___: 83 Abdomen: no tenderness, no masses, no palpable organomegaly and no hernia Bedside u/s with MFM (Dr. ___ Dr. ___ Twin A confirmed oligo, very low in pelvis so difficulty clearly visuaizing, no fhr seen Twin B appears normal, nomal fhr, and normal fluid see ___ notes for details Repeat speculum exam with MFM (twin A so low, wanted to confirm that she was not delivering) Os closed, no fetal parts noted, pooling Labs: CBC pending IMPRESSION: ___ yo G1P0 at 18w4d, di/di twins, second trimester PPROM this morning, no S&S of infection at this time PLAN: Explained to pt and family poor prognosis of PPROM in second trimester Reviewed risk of possible skeletal deformations, contractures, and pulmonary hypoplasia as a result of development in a severely low amniotic fluid environment, chorioamnionitis, maternal sepsis, Spont labor, possible risk of chorio in twin B, fetal/maternal death, etc termination recommended due to previable and poor prognosis Discussed induction of labor vs D&E After discussing risks/benefits/alternatives, pt and partner decline any intervention, requests expectant management for now ___ consulted, Dr. ___ Dr. ___ overnight due to cramping and Twin A being so low Explained to pt, high likelihood she will deliver twin A spontaneously, and that Twin B may also deliver spontaneously at that time Close monitoring plan formal ultrasound tomorrow morning, The patient was admitted to antepartum for observation x 24 hours Patient was seen and evaluated by: ___, MD. ___ Pt sent to l and d for contractions noted to be fully dilated delivered svd Baby A at 11:30 baby B and placenta at 12:30 no lacerations PP #1 stable afebrile
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11334281-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> For repeat ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean section <HISTORY OF PRESENT ILLNESS> ___ yo G4P1 ___ ___ by ___ consistent with 21 week ultrasound, for repeat c/s number 2. Antepartum - benign - late registrant for prenatal care 18 weeks. Normal fetal survey, posterior placenta Low risk quad screen GBS+ RPR neg A+ Rub ___ Hep B neg Hiv - Neg GC Cl x 2 <PAST MEDICAL HISTORY> POBhx: ___ Primary c-sections NRFHR 40 ___ 2980 gms male PMH/SH neg <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> PE 120/70 weight 146 Lungs - clear cor rrr abd gravid ext trace edema <PERTINENT RESULTS> CBC 9.6>8.7/29.4<134 UA neg <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp: *60 Capsule(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q3-4H () as needed. Disp: *30 Tablet(s)* Refills: *0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean delivery <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call or return to the hospital if you have increased pain, fevers, chills, redness or drainage from your incision, vaginal bleeding soaking more than one pad per hour, or any other questions or concerns. Nothing in the vagina for at least 2 weeks. You cannot drive while taking narcotic pain medications.
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___ G4P1 presented for repeat cesarean section. Procedure was uncomplicated. Please see full operative note for details. Postpartum course was also uncomplicated and pt was discharged home in stable condition on POD#4 to follow up at ___.
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| 53
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11335476-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ year old G2P0 at 26 weeks 5 days gestational age with chronic hypertension, on no medications, who had a blood pressure of 160/90 at her OB appointment yesterday and was referred to OB Triage for continued evaluation. She reports a one week history of constant bilateral frontal headache, described as sharp and throbbing. Headache has awakened her from sleep. She has a history of infrequent (once montly) headaches prior to pregnancy that resolved with Excedrin and Tylenol, but this headache feels different than her previous headaches and does not improve with tylenol. No photophobia or phonophobia. Denies vision changes or right upper quadrant pain. Denies new onset weakness or numbness (has baseline numbness in right hip/leg due to prior surgery). While in OB Triage she received 2 tabs of fioricet which did not improve her headache. Next she received reglan and benadryl which made her sleep but headache returned upon awakening. Dilaudid was given which worsened her headache. She rates her current headache ___. Dating: ___ is ___ by LMP of ___, consistent with 10 week ultrasound. Labs: O+/antibody neg, HIV negative/HBsAg negative/Rubella ___ negative. ___: 24 hr urine protein 144 mg. Pap smear- negative, +trich Screening: CF negative. Low ___ on first trimester screen. Hgb electrophoresis hemoglobin A2 2.6% with low MCV FFS: normal US ___: EFW 768g (56%ile) Issues: CHTN, anemia, obesity <PAST MEDICAL HISTORY> OBHx: G1 - sAB G2 - current PMH: Chronic HTN (never on meds), obesity, hypothyroidism. S/p MVA ___ years ago during which she sustained a pelvic fracture. PSH: right hip plate from surgery s/p MVA, eye surgery. <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Upon discharge: VSS, normotensive Well appearing, NAD Abd soft, gravid, nontender Ext without edema or tenderness <PERTINENT RESULTS> ___ 02: 54PM URINE MUCOUS-RARE ___ 02: 54PM URINE AMORPH-RARE ___ 02: 54PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE EPI-6 ___ 02: 54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 02: 54PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 02: 54PM URINE HOURS-RANDOM CREAT-161 TOT PROT-17 PROT/CREA-0.1 ___ 03: 16PM PLT COUNT-389 ___ 03: 16PM WBC-10.6* RBC-3.47* HGB-8.8* HCT-27.4* MCV-79* MCH-25.4* MCHC-32.1 RDW-16.8* RDWSD-47.7* ___ 03: 16PM HAPTOGLOB-205* ___ 03: 16PM URIC ACID-5.2 ___ 03: 16PM ALT(SGPT)-15 AST(SGOT)-16 LD(LDH)-117 ___ 03: 16PM estGFR-Using this ___ 03: 16PM CREAT-0.5 EXAMINATION: MRA BRAIN W/O CONTRAST T9711 MR HEAD INDICATION: ___ gravid female experiencing persistent headache. Evaluate for venous sinus thrombosis and/or intracranial process. TECHNIQUE: 3 dimensional time-of-flight MRA and MRV was performed through the brain. No contrast was administered. Three dimensional maximum intensity projection and segmented images were generated. This report is based on interpretation of all of these images. No contrast was administered. COMPARISON: ___ noncontrast brain MRA. FINDINGS: MRA: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. The bilateral posterior communicating arteries are visualized. The left vertebral artery predominantly ends and ___ with small anastomotic branch to the basilar artery. MRV: The intracranial venous sinuses and major veins are patent without evidence of thrombosis. On the sagittal T1 sequence, there is normal brain morphology and signal. The ventricles and extra-axial spaces are unremarkable. The visualized osseous structures demonstrate low marrow signal (C5: 11). IMPRESSION: 1. No acute intracranial abnormality. 2. No evidence of venous sinus thrombosis. 3. Decreased marrow signal. Differential considerations include marrow conversion related to anemia, with infiltrative process less likely. Recommend clinical correlation and correlation with CBC. <MEDICATIONS ON ADMISSION> PNV, iron <DISCHARGE MEDICATIONS> 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H: PRN headache RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth q8hrs Disp #*10 Tablet Refills: *0 2. Prenatal Vitamins 1 TAB PO DAILY 3. Prochlorperazine 10 mg PO Q6H RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6hrs Disp #*20 Tablet Refills: *0 4. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at ___ headache <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum floor for further testing and evaluation of your headache. You had a reassuring evalation, including a head MRI. The neurologist that saw you recommended an eye exam with ophthamology which can be done as an outpatient. Please continue taking tylenol, compazine, or fioricet as needed for your headaches. Stay hydrated. You had no evidence of preeclampsia. Fetal testing was reassuring while you were here. You were noted to have iron deficiency anemia. Please continue taking iron supplements at home. Continue a stool softener (colace) to avoid constipation from the iron.
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Ms. ___ was admitted to the antepartum service for intractable headache in the setting of chronic hypertension. Her blood pressures were initially labile but normalized without antihypertensives. She received a course of magnesium for seizure prophylaxis and was made betamethasome complete on ___. She had a 24 hour urine protein initially elevated but contaminated by hematuria after patient removal of her own foley catheter. Repeat 24 hour urine was negative at 131mg. She had HELLP labs all within normal limits. During her hospitalization, she was seen by neurology who recommended MRA/MRV head imaging. These studies were without evidence of acute intracranial process but did note depressed marrow signal, reflecting possible anemia or infiltrative process. Iron studies were sent and returned suggestive of iron deficiency anemia, for which the patient has been taking iron supplementation during her pregnancy. On hospital day #4, she had significant improvement of her headache with various medications including compazine, benadryl, fioricet, and acetaminophen. She had reassuring fetal testing throughout her stay. She was discharged home with outpatient follow up scheduled, including ophthalmology for formal fundoscopic and visual field evaluation.
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11335476-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> headache, elevated BP <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P0 at ___ with chronic HTN presenting from clinic where she had elevated BP to 175/125 with severe frontal headache that started this AM. Pt states her headache is frontal, between her eyes, no alleviating or aggravating sx. No photophobia or photophobia. She says her h/a has been ___ in severity since the beginning of ___ it is still ___ but no worse than baseline. She took PO compazine around noon and 2 fioricets in triage. No visual changes or RUQ pain. No chest pain or shortness of breath. <PAST MEDICAL HISTORY> PNC: - ___ ___ - O+/abs-/HIV-/HbaAg-/RI/GBS neg (___) - LR ___ trimester screen, low ___ - nl GLT (132) - nl FFS - U/S ___ for obesity, HTN: 1840gm, 69% - Issues: *) Morbid obesity, BMI ___ *) cHTN: booking blood pressure 155/102 (5 wga), no meds, 24h protein 144mg on ___ and 131mg on ___ *) anemia, iron studies c/w iron def anemia, also possible alpha thal trait vs. beta thal trait. *) low ___ *) Admission to antepartum from ___ for headache and r/o pre-eclampsia, where she was made betamethasone complete. 24 hr urine 131 mg on ___. Neurology consulted, MRV negative for clot. Seen by Neurology as outpatient, think most c/w migraine. Recently started on cyproheptadine by Neurology (but pt has not yet started taking). Seen by Ophthomology, thought to have refractory error and given spectacles. Scheduled for sleep study ___. PObHx: G2P0 - G1: SAB, no D&C PMH: Chronic HTN (no meds), obesity, hypothyroidism (per record, but TSH normal in ___, no meds). S/p MVA ___ years ago during which she sustained a pelvic fracture PSH: right hip plate from surgery s/p MVA, eye surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> PE: T 98.0 HR 108 RR 16 BP 133/107, 198/84, 185/81, 122/108, 103/85, 159/125 General: NAD, appears comfortable, pleasant CV: RRR Lungs: CTAB Abdomen: soft, obese, gravid, no fundal tenderness, no rebound, no guarding SVE: Deferred Ext: trace b/l pedal edema Discharge exam: VSS Gen NAD CV RRR P no resp distress on RA Abd soft, obese, gravid, nontender Ext WWP <PERTINENT RESULTS> ___ 02: 55PM GLUCOSE-89 UREA N-6 CREAT-0.4 SODIUM-136 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-18* ANION GAP-16 ___ 02: 55PM ALT(SGPT)-16 ___ 02: 55PM CALCIUM-10.0 PHOSPHATE-4.5 MAGNESIUM-1.7 URIC ACID-6.3* ___ 02: 55PM TSH-1.5 ___ 02: 55PM URINE HOURS-RANDOM CREAT-116 TOT PROT-16 PROT/CREA-0.1 ___ 02: 55PM WBC-9.9 RBC-3.42* HGB-8.7* HCT-26.3* MCV-77* MCH-25.4* MCHC-33.1 RDW-16.8* RDWSD-46.7* ___ 02: 55PM PLT COUNT-379 ___ 02: 55PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 02: 55PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-5 ___ 02: 55PM URINE MUCOUS-RARE <MEDICATIONS ON ADMISSION> iron, benadryl, cyclobenzaprine, cyproheptadine (not taking) <DISCHARGE MEDICATIONS> 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H: PRN headache 2. Cyclobenzaprine 15 mg PO HS 3. Cyproheptadine 2 mg PO QHS 4. Ferrous Sulfate 325 mg PO BID 5. Prenatal Vitamins 1 TAB PO DAILY 6. Prochlorperazine 10 mg PO Q6H: PRN headache <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at ___ chronic hypertension chronic headache <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___, You were admitted to the ___ service for observation due to elevated blood pressures and headache. While you were here, your blood pressures normalized and you had no evidence of preeclampsia. Your headache was overall stable while you were here. Please try to stay hydrated and take the medications (as prescribed by neurology) as need for the headache. Fetal testing was reassuring while you were here. We have provided you with a chart of recommended medications for your headache. Please follow-up with your neurologist, and if you feel that your headache is so severe that you cannot manage it at home, call us. Please wear your glasses if able to help. Please take the medications prescribed by your neurologist.
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___ yo G2P0 with cHTN and labile BP and chronic HA admitted for BP monitoring *) cHTN, labile BP - Lytes wnl, TSH 1.5 - 24 hour urine for protein 189 (___) - ___ +barbituates (fioricet) - no evidence of preeclampsia *) chronic HA - s/p neuro w/w with neg MRV and neg optho eval for papilledema - cont home meds compazine, cyclobenaprine, cyproheptadine, benadryl, tylenol, fioricet - neuro consult if no improvement in HA w/ recommended medications (deferred for now with outpatient follow up) * Cyproheptadine IS covered by her insurance, spoke to her pharmacy to clarify and they are processing the prescription- will call pt when ready . *) anemia: continue Fe supplements
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11335476-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Low transverse cesarean section Chronic hypertension Pre-eclampsia Postpartum Hemorrhage Endometritis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean section <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ year old Gravida 1, Para 0 LMP 1 16 ___ 11 2 at 38 weeks, 3 days with labile blood pressures, diagnosis of chronic hypertension preceding pregnancy (no meds during pregnancy), and now ___ of protein in a 24 hour urine sample this week. The patient has suffered with headaches throughout the pregnancy. No visual changes. No epigastric pain. Pregnancy course notable for BMI 53, total weight gain during pregnancy 16 lbs, likely chronic hypertension (no meds, mostly normal through pregnancy, except for last 10 days). Baby has been active. Rare contractions. No bleeding. <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On day of admission: BP: a) 133/88; b) 120/90. Weight: 300 BMI: 53.1. Gen: well appearing Abd: nontender Bimanual: cervix closed, 50%, midposition, midconsistency, -1 station, cephalic. Bishop's ___ On day of discharge: Vital signs stable Gen: well appearing, NAD, comfortable CV: RRR Resp: ctab, normal work of breathing Abd: soft, nondistended, appropriately tender around incision. Incision clean, dry, and intact. No sign of infection. Ext: nontender, trace edema b/l <PERTINENT RESULTS> ___ 03: 20PM BLOOD WBC-14.3* RBC-2.59* Hgb-6.3* Hct-19.9* MCV-77* MCH-24.3* MCHC-31.7* RDW-17.1* RDWSD-48.3* Plt ___ ___ 10: 30AM BLOOD WBC-15.7*# RBC-2.78* Hgb-6.8* Hct-21.6* MCV-78* MCH-24.5* MCHC-31.5* RDW-17.2* RDWSD-48.8* Plt ___ ___ 02: 24AM BLOOD WBC-9.7 RBC-3.36* Hgb-8.2* Hct-26.1* MCV-78* MCH-24.4* MCHC-31.4* RDW-17.3* RDWSD-49.1* Plt ___ ___ 07: 58PM BLOOD WBC-8.5 RBC-3.25* Hgb-8.0* Hct-25.3* MCV-78* MCH-24.6* MCHC-31.6* RDW-17.4* RDWSD-49.2* Plt ___ ___ 03: 20PM BLOOD Creat-0.6 ___ 08: 14AM BLOOD Glucose-111* UreaN-7 Creat-0.6 Na-136 K-4.5 Cl-105 HCO3-18* AnGap-18 ___ 02: 24AM BLOOD Creat-0.5 ___ 03: 20PM BLOOD ALT-8 ___ 02: 24AM BLOOD ALT-12 AST-26 ___ 07: 58PM BLOOD ALT-12 AST-16 ___ 08: 14AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.6 ___ 02: 24AM BLOOD UricAcd-7.1* ___ 07: 58PM BLOOD UricAcd-6.5* ___ 07: 58PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 07: 58PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-8* pH-6.5 Leuks-MOD ___ 07: 58PM URINE RBC-4* WBC-9* Bacteri-FEW Yeast-NONE Epi-3 ___ 07: 58PM URINE Mucous-MOD ___ 07: 44PM URINE Hours-RANDOM Creat-345 TotProt-182 Prot/Cr-0.5* **Placental pathology pending <MEDICATIONS ON ADMISSION> - Cyclobenzaprine - Prenatal vitamin - Diphenhydramine - Colace - Ferrous sulfate <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN Pain Do not exceed more than 4,000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *1 3. 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 #*40 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN pain Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *1 5. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*42 Syringe Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean section Chronic hypertension with preeclampsia Post-partum hemorrhage Endometritis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms ___, Congratulations on the beautiful new addition to your family!! Please follow the instruction 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 L&D service on ___ at 38w4d for induction of labor for chronic hypertension with superimposed pre-eclampsia. Patient had a 24 hour urine with protein of 557 and protein/creatinine ratio of 0.6. Patient with labile, but non-severe blood pressures during pregnancy. Her cervix was unfavorable upon the initiation of her induction. During her induction course, patient received a total of 5 cytotec. Pitocin was initiated on ___, and she spontaneously ruptured her membranes. Foley bulb and epidural were placed on ___. At this point, patients cervix had dilated to 3cm and her Pitocin was increased to a maximum dose of 30 because contractions were not adequate. Patient failed to progress beyond 4cm dilation despite Pitocin for over 24 hours and spontaneous rupture of membranes for over 24 hours. Fetal status remained reassuring. Given patient's failure to progress beyond 4cm, she was diagnosed with failed induction of labor and it was recommended she undergo a cesarean delivery. On ___ Ms ___ underwent an uncomplicated cesarean delivery. She had a liveborn female infant weighing 4065g with Apgars of 9 and 9 at 1 and 5 minutes. She had clear amniotic fluid and a placenta that was spontaneously delivered with a 3 vessel cord. Cesarean was complicated by postpartum hemorrhage, due to uterine atony. Total estimated blood loss was 1500mL. Her post-op Hct was 21, down from 26 pre-op. She was given 2 units of pRBCs on ___. She was stable after blood and no further labs or blood products were indicated. Patient also had a temperature of 102 degrees postpartum with concern for endometritis. She was given ampicillin, gentamicin, and clindamycin for 24 hours afebrile. She tolerated the medication well. By ___, patient was afebrile, tolerating a regular diet, and her pain was well controlled with oral pain medications. She was voiding and ambulating without issue. She was then discharged home in stable condition with outpatient follow up scheduled.
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| 471
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11335476-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ___ evaluation <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G4P1 at 34w5d presenting to triage for ___ evaluation for elevated BPs in clinic. Mild HA that is typical of her headaches outside of pregnancy. Normally does not take medications for these headaches. Denies changes in vision, CP, SOB, and RUQ pain. Denies ctx, VB, LOF. +FM. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP - Labs Rh+/Abs-/Rub I/RPR NR/HBsAg-/HIV- - Screening: late presentation to care - FFS: wnl, normal placentation - GLT: [ ] performed today - Issues: *) cHTN - H/o pre-eclampsia in prior pregnancy - cont ASA - labetalol 200mg BID *) Late presentation to care - Presented to ___ in ___ [ ] Records from ___ *) Elevated BMI OBHx: G4P1 - G1: pLTCS for failed IOL for cHTN w/ siPEC, c/b PPH - G2: SAB - G3: SAB - G4: current GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - Depression - H/o +PPD, negative CXR ___) - cHTN - Thalassemia trait - Iron def anemia PSH: - Lsc cholecystectomy - pLTCS - Ophthalmologic surgeries - Pelvic fracture s/p repair after MVA Meds: - PNV - Labetalol 200mg BID All: - NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: ___ 12: 29BP: 135/75 (89) ___ ___: 104 ___ 12: 52BP: 127/98 (104) ___ ___: 107 ___ ___: 104 ___ 13: 17BP: 131/56 (75) ___ ___: 106 ___ 13: 41Temp.: 98.2°F Gen: A&O, comfortable Resp: breathing comfortably on RA Abd: soft, gravid, nontender Ext: no lower extremity edema FHT: 130/moderate variability/+accels/-decels Toco: flat On discharge: 24 HR Data (last updated ___ @ 521) Temp: 98.5 (Tm 98.5), BP: 106/72 (97-117/55-78), HR: 96 (90-97), RR: 20 (___), O2 sat: 100% (97-100), FHR: 150-160 (140-160) Gen: NAD Resp: No evidence of respiratory distress Abd: Soft, non-tender Ext: No lower extremity edema <PERTINENT RESULTS> 24 hour urine protein: 242mg ___ 11: 40AM BLOOD WBC-10.1* RBC-3.82* Hgb-9.2* Hct-30.1* MCV-79* MCH-24.1* MCHC-30.6* RDW-18.3* RDWSD-52.5* Plt ___ ___ 11: 40AM BLOOD Glucose-147* ___ 11: 40AM BLOOD Glucose-138* Creat-0.5 ___ 11: 40AM BLOOD ALT-14 AST-15 ___ 11: 40AM BLOOD UricAcd-4.5 ___ 11: 40AM BLOOD RUB IgG-POS* VZV IgG-POS* ___ 11: 40AM BLOOD HBsAg-NEG ___ 11: 40AM BLOOD HIV Ab-NEG ___ 11: 40AM BLOOD HCV Ab-NEG <MEDICATIONS ON ADMISSION> labetalol 200mg BID <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID 2. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills: *0 3. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cHTN, rule out pre-eclampsia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with elevated blood pressures. Your blood pressures were monitored overnight and remained normal. Your urine collection indicated that you do not have pre-eclampsia. You were also found to have elevated glucose and there is concern for gestational diabetes. You were prescribed a glucose meter. Please check your glucose once in the morning during fasting (before breakfast) and 1 hour after every meal. Please record the numbers in a piece of paper and bring this to your next OB visit. We think it is now safe for you to go home. Please attend all appointments with your obstetrician and all fetal scans. 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 ___ G4P1 with chronic hypertension who was admitted on ___ for BP monitoring at 34weeks and 0 days. On presentation, she was noted to have normal range BPs. She reported a headache that resolved after taking Tylenol, Compazine, benadryl. She was continued on labetalol 200mg BID for her chronic hypertension. Her PIH labs were normal and a urine p:c was 0.1. Her 24 hour urine protein was 242mg. Given negative 24 hour urine, patient was discharged to home with close follow up and plan for weekly prenatal visits and BPPs.
| 1,264
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11336382-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P1 at 25w6d transferred from ___ with vaginal bleeding in the setting of a low lying placenta. Pt was told she had a "marginal previa" at ___. She had episode of bleeding shortly after this scan and was expectantly managed. Pt presents today for evaluation by midwife after two painful ctx's followed by BRB staining half a pad and quarter size clot. Bleeding lasted 1.5 hours. Fetal status reassuring. First dose of betamethasone administered at 0115, pt transferred to ___. On evaluation here, she denies ongoing VB, ctx, abd pain, LOF. Reports +FM. ROS: Denies fevers/chills or recent illness. Denies HA, vision changes. Denies chest pain/shortness of breath/palpitations. Denies abdominal pain. Denies recent falls or abdominal trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w first trimester u/s - Labs Rh+ /Abs- /___ /RPRNR /HBsAg- /HIV- /GBS unknown - LR ERA - FFS wnl, marginal placenta previa with edge 5mm from os - GTT not yet done OBHx: G2P1001 - G1: SVE, 37wks, &.5# (___) - G2: current GynHx: - denies abnormal Pap or cervical procedures - denies fibroids/endometriosis - denies STIs, including HSV PMH: Marfan-like connective tissue disorder, lactose and fructose malabsorption PSH: excision of benign breast fibroadmona, wisdom teeth extraction <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS: T 98.5, HR 79, RR 18, BP 112/52 Gen: A&O, comfortable Pulm: nl work of breathing Abd: soft, gravid, nontender, no fundal tenderness SSE: nl external genitalia, parous os with old blood at external os cleared with two scopettes, no ongoing bleeding Toco flat FHT 140/mod var/+accels/rare quick variables -> AGA <PERTINENT RESULTS> ___ WBC-11.7 RBC-3.24 Hgb-10.1 Hct-30.6 MCV-94 Plt-168 ___ ___ PTT-24.0 ___ ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Ferrous Sulfate 325 mg PO DAILY 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> low lying placenta <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for vaginal bleeding in the setting of a low lying placenta. You received betamethasone, a steroid injection, to improve fetal lung maturity. You had an ultrasound that showed a low lying placenta 1cm from the cervix. You were monitored closely and had no further bleeding. It is safe for you to be discharged home. Please continue pelvic rest.
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___ y/o G2P1 with known low-lying placenta versus placenta previa admitted at 25w6d with vaginal bleeding. . On admission, she was hemodynamically stable with no further bleeding. She had no evidence of preterm labor and fetal testing was reassuring. She received a course of betamethasone for fetal lung maturity (complete ___ and the NICU was consulted. She had a transvaginal ultrasound in the ___ Maternal Fetal Medicine unit on ___ and her placenta was noted to be 1cm from the cervical os. Fetal testing was otherwise reassuring. The estimated fetal weight was 1049 grams (70th percentile). She remained clinically stable without any bleeding and she was discharged home on ___.
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11336382-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> NSVD <HISTORY OF PRESENT ILLNESS> ___ G2P1 at 27+2, known low lying placenta and 2 prior bleeds, presents today with BRVB, small stringy clot and abd cramping. Denies feeling lightheaded, dizzy or weak. Denies recent intercourse or trauma. +AFM. Was BMZ complete ___ after last bleed. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w first trimester u/s - Labs Rh+ /Abs- /___ /RPRNR /HBsAg- /HIV- /GBS unknown - LR ERA - FFS wnl, marginal placenta previa with edge 5mm from os - GTT not yet done, pt declined. nl ___ x 48hrs OBHx: G2P1001 - G1: SVE, 37wks, &.5# (___) - G2: current GynHx: - denies abnormal Pap or cervical procedures - denies fibroids/endometriosis - denies STIs, including HSV PMH: Marfan-like connective tissue disorder, lactose and fructose malabsorption PSH: excision of benign breast fibroadmona, wisdom teeth extraction <SOCIAL HISTORY> ___ <FAMILY HISTORY> Ethnic background of patient is ___ and ___ descent and partner is of ___ descent. Denies known family history of inherited genetic disorders, developmental anomalies, recurrent pregnancy loss <PHYSICAL EXAM> (on admission) VS: T 98.4, HR 84, BP 108/74 Gen: NAD Abd: gravid, soft, NT SSE: dark red blood in vault, 1 large grape sized clot, no active bleeding, cervix visually closed NST: baseline 150, mod var, +accels, no decels, AGA Toco: flat <PERTINENT RESULTS> ___ WBC-9.6 RBC-3.20 Hgb-10.1 Hct-30.7 MCV-96 Plt-161 ___ WBC-10.8 RBC-3.27 Hgb-10.4 Hct-31.0 MCV-95 Plt-201 ___ WBC-10.6 RBC-3.22 Hgb-10.1 Hct-30.7 MCV-95 Plt-138 SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. 1+ (<1 per 1000X FIELD): BUDDING YEAST YEAST VAGINITIS CULTURE (Final ___: YEAST. SPARSE GROWTH. R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> PPROM NSVD Superficial thrombophlebitis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> PPROM Preterm Labor
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___ G2P1 with low lying placenta admitted at 27w2d with vaginal bleeding. On admission, she was hemodynamically stable without active bleeding. She had no evidence of preterm labor and fetal testing was reassuring. She was already betamethasone complete on ___. She was transferred to the antepartum service for further observation. She continued to have intermittent small episodes of bleeding and the decision was made to keep her hospitalized until delivery. She received a rescue course of betamethasone (complete ___. She remained clinically stable until 30w4d when she PPROM'd. She was afebrile and had no evidence of preterm labor or infection. Transvaginal ultrasound confirmed that the low lying placenta had resolved. She was started on latency antibiotics and managed expectantly. She went into active preterm labor and had an uncomplicated vaginal delivery at 32w3d. She delivered a female weighing 2090 grams. Neonatology staff was present for delivery and transferred the neonate to the NICU for prematurity. Ms ___ had an uncomplicated postpartum course and was discharged home in stable condition on PPD#2.
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11337191-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / atorvastatin / Demerol <ATTENDING> ___. <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic bilateral salpingo-oopherectomy converted to exploratory laparotomy, total abdominal hysterectomy, pelvic and para-aortic lymph node dissection, omentectomy <HISTORY OF PRESENT ILLNESS> This is a ___ G2P2 with a remote history of breast DCIS who presented with right lower quadrant pain in ___. Pelvic ultrasound on ___ revealed a 6.7 x 2.4 x 4.3 cm uterus with a 2 mm endometrium and a normal left ovary. The right ovary appeared enlarged at 2.8 x 2.5 x 1.8 cm and there was a 4 x 3 x 4 mm echogenic focus with some peripheral venous flow. Pelvic MRI was recommended. Repeat pelvic ultrasound on ___ was notable for a normal-appearing right ovary with a relatively heterogeneous somewhat lobular area underneath and attached to the ovary, measuring 29 x 27 x 23 mm. There was a small internal area of calcification and minimal if any color flow. Pelvic MRI on ___ revealed a solid mass measuring 2.3 cm x 2.5 cm x 2.5 cm attached to or arising from the right ovary, which demonstrates enhancement except for the small central region of necrosis consistent with ultrasound findings. Surgical evaluation was recommended. Labs on ___ were notable for CA-125 of 8, CEA of 1.2, HE4 of 109 (normal <150). She currently reports no other symptoms. No other pains, changes to bladder or bowel, rectal bleeding, bloating, early satiety or loss of appetite. She has had an intentional 20lb weight loss since joining ___. She notes vaginal bleeding intermittently approximately ___ times yearly, most recently one year ago. She presented for planned laparoscopic BSO, possible exploratory laparotomy with staging. <PAST MEDICAL HISTORY> OBGYN History Menopause ___, rare vaginal bleeding (spotting) as above Last Pap ___, negative, +HR HPV but negative for subtypes ___. Last ___ ___ Last colonoscopy ___ years ago, will be due in ___ Last BMD ___ Denies history of STI Not currently sexually active History of COCPs for approximately ___ years, tamoxifen ___, no HRT G2P2, SVD ___ and ___ PMH DCIS right breast ___, s/p lumpectomy, radation, ___ years tamoxifen GERD Basal cell carcinoma of ear and RUE s/p resection Hyperlipidemia Osteoporosis Restless legs Denies HTN, asthma, diabetes, problems with anesthesia or bleeding/clotting diathesis PSH ___ BTL ___ right breast lumpectomy ___ LSC CCY ___ urethral sling ___ repair epigastric hernia <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of breast, ovarian, uterine, cervical, or colon cancers. Mother with skin cancer but deceased age ___. Mother with HTN and heart problems. Sister and daughter with no cancers. <PHYSICAL EXAM> Prior to admission: Height 5'5" Weight 160lb Gen: A&O, No respiratory distress Lungs: clear to auscultation bilaterally Heart: regular rate and rhythm Abd: soft, nontender, nondistended Lymphatics: no inguinal lymphadenopathy Pelvic: normal vulva without lesions, vulva atrophic, vagina atrophic without lesions, cervix normal appearing without lesions. Uterus small, mobile, anteverted, nontender. Mobile 3cm right adnexal mass nontender. No left adnexal abnormality palpable. Ext: nontender On discharge: Gen: NARD, comfortable CV: RRR Lungs: CTAB Abdomen: Soft, appropriately tender, nondistended, no rebound or guarding Incision: Vertical midline incision with staples clean/dry/intact Extremities: Nontender <PERTINENT RESULTS> ___ 03: 08PM BLOOD WBC-8.4 RBC-4.88 Hgb-13.2 Hct-40.5 MCV-83 MCH-27.0 MCHC-32.5 RDW-14.5 Plt ___ ___ 04: 00AM BLOOD WBC-11.3* RBC-4.36 Hgb-11.6* Hct-36.7 MCV-84 MCH-26.6* MCHC-31.7 RDW-14.2 Plt ___ ___ 07: 30AM BLOOD WBC-8.0 RBC-3.94* Hgb-10.9* Hct-33.0* MCV-84 MCH-27.7 MCHC-33.1 RDW-14.6 Plt ___ ___ 08: 00AM BLOOD WBC-6.9 RBC-4.37 Hgb-12.0 Hct-36.2 MCV-83 MCH-27.4 MCHC-33.1 RDW-14.5 Plt ___ ___ 03: 08PM BLOOD Glucose-171* UreaN-17 Creat-0.7 Na-140 K-4.1 Cl-107 HCO3-27 AnGap-10 ___ 04: 00AM BLOOD Glucose-140* UreaN-18 Creat-0.7 Na-139 K-4.5 Cl-104 HCO3-30 AnGap-10 ___ 07: 30AM BLOOD Glucose-69* UreaN-12 Creat-0.6 Na-138 K-4.3 Cl-103 HCO3-27 AnGap-12 ___ 08: 00AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-140 K-3.6 Cl-100 HCO3-32 AnGap-12 ___ 03: 08PM BLOOD Calcium-9.0 Phos-4.0 Mg-1.7 ___ 04: 00AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.4 ___ 07: 30AM BLOOD Calcium-8.4 Phos-1.4*# Mg-1.9 ___ 08: 00AM BLOOD Calcium-8.8 Phos-1.9* Mg-2.0 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO HS 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 3. Rosuvastatin Calcium 20 mg PO DAILY 4. Venlafaxine XR 300 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Venlafaxine XR 300 mg PO DAILY 2. Gabapentin 600 mg PO HS 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. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 5. Rosuvastatin Calcium 20 mg PO DAILY 6. 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 7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not exceed 4000 mg of aceatminophen in 24 hours. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> serous 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: * 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. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor ___ ___ 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 laparoscopic bilateral salpingo-oopherectomy converted to exploratory laparotomy, total abdominal hysterectomy, pelvic and para-aortic lymph node dissection and omentectomy for likely serous adenocarcinoma. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with a dilaudid PCA, IV toradol and IV acetaminophen. Her diet was advanced slowly without difficulty. On postoperative day #2, she was transitioned to oral percocet and motrin for pain control. Her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She received 2 doses of kefzol postoperatively. She received lovenox for venous thromboembolism prevention. By post-operative day #3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11337374-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine <ATTENDING> ___ <CHIEF COMPLAINT> endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G0 who had postmenopausal bleeding in ___. Endometrial biopsy was done which showed a grade 1 endometrial cancer. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> 1. Asthma. 2. Hypertension. 3. Hypercholesterolemia, new. 4. She is up-to-date on mammograms and colonoscopies. Past Surgical History: Multiple left foot surgeries secondary to fracture in ___. Recent amputation of the fourth toe of her right foot secondary to pain and deformity - she has recovered well. Past Ob/Gyn History: G0. Menopause in the early ___. No history of abnormal Paps. She was on hormone replacement for six to ___ years. Known fibroids. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of ovarian, colon, or uterine cancer. Maternal great aunt had breast cancer. <PHYSICAL EXAM> PreOp exam: On exam, she is in no acute distress. She appears her stated age. Affect is appropriate. Eyes anicteric. Mouth moist. Neck: Supple. No supraclavicular lymphadenopathy. Heart: Regular rate and rhythm. Lungs: Clear bilaterally. No CVA tenderness. No skin rashes. Abdomen: Soft, obese, nontender, no masses, hepatosplenomegaly, or hernias. No groin adenopathy, no lower extremity edema. External genitalia unremarkable. Introitus smooth. Vaginal mucosa is smooth. The vagina is somewhat narrowed. Cervix is nulliparous. On rectovaginal exam, a smooth mass is appreciated in the cul-de-sac. Clinically, this is consistent with a fibroid. On Discharge: AVSS NAD RRR CTAB Abdomen soft, ND, appropriately TTP, incision c/d/i without erythema ext NT, NE <PERTINENT RESULTS> ___ 05: 14PM WBC-10.5# RBC-3.70* HGB-11.0* HCT-34.4* MCV-93 MCH-29.7 MCHC-32.0 RDW-12.8 ___ 05: 14PM PLT COUNT-159 ___ 05: 14PM NEUTS-79* BANDS-8* LYMPHS-8* MONOS-5 EOS-0 BASOS-0 ___ MYELOS-0 ___ 05: 14PM GLUCOSE-201* UREA N-32* CREAT-1.8* SODIUM-138 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-19* ANION GAP-16 ___ 05: 14PM CALCIUM-9.5 PHOSPHATE-4.3 MAGNESIUM-2.1 Pathology: Tumor limited to endometrium,invasion 10%. Involves LUS, cervix/ ov/ tubes benign. washings benign. lymph nodes benign. <MEDICATIONS ON ADMISSION> Atenolol 100, celexa 20, lisinopril 40, zocor 40 <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 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 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* 4. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). <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> 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. ___ was admitted to GYN oncology after uncomplicated total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection for grade 1 endometrial cancer. Her postoperative course was routine. By discharge on postop day 4, she was ambulating, voiding, spontaneously, tolerating regular diet, and her pain was well controlled with oral medications.
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11337568-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> peanuts, shell fish <ATTENDING> ___. <CHIEF COMPLAINT> pelvic inflammatory disease <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, mild RLQ tenderness, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> -- Labs -- ___ 04: 40PM BLOOD WBC-6.3 RBC-3.99 Hgb-11.6 Hct-37.5 MCV-94 MCH-29.1 MCHC-30.9* RDW-13.7 RDWSD-46.8* Plt ___ ___ 04: 40PM BLOOD Neuts-52.0 ___ Monos-7.9 Eos-4.6 Baso-0.9 Im ___ AbsNeut-3.30 AbsLymp-2.18 AbsMono-0.50 AbsEos-0.29 AbsBaso-0.06 ___ 04: 40PM BLOOD ___ PTT-31.2 ___ ___ 04: 40PM BLOOD Glucose-76 UreaN-7 Creat-0.7 Na-138 K-4.1 Cl-104 HCO3-23 AnGap-15 -- Urine -- ___ 04: 30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04: 30PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG ___ 04: 30PM URINE Mucous-RARE ___ 04: 30PM URINE UCG-NEGATIVE -- Microbiology -- ___ 6: 56 pm SWAB Site: CERVIX **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. -- Imaging -- CT Abdomen/Pelvis ___ IMPRESSION: 1. Normal appendix. 2. Large fecal loading of the colon. 3. Right ovarian dermoid as seen on same-day pelvic ultrasound. 4. Uterine fibroid also better assessed on same-day pelvic ultrasound. Pelvic Ultrasound ___ FINDINGS: The uterus is anteverted and measures 7.8 x 3.6 x 5.2 cm. The endometrium is homogenous and measures 11 mm. A fundal fibroid is noted. The right ovary measures 5.3 x 2.2 x 3.2 cm. A heterogeneous mass is seen with an, consistent with a dermoid, and measures 3.4 x 3.2 x 3.5 cm. Normal arterial and venous Doppler waveforms are seen within. In addition, a corpus luteum is seen within the right ovary. There is small pelvic free fluid. The left ovary is normal. IMPRESSION: 1. 3 cm dermoid in the right ovary. Normal arterial and venous waveforms. No definite evidence of torsion, though intermittent torsion difficult to exclude. 2. Right-sided corpus luteum cyst with small pelvic free fluid. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Doxycycline Hyclate 100 mg PO Q12H Limit sun exposure, wear sunscreen when outside RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice per day Disp #*27 Tablet Refills: *0 2. Ibuprofen 400 mg PO Q8H: PRN Pain - Moderate Please take with food RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills: *0 3. Ondansetron ___ mg PO Q8H: PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic inflammatory disease <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 treatment of pelvic inflammatory disease. 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. For your pelvic inflammatory disease: * Continue taking doxycycline for 14 days as prescribed. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * You may eat a regular diet. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * 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 for inpatient treatment of presumed PID. Her hospital course is detailed as follows: Upon presentation to the ED, patient had a pelvic ultrasound to evaluate right lower quadrant pain. Ultrasound showed a 3 cm dermoid cyst in the right ovary with normal arterial and venous waveforms and no evidence of torsion. On exam, there was no evidence of torsion or cervical motion tenderness although patient exhibited voluntary guarding upon RLQ palpation. She had a CT scan that showed normal appending ruling out possible appendicitis. Given these findings, she was initiated on treatment for presumed PID with ceftriaxone IM and PO doxycycline. Patient was unable to tolerate PO doxycycline and was transferred to the inpatient floor for IV antibiotics. Of note, patient was afebrile with a white count of 6.3. She was started on IV gentamicin and clindamycin for 24 hour course. She received IV fluids for hydration. She received IV toradol for pain control. On hospital day 1, she was slowly encouraged to try PO intake. Her diet was advanced without difficulty. She was transitioned to PO oxycodone and ibuprofen for pain control. Once she was tolerating a regular diet, she was transitioned to PO doxycycline and was able to tolerate the medication. By hospital 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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11337783-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Prednisone / amlodipine / Cortisone <ATTENDING> ___. <CHIEF COMPLAINT> initially presented with RUQ pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-ophorectomy <HISTORY OF PRESENT ILLNESS> ___ gravida 1 para 1 with multiple medical comorbidities including renal failure on dialysis with recent diagnosis of endometrial intraepithelial neoplasia. She reports she was complaining of right lower pelvic groin pain and an ultrasound was obtained. Ultrasound on ___ showed a small anteverted uterus with a thickened endometrium of 15 mm and a 1 cm cervical polyp. She had previously had a CT scan for right upper quadrant pain showing thickened endometrium. She denies any postmenopausal bleeding. She reports she is anxious about this diagnosis but is overall in her baseline state of health. Again, she denies any vaginal bleeding or abnormal vaginal discharge. She notes intermittent sometimes right lower pelvic pain. She has no other localizing symptoms. Continues to receive hemodialysis at ___ 3 times a week. On further review of systems, patient denies any significant chest pain or shortness of breath. She reports that she does get short of breath when walking down a single block. No recent fevers or chills, no nausea or vomiting. She reports stable bowel and bladder function. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Anemia: Normacytic. 2. Arthritis. 3. CAD: CHF. 4. Diabetes. 5. High cholesterol. 6. Hypertension. 7. Incontinence: Urge. 8. Stage V CKD diabetic nephropathy on hemodialysis. 9. Hep B. 10. COPD severe restrictive. PAST SURGICAL HISTORY 1. Laser OS. 2. Right UE AV fistula ___. 3. Neurome right foot ___. PAST OB HISTORY: G1P1 - NSVD x 1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian, uterine or colon cancers. Her mother is deceased from leukemia. Her father deceased of kidney disease. She lost a son to a sudden heart attack at age ___ and subsequently his son passed away only a year ago at age ___ also a sudden cardiac event. She has 2 other grandchildren who she helped raise following her son's death in addition to the one who passed away last year. <PHYSICAL EXAM> Physical Exam at Initial Presentation: ___ CONSTITUTIONAL: Well appearing, NAD NEURO: A&Ox3, walks with walker but is able to move around exam room independently. PSYCH: Normal affect HEENT: NCAT, EOMI, Sclera anicteric, Neck supple, no masses LYMPH NODES: No supraclavicular, cervical or inguinal adenopathy. GI: Soft, obese, ND, NT. No hepatosplenomegaly, no masses palpable GU: No CVA tenderness, NEFG, normal urethral meatus. Normal vaginal vault no blood or discharge, cervix without lesions. Bimanual: Smooth vaginal walls, cervix without lesions. Very small, mobile, sharply anteverted uterus. No adnexal masses or tenderness. MSK: Extremities WWP. ___ without edema, nontender. Physical Exam at Discharge ___/: Neuro: AxOx3 CV: RRR, no rubs/murmurs/gallops Pulm: LCTAB, normal WOB Abd: obese, normoactive BS, soft, nondistended, nontender, no rebound or guarding, incisions with dermabond, dry and intact with minimal bruising but without any surrounding erythema MSK: ___ without edema, erythema, or TTP. pneumoboots in place <PERTINENT RESULTS> ___ 06: 41PM PLT COUNT-217 ___ 06: 41PM WBC-8.6 RBC-4.23 HGB-12.2 HCT-39.7 MCV-94 MCH-28.8 MCHC-30.7* RDW-14.4 RDWSD-48.8* ___ 06: 41PM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-2.2 ___ 06: 41PM estGFR-Using this ___ 06: 41PM GLUCOSE-250* UREA N-25* CREAT-4.5* SODIUM-137 POTASSIUM-5.7* CHLORIDE-93* TOTAL CO2-30 ANION GAP-14 <MEDICATIONS ON ADMISSION> AMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) (Not Taking as Prescribed) B COMPLEX WITH ___ ACID [NEPHROCAPS] - Nephrocaps 1 mg capsule. 1 capsule(s) by mouth once a day - (Prescribed by Other Provider) CALCIUM ACETATE - calcium acetate 667 mg capsule. 1 capsule(s) by mouth three times a day Take 1 capsule with each meal. CARVEDILOL - carvedilol 25 mg tablet. 1 tablet(s) by mouth twice a day - (Not Taking as Prescribed) FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) FUROSEMIDE - furosemide 40 mg tablet. 1 tablet(s) by mouth twice a day - (Not Taking as Prescribed) INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous solution. 14 units in a.m.,10 units in p.m. units IM several times weekly - (Prescribed by Other Provider; Dose adjustment - no new Rx) SIMVASTATIN - simvastatin 40 mg tablet. 1 tablet(s) by mouth at bedtime - (Prescribed by Other Provider) (On Hold from ___ to unknown for Interaction concern.) <DISCHARGE MEDICATIONS> 1. Acetaminophen (Liquid) 650 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 4000mg in 24 hours RX *acetaminophen [8HR Muscle Ache-Pain] 650 mg ___ tabs by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID hold for loose stools RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity do not drink or drive on this medication RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 hours as needed Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> endometrial intraepithelial neoplasia end-stage diabetic nephropathy on dialysis congestive heart failure chronic obstructive pulmonary disease hypertension <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 after undergoing the procedures listed below. Your potassium level was high on ___, and so you received additional dialysis while in the hospital. You received your regular scheduled dialysis on ___ and ___. You remained on oxygen in order to keep your oxygen levels in a normal range. You had a chest XRAY which showed signs of congestive heart failure. You were given inhaled medications for your lungs, your oxygen levels improved, and you were able to be weaned off of oxygen. You worked with physical therapy, who recommended discharging you to a rehabilitation center in order to work more with physical therapy to improve your strength. 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 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. * 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 ___. 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.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing robotic-assisted, total laparoscopic hysterectomy and bilateral salpingo-ophorectomy. 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 Tylenol. Her diet was advanced without difficulty and she was transitioned to oral dilaudid and acetaminophen. On post-operative day #1, her Foley catheter was removed. Patient has baseline anuria, and did not void while inpatient. Nephrology was consulted, given patient's history of ESRD on HD due to diabetic nephropathy. On post-operative day #0, patient was hyperkalemic to 5.7. EKG was unchanged from baseline and patient was given IV insulin and dextrose. On post-operative day #1, patient's potassium was 6.0 and she was dialyzed for hyperkalemia. While inpatient, she received scheduled dialysis treatments on post-operative days #3 and #5 (consistent with her outpatient dialysis schedule of ___, and ___. Patient's fingersticks were checked inpatient and elevated to 200-300s range. She was covered with a Humalog insulin sliding scale initially, and was then transitioned to her home Lantus regimen when she began tolerating oral intake. Given her history of congestive heart failure and COPD, patient's oxygen saturations were closely monitored while inpatient. Patient's initial pre-operative oxygen saturation was 96% on room air, however she was requiring 1 liter of oxygen to maintain normal saturations post-operatively. Patient was unable to be weaned off of oxygen on post-operative day #3. A chest xray was obtained which revealed no evidence of pneumonia or significant pulmonary edema. Patient received one treatment of albuterol/ipratropium on post-operative day #4 and was able to be weaned off of oxygen. In the early morning on post-operative day #5, patient's oxygen saturations were noted to be in the low 80's on room air while she was sleeping. When nursing team attempted to place nasal cannula for oxygen, she awoke with delirium and severe agitation. A code purple (psychiatric emergency code) was called and psychiatry arrived to help take care of her as well. Her vitals were notable for blood pressure in 150s/80s, heart rate 110s, oxygen saturations 96% on room air. She was oriented to person and place but was not oriented to year. She was irritable with disorganized thought processes and was actively pulling out her IV lines and telemetry leads. Her agitation was not amenable to redirection and she was refusing medical intervention in the setting of hypoxia, so she was given IM Haldol 0.5mg and briefly mechanically restrained to protect her safety. Team ordered infectious workup due to concern for infection causing delirium, however patient refused a chest xray, electrocardiogram, electrolytes, urine studies, and telemetry. The following morning, patient was alert and oriented to person, place, and time, and denied confusion. Her family members present bedside stated that patient had returned to her baseline. She worked with physical therapy while inpatient on strength and mobility. Physical therapy recommended patient be discharged to an ___ rehabilitation facility to to improve functional independence. Patient adamantly declined rehabilitation facility, however she accepted physical therapy services at home. For DVT prophylaxis, patient received subcutaneous heparin twice daily and wore pneumoboots. By post-operative day #5, she was tolerating a regular diet, voiding spontaneously, ambulating with assistance of walker per her baseline, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled and physical therapy home services arranged.
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11337848-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> heavy menstrual bleeding and suspected adenomyosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> HYSTERECTOMY VAGINAL; BILATERAL SALIPINGECTOMY <HISTORY OF PRESENT ILLNESS> S: pt reutrns for pre-op visit. Menses started again, using TXA with some decrease in flow. notes nausea that starts with menses. no orthostatic symtpoms. ___ has decided on definitive treatment with hysterectomy. She continues to experience significant bleeding with prolonged periods lasting ___ days despite OCs. She has vertigo and dizzyness with her periods (baseline BPV, worse during menses, this has been evaluated by neurology in the past without clear etiology determined, and experiences nausea as well. She has tried hormonal and conservative surgical management with little relief. She is done with childbearing. <PAST MEDICAL HISTORY> Problems (Last Verified ___ by ___, MD): ABDOMINAL PAIN duodenal ulcer ___. gastritis ___, tx'd for h. pylori. IRREGULAR MENSES MEMORY PROBLEMS MICROSCOPIC HEMATURIA PCOS hirsuitism POSITIVE HEPATITIS A ANTIBODY ___ PREMENSTRUAL SYNDROME SEIZURE DISORDER ___ HEADACHE CARPAL TUNNEL SYNDROME PCOS HYPOTHYROIDISM H/O HEART MURMUR ___ nl echo ___ H/O POSITIVE H. PYLORI ___ treated with prevpac. H/O SHORTNESS OF BREATH ___ Mild Restrictive ventilatory effect H/O PAS POSITIVE RIGHT BIG TOENAIL H/O NAUSEA H/O OVERACTIVE BLADDER prev. on oxybutynin H/O ABNORMAL PAP SMEAR ___ ASCUS/HPV+ ___ colpo - neg ECC ___ neg pap ___ neg pap ___ neg pap/neg HPV Surgical History (Last Verified ___ by ___, MD): HYSTEROSCOPY ___ BREAST FIBROADENOMA ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family History (Last Verified ___ by ___, MD): Relative Status Age Problem Onset Comments Mother Living Father Living ___ HYPERTENSION MGM Deceased PANCREATIC CANCER MGF DIABETES MELLITUS PGM Deceased ESOPHAGEAL CANCER <PHYSICAL EXAM> INITIAL EXAM Pleasant female, NAD Abdomen: soft, NT, no CVAT or masses, no inguinal lymphadenopathy Ext Gen: normal female, no lesions discharge or blood Vagina: no lesions, discharge or blood Cx: parous, no CMT, no lesion or blood Ut: 7-8 cm, retroverted , NT, mobile Adn: NE, NT Rectal: deferred Extr: no edema, calf tenderness. -========= -------------------- 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> levoxyl 50mcg QD, omeprazole, colace <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Severe Take with food. 3. Ondansetron ODT 4 mg PO Q8H: PRN Nausea/Vomiting - First Line Can take with oxycodone to reduce nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*15 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. 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Omeprazole 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> heavy menstrual bleeding and suspected adenomyosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. 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 ___ BS for heavy menstrual bleeding and suspected adenomyosis. Please see the operative report for full details. *)Post-op She was admitted after her procedure due to post-operative nausea and pain control issues. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid/Toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone/ibuprofen/acetaminophen. *) Hypothyroidism: She continued her home dosage of levothyroxine during her admission. 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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11341761-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> 1. Uterine prolapse. 2. Stress urinary incontinence with urethral hypermobility. 3. Vault prolapse. 4. Cystocele. <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Total vaginal hysterectomy. 2. Tension-free vaginal tape Exact sling procedure. 3. Bilateral sacrospinous ligament vault suspension. 4. Cystoscopy. <HISTORY OF PRESENT ILLNESS> ___ yo G4P3SAb1 with POP. She has been using a pessary for approximately ___ year for pelvic floor prolapse, and is becoming less satisfied with this method as she developed symptoms of SUI with the restoration of normal pelvic support. Additionally she has had episodes of bacterial vaginitis. She would like at this time to move toward surgery. She has consulted with ___ uro-gyn, who evaluated for stress urinary incontinence. His recommendations included placement of a TVT sling and an anterior colporrhaphy. The patient has been counseled on several occasions regarding risks and benefits of surgery and would like to proceed. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> BACK PAIN H. PYLORI HORDEOLUM HYPERLIPIDEMIA TOBACCO ABUSE PastSurgical History: TUBAL LIGATION CYSTOCELE RECTOCELE OB/GYN History 1. D&C. 2. SVD: First pregnancy was a twin pregnancy, babies delivered by forceps, second twin died, near term. Largest baby was 3.7kg, smallest ( both twins ) 2kg. twin pregnancy complicated by pre-eclampsia, pt states she "was in a coma for 10 days" after the delivery, doesn't think she had seizures; delivered in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> nc <PHYSICAL EXAM> On day of discharge: NAD/ well appearing CV: RRR Lungs: CTABL Abd: soft, NT, ND incisions C/D/I minimal vaginal bleeding Ext: wnl <PERTINENT RESULTS> ___ 07: 00PM WBC-19.1*# RBC-4.12* HGB-12.3 HCT-36.5 MCV-89 MCH-29.8 MCHC-33.6 RDW-12.8 ___ 07: 00PM PLT COUNT-294 <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your surgery. You have recovered well and the team believes you are ready to be discharged home. 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) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. 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 vaginal hysterectomy, tension free vaginal tape exact sling, bilateral sacrospinous ligament vault suspension, and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with tylenol and dilaudid. On post-operative day 1, her urine output was adequate so her foley was removed. Her diet was advanced without difficulty and she was transitioned to flexeril, tylenol, and oxycodone. 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. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain do not take over 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h:prn Disp #*50 Tablet Refills:*0 2. Cyclobenzaprine 10 mg PO TID:PRN pain RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth q8h:prn Disp #*20 Tablet Refills:*0 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain may cause drowsiness: DO NOT drive, take with alcohol or sedatives RX *oxycodone 5 mg 1 capsule(s) by mouth q4-6h:prn Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1. Uterine prolapse. 2. Stress urinary incontinence with urethral hypermobility. 3. Vault prolapse. 4. Cystocele. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11343077-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodinated Contrast Media - IV Dye <ATTENDING> ___. <CHIEF COMPLAINT> Acute blood loss anemia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Endometrial Biopsy <HISTORY OF PRESENT ILLNESS> ___ G5P3 presents complaining of ongoing vaginal bleeding with clots x 2 weeks. She reports that she has had irregular bleeding since ___ with her menses skipping every other month. In ___, she did bleed for two weeks. This month, she has bled for 2 weeks, bleeding from 2 pads a day to 8 pads a day. She reports blood clots passing. She was prescribed provera 10mg daily by her PCP, which she took for just ___ days. She has felt many episodes of feeling dizzy and lightheaded. Her husband states that she appears pale. She says that clots continue to come out particularly when she walks or coughs. Today, she felt like she almost had a syncopal event. ROS: She also complains of subacute epigastric and RUQ pain intermittently to the ED team, which she no longer endorses at the time of my interview. She denies dysuria, changes in urinary frequency, constipation, diarrhea, changes in appetite, abdominal enlargement or pelvic pain. <PAST MEDICAL HISTORY> PMH: asthma PSH: left ankle surgery OBHx: G5P3 SAB x2 SVD x 3, last in ___ GYNHx: last Pap wnl in ___, no abnl Paps <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father with stomach cancer, no family history of ovarian, cervical, endometrial, breast or colon cancer. No family history of blood clots <PHYSICAL EXAM> Physical Exam on Admission 97.9 120 127/81 20 100% on RA 99.8 88 ___ 99% on RA Gen: A&O, NAD, pale appearing CV: RRR Resp: CTAB Abd: soft, NT/ND, no rebound or guarding Ext: calves nontender bilaterally, no c/c/e SSE: Normal vaginal mucosa with pink tinge, no lesions Normal cervix with pink tinge, no lesions 4 scopettes of blood in vault, with one golf size clot Dark blood from os BME: Anteverted uterus No fundal tenderness No adnexal tenderness bilaterally Physical Exam on Discharge Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, nontender, nondistended. +BS GU: Mild spotting on pad Ext: no TTP <PERTINENT RESULTS> ___ 06: 22AM BLOOD WBC-6.8 RBC-3.27* Hgb-8.7*# Hct-27.8* MCV-85 MCH-26.6 MCHC-31.3* RDW-19.9* RDWSD-55.6* Plt ___ ___ 02: 45PM BLOOD WBC-6.8 RBC-2.72* Hgb-6.9* Hct-22.7* MCV-84 MCH-25.4* MCHC-30.4* RDW-19.9* RDWSD-51.4* Plt ___ ___ 02: 45PM BLOOD Neuts-71.2* Lymphs-17.0* Monos-6.8 Eos-3.1 Baso-0.3 NRBC-0.3* Im ___ AbsNeut-4.85 AbsLymp-1.16* AbsMono-0.46 AbsEos-0.21 AbsBaso-0.02 ___ 02: 45PM BLOOD ___ PTT-25.1 ___ ___ 02: 45PM BLOOD Glucose-169* UreaN-6 Creat-0.7 Na-139 K-3.5 Cl-105 HCO3-22 AnGap-16 ___ 02: 45PM BLOOD ALT-29 AST-25 AlkPhos-50 TotBili-0.2 DirBili-0.1 IndBili-0.1 ___ 02: 45PM BLOOD Lipase-20 ___ 02: 45PM BLOOD Albumin-3.9 ___ 02: 45PM BLOOD HCG-<5 . Pathology Pending . Pelvic Ultrasound (___) IMPRESSION: 9 mm posterior uterine fibroid. Heterogeneous endometrium likely due to current menstruation. Otherwise unremarkable pelvic ultrasound. . Liver/Gallbladder Ultrasound (___) IMPRESSION: Normal right upper quadrant ultrasound. No acute process identified. . <MEDICATIONS ON ADMISSION> Omeprazole, albuterol, flovent <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler ___ PUFF IH Q4H: PRN SOB 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. MedroxyPROGESTERone Acetate 10 mg PO Q12H RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth twice a day Disp #*18 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *0 5. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Abnormal uterine bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for vaginal bleeding and acute blood loss anemia. You have recovered well and the team believes you are ready to be discharged home. Please call the Resident Clinic at ___ with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * No strenuous activity 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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On ___, Ms. ___ was admitted to the gynecology service after being seen in the Emergency Department for acute blood loss anemia due to abnormal uterine bleeding. . On initial presentation, patient had a hematocrit of 22.7. She was given 2 units of pRBCs and hematocrit increased to 27.8. Her bleeding was controlled with Provera 10mg BID. Pad counts were performed. . On hospital day 2, an endometrial biopsy was performed in gyn triage for endometrial sampling. Please see procedure note for more details. . By hospital day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and bleeding was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11343077-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodinated Contrast Media - IV Dye <ATTENDING> ___. <CHIEF COMPLAINT> abnormal uterine bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingectomy, rigid sigmoidoscopy, cystoscopy, lysis of ahesions, repair of bowel serosa, and ureterolysis <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G5P3 with persistent abnormal bleeding since ___ resulting in acute on chronic blood loss anemia to hct of 22 requiring hospitalization and transfusion of pRBC, now s/p confirmed expulsion of Mirena IUD. Presents today for f/u visit and further discussion of management. Her brief history is as follows: She began having heavy bleeding at the end of ___. She had previously had regular periods until ___ when her periods became more irregular. She was admitted to Gyn service from ___ after 2 weeks of heavy bleeding and passing clots, with symptomatic blood loss anemia, resulting in hct 22.7. She was transfused 2 units of pRBCs with increase in Hct to 27.8. PUS revealed a 9 mm posterior uterine fibroid and heterogenous endometrium likely due to mentruation, otherwise normal. EMB was performed and benign. She was started on Provera which improved her bleeding. I then saw her in clinic on ___ where she underwent Mirena IUD placement. She then developed acutely worsening and heavy bleeding around ___ and seen in triage on ___ where there was no e/o IUD on exams. PUS and KUB confirmed expulsion. She was placed on Provera BID again. She was then seen by Dr. ___ on ___ at which point her bleeding was improved but not resolved. She was counseled on all options for management and ultimately decided to proceed w DMPA, first injection received at that visit. At that visit, she also reported persistent mild lower abdominal discomfort and fullness, unrelieved by tylenol. She reports that she is still continuing to bleed. She is using approx 3 pads per day, no clots. She continues to have lower abdominal pressure and fullness. Some discomfort w urinating but no burning. Moving bowels regularly. She is using tylenol w/o relief. She is very frustrated and strongly desires definitive management w hysterectomy. She denies dizziness, chest pain, shortness of breath, nausea, vomiting, hot flashes. She also notes that she has an umbilical hernia. She has recently undergone CT imaging at ___ and has an appt to see a General Surgeon at ___. She is interested in doing a combined procedure for hysterectomy and hernia repair if possible. <PAST MEDICAL HISTORY> PMH: asthma PSH: left ankle surgery OBHx: G5P3 SAB x2 SVD x 3, last in ___ GYNHx: last Pap wnl in ___, no abnl Paps <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father with stomach cancer, no family history of ovarian, cervical, endometrial, breast or colon cancer. No family history of blood clots <PHYSICAL EXAM> Physical Exam Discharge AVSS Gen NAD CV RRR P CTAB Abd soft, nondistended, appropriately tender to palpation, incisions c/d/I Ext WWP <PERTINENT RESULTS> ___ 07: 00AM HCT-40.0# <MEDICATIONS ON ADMISSION> Albuterol INH Flovent Omeprazole <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Maximum 4000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Ferrous Sulfate 325 mg PO DAILY 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abnormal uterine bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing total laparoscopic hysterectomy, bilateral salpingectomy, rigid sigmoidoscopy, cystoscopy, lysis of ahesions, repair of bowel serosa, and ureterolysis for abnormal uterine bleeding. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, ibuprofen, and Tylenol (pain meds). She was maintained on Ancef and Flagyl for 24 hours post operatively, given the extensively adherent bowel requiring careful intraoperative dissection and oversewing of the bowel serosa. The JP drain in the left lower quadrant had minimal output, serosanguinous in nature, and was removed on POD1. 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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11343811-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic organ prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> total vaginal hysterectomy vaginal vault suspension suburethral sling <HISTORY OF PRESENT ILLNESS> Mrs. ___ returns today stating that she has stopped her Trospium because she ran out of refills. She reports worsening nocturia up to 5 times. She admits to stress incontinence events with coughing and lifting. Mrs. ___ reports lower pelvic pressure and discomfort.She had tried a pessary but had it removed and is inquiring about surgical options. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> GERD, anxiety, depression, high cholesterol Past Surgical History: RSO, Appendectomy, cholecystectomy OB History: G4P3 <SOCIAL HISTORY> ___ <FAMILY HISTORY> N/A <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3, comfortable CV: RRR Resp: no acute respiratory distress, CTAB Abd: soft, nontender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> ___ 07: 05AM BLOOD WBC-8.2 RBC-3.52* Hgb-10.3* Hct-31.5* MCV-90 MCH-29.3 MCHC-32.7 RDW-13.2 RDWSD-43.3 Plt ___ <MEDICATIONS ON ADMISSION> levothyroxine 75 mcg daily meclizine 25 mg TID prn vertigo metformin ER 500 mg daily omeprazole 40 mg daily pravastatin 10 mg QHS trazodone 100 mg QHS tropsium 20 mg BID venlafaxine ER 150 mg daily ASA 81 mg daily <DISCHARGE MEDICATIONS> 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Omeprazole 40 mg PO DAILY 3. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain ___ cause drowsiness RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 4. Venlafaxine XR 150 mg PO DAILY 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth every 12 hours Disp #*60 Capsule Refills: *2 6. Acetaminophen 650 mg PO TID Do not exceed 4000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *2 7. Ibuprofen 400 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse stress urinary incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. 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 vaginal hysterectomy, vault suspension, TVT, and cystoscopy for pelvic organ prolapse. 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. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, ibuprofen, and acetaminophen. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: instilled 300 mL, voided 250mL with 174mL residual on bladder scan. She the voided 200mL spontaneously 0mL residual on bladder scan. 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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11346199-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> menorrhagia, dyspnea on exertion, weakness/fatigue <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___ yo G3P1112 with current vaginal bleeding that began on ___. Her heavy vaginal bleeding has persisted since that time requiring "doubling up on Tampons and pads" with clots. Today, her bleeding has decreased. the patient presented to her PCP ___. She reported dyspnea on exertion x 7 days. Her PCP obtained ___ HCT which returned as 15. She was called into the ED for evaluation and transfusion. The patient missed her menstrual period in ___ previous to that she had regular cycles that were becoming heavier. Currently, patient denies shortness of breath, chest pain, lightheadedness, dizziness. Tired. <PAST MEDICAL HISTORY> GYNHx: Regular cycles until ___. Increasing flow over last 6 months with clots. Denies STIs Denies abnormal Paps; last Pap within last year and normal Infertility; unexplained OBHx: 1 C/S for 32 week NRFHR with PPROM at 29 weeks; chorio 1 Repeat C/S Term 9# 11 oz 1 SAB PMHx: Denies PSHx: Endometrial biopsy for infertility workup diagnostic LSC for infertility workup breast reduction egg retrieval <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> 94-109, 118/68, 100% room air, 16 well, NAD, appears slightly pale, able to sit up without difficulty and get into stretcher RRR, Lungs clear anteriorly and posteriorly Abd: soft, non-tender, no peritoneal signs, well healed Phannenstiel incision Bimanual: Slightly enlarged uterus, non-tender, no adnexal masses, no adnexal tenderness Speculum: 5 scolpettes used to remove 20 cc of blood in vault. Small amount of dark blood from os. Os closed. No clots seen. Ultrasound: Uterus 111x7x7.6 cm, 2.7 cm Endometrial stripe. Small 2-3 cm fundal fibroid. Simple cyst left ovary 2x2cm. Prelim read <PERTINENT RESULTS> ___ 05: 00PM ___ PTT-22.4 ___ ___ 05: 00PM PLT COUNT-404 ___ 05: 00PM WBC-5.2 RBC-1.81* HGB-5.3* HCT-15.9* MCV-88 MCH-29.3 MCHC-33.4 RDW-15.5 ___ 05: 00PM cTropnT-<0.01 ___ 05: 00PM GLUCOSE-112* UREA N-7 CREAT-0.7 SODIUM-139 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp: *10 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> menorrhagia, symptommatic anemia <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience heavy vaginal bleeding requiring one pad a hour, chest pain, trouble breathing, dizziness, fainting or near-fainting, or if you have any other questions or concerns. - Please keep your follow-up appointments as outlined below.
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The patient was admitted to the gynecology service and transfused 2 units pRBCs without complication. Hematocrit rose appropriately from 15.1 to 22.2. Dyspnea, weakness, and fatigue resolved. The patient felt well on HD#2.
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11350046-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> transfer for preeclampsia <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary LTCS <HISTORY OF PRESENT ILLNESS> ___ yo G3P1 at 31w6d transferred from ___. She was followed for a prior h/o an SGA infant with growth scans and was noted to have an EFW ___ of 36%ile which was repeated on ___ and noted to be ___ percentile with elevated dopplers. She was also noted to have mild-range blood pressures and was worked up for pre-eclampsia and noted to have a UP: C ratio of 1.9. She of note did have one blood pressure recorded in ___ of 145/74. She was send to L&D for evaluation and was noted on fetal testing to have 2 spontaneous decelerations, only description notes a 2.5min decal to nadir of 60 with recovery to moderate variability. She was given betamethasone ad 1520 and started on magnesium 4->2 for neuroprotection and transferred to ___ for further workup and evaluation. She currently reports a slight headache which she attributes to having had nothing to eat all day. She did note mild leg swelling that started yesterday. She denies visual changes or epigastric pain, SOB, CP, VB, ctx, LOF. +FM. Also reports a recent cold with mild cough. Denies fevers. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w early ultrasound - Labs Rh +/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS unk - Screening LR NIPT - FFS normal, ant placenta - GTT normal - U/S ___ <10%ile, S/D 3.95, AFI 13.6 BPP ___, vertex - Issues *) likely CHTN with SIP, no baseline labs *) h/o SGA infant *) newly diagnosed IUGR OBHx: - SVD x1 of SGA infant at term - SAB x1 GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - h/o depression, not on meds - vitamin D deficiency - hypercholesterolemia PSH: - liposuction <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS: HR 78 BP 144/89 Gen: A&O, comfortable CV: RRR PULM: normal work of breathing, CTAB with occasional cough Abd: soft, gravid, nontender Ext: no calf tenderness, trace edema bilaterally. pboots in place SVE: deferred Toco isolated ctx FHT 125/moderate variability/+10x10 accels/-decels <PERTINENT RESULTS> ___ WBC-9.7 RBC-3.61 Hgb-12.7 Hct-36.7 MCV-102 Plt-187 ___ Creat-0.6 ALT-14 AST-22 LD(LDH)-181 UricAcd-6.9 Hapto-98 ___ URINE pH-6 Hours-24 Volume-1600 Creat-89 TotProt-214 Prot/Cr-2.4 ___ URINE 24Creat-1424 24Prot-3424 R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> -Preeclampsia with severe features -Cesarean 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 baby! Please refer to your discharge packet and the instructions below: -Nothing in the vagina for 6 weeks (No sex, douching, tampons) -No heavy lifting for 6 weeks -Do not drive while taking oxycodone -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 100.4 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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___ yo G3P1 with likely cHTN admitted at 31w6d with superimposed preeclampsia and IUGR/elevated dopplers. On admission, she had mild range blood pressures and labs notable only for an elevated uric acid (6.9) and urine p/c (2.4). Fetal testing was reassuring. She was admitted to the antepartum service for close monitoring and a 24 hour urine collection. Her blood pressures remained in the mild range and her 24 hour urine revealed 3424mg of protein. In the evening on ___, her NST was concerning for late decelerations and she was transferred back to labor and delivery. Her tracing remained nonreassuring with recurrent late decels and the decision was made to proceed with delivery. She was delivered by primary LTCS at 32w0d and delivered a liveborn female weighing 1280 grams with Apgars of 6 and 9. Neonatology staff was present for delivery and transferred the baby immediately for prematurity. Please see operative report for details. . Ms ___ had an uncomplicated postop course. She did not require any anti-hypertensive medication and her BPs stayed in the normal to mildly elevated range. She was discharged home in stable condition on POD#4 and will get a BP check within one week at CHA.
| 1,161
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11353478-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal birth <HISTORY OF PRESENT ILLNESS> ___ G3P1 @ ___ GA presents with painful ctxs. SROM @ 0215. +AFM. ___ ___ by early u/s. B+/Ab neg/HBsAg neg/RPRNR/RI/GBS neg low risk ERA, nl FFS, declined amnio GDMA2: per OMR on humalog ___ Most recent EFW 36% <PAST MEDICAL HISTORY> PMH: asthma - no hospitalizations or intubations, depression, GDMA2 as above PSH: appy, bunionectomy POb: SVD x 1, 8#7, TAB x 1 PGyn: h/o small anterior fibroid in prior preg, not described on imaging since. H/o abnl paps -> no cervical surgeries <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On Admission: ___ 119 T 95.3 HR 84 BP 133/70 Gen: uncomfortable Abd soft, NT, gravid SVE: fully in triage Ext NT, no edema <PERTINENT RESULTS> ___ 04: 46AM WBC-12.9* RBC-3.51* HGB-11.3* HCT-32.4* MCV-92 MCH-32.3* MCHC-35.0 RDW-13.8 ___ 04: 46AM PLT COUNT-207 <MEDICATIONS ON ADMISSION> PNV, albuterol prn, humalog <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: *1* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *60 Capsule(s)* Refills: *2* 3. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for Pain. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal birth Gestaional Diabetes, insulin-requiring Back spasm <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Pelvic Rest
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Ms. ___ is a ___ G3P1 with GDMA2 who was admitted to L&D in active labor. She had an uncomplicated vaginal delivery on ___. During her postpartum course she was followed by ___ who monitored and then discontinued fingersticks as her blood sugar was in satisfactory range. She will have 6 week follow up. Her postpartum course was complicated by back spasm for which she took flexeril as well as NSAIDs and used heat and ice. ___ was consulted and her symptoms resolved with time. She was discharged home in stable condition on post-partum day #3.
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11354018-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> urinary frequency <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1 at 39+2 with urinary frequency q5min x 1 day. No dysuria or f/c, no incomplete void. No ctx/LOF/VB. +AFM. She is here with her boyfriend who is translating (___) <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP = second trimester U/S - B pos, ab neg, RI, RPRNR, HepB neg, Hep C neg, HIV neg, GC/Chlamydia neg, GBS POS - low risk quad, nl ffs - GTT neg * Issues - anemia getting IV Fe. OB Hx: G1 Gyn Hx: denies abnl pap/STI Med Hx: hx suicide attempt (tylenol overdose), hx anemia Surg Hx: denies <SOCIAL HISTORY> denies T/E/D, here with boyfriend Physical ___: (on admission) BPs 144/80 -> 120s/60s GENERAL: NAD, appropriate ABDOMEN: soft NT gravid, 8# leopolds EXTREMITIES: NT,NE No CVAT FHT: reactive no decels TOCO: irreg SVE: closed per RN in triage (2cm on last visit with Dr. ___ <PERTINENT RESULTS> ___ WBC-5.0 RBC-4.15 Hgb-11.1 Hct-34.9 MCV-84 Plt-244 ___ Hct-30.0 Creat-0.5 ALT-12 AST-16 UricAcd-4.2 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-4 TransE-<1 ___ URINE Hours-RANDOM Creat-26 TotProt-<6 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> prenatal vitamins iron supplementation <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. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *50 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p vaginal delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see nursing sheets
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___ y/o G1 admitted at 39w2d with elevated BP's. Her blood pressures were initially 140s/80s, then improved signficantly. She had no evidence of preeclampsia given her normal labs and negative proteinuria. Fetal testing was reassuring. She was admitted to the antepartum service for observation and a 24 hour urine collection. On hospital day #2, she developed a headache and the decision was made to proceed with induction of labor. She received one dose of Cytotec followed by Pitocin and subsequently had a spontaneous vaginal delivery. She delivered a liveborn female weighing 3185g with apgars of 8 and 9. Shortly after delivery, Ms ___ was noted to have approximately 200cc of clot in the lower uterine segment which was expressed by bimanual exam. She received IV Pitocin as well as Cytotec 800mcg rectally. Her bleeding resolved and she remained hemodynamically stable. She was discharged home in stable condition on PPD#2. Of note, social services was consulted to assess supports and she was given a referral to Healthy Families.
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11354160-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ace Inhibitors / Atenolol <ATTENDING> ___ <CHIEF COMPLAINT> "Inside falling out" <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic Supracervical hysterectomy, sacral colpopexy, perineorrhaphy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ Caucasian female who presents with complaints of her "inside falling out." She states that her prolapse is getting worse and increasingly bothersome. She notes protrusion and bulge in the vagina. She also notes recurrent urinary tract infections. Her symptoms are typically those of frequency, burning, dysuria and feeling unwell. She has had a particularly bad bout of bladder infections in the last few months with one after the other. On review of her urinalysis in OMR, she has a urine culture from ___ positive for enterococcus species. She has a history of drug-resistant organisms. She was called in a prescription for ampicillin for 14 days by Dr. ___ ID for that last urine culture. The patient does not feel, however, that it has been effective. On review of the infectious disease note, on ___, she had a urine sample likely E. coli. She then felt well between ___ and ___, at which point she submitted a new sample that also grew E. coli and was treated with Cipro for 14 days. She felt well for a brief period between ___ and ___, at which point she submitted another urine sample, which grew enterococcus and was treated with Macrobid for 14 days. Then again between ___ and ___, she felt well at her appointment. On ___, submitted another sample, which ultimately proved to be another positive urine culture. The patient had first gone to the infectious disease clinic in ___ for suggestions on how to avoid recurrent urinary tract infections. At that time, she was advised to stop taking prophylactic Keflex due to development of resistant organisms. The patient noted that when she was on it; however, she did work to reduce bladder infections. At that time, it was also suggested that she start vaginal estrogen cream. She has been taking the vaginal estrogen cream up until a week ago because she felt some burning while using it with a bladder infection. She also has been taking cranberry extract capsules as has been advised. Complicating the issues, the patient has a ___ history of self-catheterization for neurogenic bladder. She is followed by Dr. ___ this in urology. Outside of her bladder infections, the patient does have usually normal urinary frequency, going to bathroom every two hours. She does wake up at night twice to urinate; however, she has no urine leakage. She denies history of kidney stones or hematuria. She says she does not strain to urinate. Her urine flow is continuous. She does not need to splint to urinate. She has occasional constipation and she is currently sexually active. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> 1. Hypertension. 2. Diabetes, on insulin. 3. Hyperlipidemia. 4. Neurogenic bladder. 5. Recurrent urinary tract infections. 6. Aortic insufficiency. 7. Mitral regurgitation. 8. Osteoporosis. Past Surgical History: Ankle surgery in ___ and ___. <FAMILY HISTORY> Mother, diabetes. Father, heart disease. Past OB History: Five pregnancies in total, four vaginal deliveries, four living children, one miscarriage. Birth weight of largest baby delivered vaginally 7 pounds. No forceps or vacuum-assisted vaginal delivery. Past GYN History: Age at menopause was ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother, diabetes. Father, heart disease. <PHYSICAL EXAM> Physical Examination was performed by Dr. ___ ___: Weight 158, blood pressure 152/64, and pulse 79. General: The patient is well developed, well groomed, overweight, no acute distress. Psych: Oriented x3, affect is normal. Neck: No masses. Trachea midline. Thyroid normal size, nontender. Nodes: No lymphadenopathy in the cervical or inguinal area. Skin: Warm and dry, no atypical rashes. Heart: No peripheral edema. Pulse is normal. Lungs: Normal respiratory effort, no use the accessory muscles. Abdomen: Nontender, not distended. No masses, guarding, or rebound. No hernia, no hepatosplenomegaly. Neurologic: The bulbocavernosus reflex is positive. The anal wink was indeterminate, grossly normal sensation in the saddle region. Genitourinary: Vulva, normal hair pattern, no lesions. Urethral meatus, urethral caruncles small. Urethra, nontender, no masses or exudate. Bladder is nonpalpable and nontender. Vagina is atrophic. Stage III cystocele, stage I uterine prolapse, see POP-Q below. Caliber is normal. Resting tone is normal. Cervix normal, no lesions or discharge. Uterus, nontender and mobile. Adnexa: Nontender, no masses. Anus and perineum, no masses or tenderness. Rectal: Deferred. Kidneys: No CVA tenderness. POP-Q: Aa +2, Ba +2, C -3. ___ 5, PB 4, TVL 8. Ap -3, Bp -3, and D -6. The supine empty stress test was negative. The post-void residual volume obtained via catheterization was 175 mL. <PERTINENT RESULTS> Cystourethroscopy Results: Normal Urethra normal bladder mucosa, no lesions, stones, tumors Normal trigone, normally positioned ureteral orifices + trabeculations Urodynamic Test Results: Unable to void for Uroflow: cathed for 300cc CMG: Although did report feeling of reaching bladder capcity at 439cc, the feeling settled and we were ultimately able to fill her bladder to 750cc without severe urgency No Latent stress urinary incontiennce No Detrusor overactivity or DO associated leakage of urine Normal bladder compliance MUCP = 125 and 148 with empty bladder PVS: patient able to void only 102cc after filling to 750cc and with sound of running water. Mounted sustained detrusor contraction with P Det 30cmH20, + valsalva, silencing of pelvic floor EMG, low amp continuous flow. <MEDICATIONS ON ADMISSION> alendronate 70mg qwk, levamir 20u qAM, novolog ___ qachs, metformin 1000mg bid, diltiazem 180mg daily, HCTZ 25mg daily, omeprazole 20mg daily, simvastatin 40mg daily, valsartan 320mg daily. <DISCHARGE MEDICATIONS> 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. oxycodone-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: *20 Tablet(s)* Refills: *0* 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *20 Capsule(s)* Refills: *0* 8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. Disp: *60 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> stage III cystocele, stage I uterine prolapse. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks.
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Ms. ___ was admitted into the gynecology service for routine post-operative care following her surgery. On the night immediately post-op, she had low urine output, which ranged between ___ per hour. She was given intravenous fluids and her hematocrit was checked and found to be 27.4, down from 32.2 pre-operatively. Her serum electrolytes were also checked and she was found to have a creatinine of 1.2, which is her baseline. Her other vitals were stable and her abdominal exam was appropriately tender from her surgery. She was monitored overnight with some improvement in her urine output to an average of >30cc per hour. Her repeat hematocrit in the morning was 24.6. However, given that other vitals were stable, urine output was improving and that patient has a history of anemia, which is being followed by her primary care physician, it was reassuring that this was not from a bleed. Her drop in hematocrit was likely from hemodilution from intravenous fluids coupled with her baseline anemia. In addition, we obtained serum and urine electrolytes, which gave us a fractional excretion of sodium of 0.11% indicating that she was prerenal. At this point, Ms ___ was tolerating oral intake and was advised to drink more fluids. Her foley catheter was left in place until 12 pm at which point, her urine output had peaked up to 50cc/hr. She was given nursing instructions on how to continue to perform her straight catheterizations at home. She was also instructed to call the doctor's office if her straight catheterizations yielded low urine outputs. She was discharged on post-operative day 1 in good condition, pain well controlled, tolerating a regular diet and with a prescription for ferrous sulfate.
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11354762-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> uterine sarcoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> TOTAL ABDOMINAL TRACHELECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, APPENDECTOMY, RADICAL RESECTION OF PELVIC TUMOR, LEFT PELVIC LYMPH NODE DISSECTION; PARTIAL CYSTECTOMY; SIGMOID COLECTOMY, MOBILIZATION OF SPLENIC FLEXURE <HISTORY OF PRESENT ILLNESS> Ms. ___ is a lovely ___ presenting for follow-up of uterine sarcoma and surgical planning. She initially was seen in ___ clinic for consultation related to newly diagnosed pelvic mass on ___. The pelvic mass involving the sigmoid colon was diagnosed on CT A/P done on ___ after she presented to urgent care with low-grade fever, fatigue, bloody stool, and urinary symptoms. She then underwent an MRI to further characterize the mass, and a colonoscopy on ___ that demonstrated a circumferential bleeding 10cm mass of malignant appearance found in the sigmoid colon. Biopsies were taken c/w smooth muscle neoplasm, concerning for uterine leiomyosarcoma. She also underwent a CT chest on ___, which showed a soft tissue rounded mass originating in the intersection of the right maor fissures and measuring 6cm. Patient was presented at Tumor Board on ___, and recommendation was made for ___ lung biopsy and consideration of chemotherapy. Lung biopsy was done ___, with pathology demonstrating metastatic smooth muscle tumor with rare mitotic figures. She then underwent 4 cycles of chemotherapy, finishing most recent cycle on ___. She continues to report decreased energy levels and decreased appetite. She reports undergoing a 2unit pRBCs transfusion on ___ for fatigue, which dramatically improved her symptoms for a few days. Her most recent Hct was 27.6 on ___. Most recent CT A/P on ___ showed 11cm heterogenous pelvic mass similar in size to prior imaging, with partial encasement of the sigmoid colon and direct contact with the superior bladder wall. It noted slight interval decrease in size of a left mesenteric and left internal iliac node. No new or enlarged lymph nodes were identified. CT Chest on ___ demonstrated slight decrease in size of right middle lobe mass, now measuring 4.1 x 4.6cm. She has been working hard on drinking protein shakes to keep her nutritional status up. She averages ___ shakes a day, with each shake containing 16g of protein (about 1000cal total per day). She continues to have regular BMs, and no issues with urination. No vaginal bleeding or abnormal discharge. She has recently seen Dr. ___ with urology and had a cystoscopy done demonstrating a mass-like indentation of the bladder dome, but no e/o mucosal disruption. She was consented for cystectomy - likely partial cystectomy with removal of about 25% of the bladder but with the possibility of radical cystectomy with creation of ileal conduit urinary diversion. She also met recently with Dr. ___ plan was made for anterior resection. Possible need for permanent stoma was discussed at that time. Patient is eager to get surgery behind her, but also very anxious about it. ROS: 14 point ROS negative except as above <PAST MEDICAL HISTORY> PAST ONCOLOGIC HISTORY: She presented to care in ___ with urinary symptoms, lower abdominal pain, and fever. CT scan (___) showed an "irregularly shaped leiomyomatous uterus" 10.8 x 12.4 x 11.9 cm. An MRI pelvis (___) showed "heterogeneous mass in the pelvis and left adnexa, measuring up to 10.1 cm, which involves the sigmoid colon with likely mucosal involvement as the mass appears within the limb, invasion of the bladder wall at the dome, likely invasion of the upper rectum, likely involvement of the right ovary, and with direct extension into the pelvic peritoneal cavity." There was also reported to be enlargement of a sigmoid colonic lymph node, 2.1 x 1.5 cm and left internal iliac lymph node measuring 1.0 x 0.9 cm, concerning for nodal involvement. On ___, she underwent colonoscopy with GI biopsies. Per report, there was a 10cm mass of malignant appearance found in the sigmoid colon. Final pathology showed a sigmoid mass, consistent with smooth muscle neoplasm. CT chest on ___ showed a soft tissue rounded mass originating in the intersection of the right major and minor fissures, 6 x 4 x 4.7 cm. Lung biopsy done ___ confirmed metastatic smooth muscle tumor with rare mitotic features. She established care with Dr ___ on ___ and was recommended for admission for port placement and initiation of chemotherapy. -___ C1 AIM -___ C2 AIM -___ Restaging CT torso with partial response -___ C3 AIM PAST MEDICAL HISTORY: - Metastatic leiomyosarcoma - Fibroid s/p supracervical hysterectomy in ___ - Borderline high blood pressure (never started on antihypertensives) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father with AML, mother with mesothelioma, both died at age ___. Breast cancer is prominent throughout her dad's family. <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM --======== BP: 133/83. Heart Rate: 103. Weight: 233. Height: 66. BMI: 37.6. GEN: NAD NEURO: AOx3 PSYCH: Appropriate mood and affect HEENT: EOMI, MMM, sclera anicteric THYROID: No thyromegaly, no nodules CV: Normal rate, regular rhythm, no murmurs/rubs/gallops, normal S1, S2 PULM: Lungs clear, no crackles ABDOMEN: Soft, nontender, nondistended, no masses BACK: No CVAT LYMPHATICS: No cervical or inguinal lymphadenopathy PELVIC: -External Genitalia: No lesions -Vagina: normal-appearing vaginal mucosa -Cervix: normal-appearing with no lesions -Uterus: surgically absent; however, there is a palpable mass noted replacing the uterus; exam somewhat limited by body habitus -Adnexa: palpable mass as above -SKIN: No ecchymoses, no lesions -EXTREM: Nontender, no edema --======== PHYSICAL EXAM ON DISCHARGE: --======== On day of discharge: Afebrile, vitals stable Gen: No acute distress CV: RRR Pulm: CTAB Abd: soft, non-distended, appropriately tender to palpation without rebound or guarding, incision shows no erythema, edema; drainage dressing was saturated with clear serosanguinous fluid; two superficial "X" scratches on both sides of abdomen above midline. JP drain in place with serosanguinous fluid drainage. GU: pad with minimal spotting, foley draining clear urine ___: non-tender, non-edematous <PERTINENT RESULTS> --======== RELEVANT LABS: --======== CBC ___ 09: 54PM BLOOD WBC-15.9* RBC-4.31 Hgb-12.1 Hct-37.2 MCV-86 MCH-28.1 MCHC-32.5 RDW-16.3* RDWSD-50.3* Plt ___ ___ 01: 20PM BLOOD WBC-14.9* RBC-3.66* Hgb-10.1* Hct-31.4* MCV-86 MCH-27.6 MCHC-32.2 RDW-16.2* RDWSD-50.0* Plt ___ ___ 06: 11AM BLOOD WBC-12.4* RBC-2.91* Hgb-8.1* Hct-26.4* MCV-91 MCH-27.8 MCHC-30.7* RDW-16.1* RDWSD-53.2* Plt ___ ___ 06: 07AM BLOOD WBC-8.5 RBC-3.29* Hgb-9.1* Hct-29.4* MCV-89 MCH-27.7 MCHC-31.0* RDW-15.8* RDWSD-51.6* Plt ___ ___ 06: 55AM BLOOD WBC-9.1 RBC-3.38* Hgb-9.3* Hct-30.0* MCV-89 MCH-27.5 MCHC-31.0* RDW-15.7* RDWSD-50.0* Plt ___ DIFFERENTIAL ___ 09: 54PM BLOOD Neuts-89.4* Lymphs-2.6* Monos-6.9 Eos-0.1* Baso-0.4 Im ___ AbsNeut-14.18* AbsLymp-0.42* AbsMono-1.09* AbsEos-0.01* AbsBaso-0.07 ___ 09: 20AM BLOOD ___ PTT-26.7 ___ BMP ___ 09: 54PM BLOOD Glucose-183* UreaN-10 Creat-0.7 Na-138 K-4.6 Cl-105 HCO3-21* AnGap-12 ___ 01: 20PM BLOOD Glucose-149* UreaN-17 Creat-0.8 Na-139 K-4.5 Cl-104 HCO3-25 AnGap-10 ___ 06: 11AM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-140 K-4.5 Cl-103 HCO3-26 AnGap-11 ___ 06: 07AM BLOOD Glucose-90 UreaN-8 Creat-0.5 Na-143 K-3.8 Cl-102 HCO3-28 AnGap-13 ___ 06: 55AM BLOOD Glucose-78 UreaN-6 Creat-0.5 Na-139 K-4.2 Cl-97 HCO3-30 AnGap-12 Ca, Mg, Phos ___ 09: 54PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.7 ___ 01: 20PM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 ___ 06: 11AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8 ___ 06: 07AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 ___ 06: 55AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.7 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H Do not take more than 4000 mg per day. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID Hold for loose bowel movements. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous once a day Disp #*28 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q6H Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 5. Nitrofurantoin (Macrodantin) 100 mg PO DAILY Take while Foley catheter in place. RX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth once a day Disp #*14 Capsule Refills: *0 6. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drive or drink alcohol while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 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: Abdominal instructions: * Your staples will be removed within 2 weeks from your surgery. This appointment should already been scheduled for you. Please call if you do not have an appointment scheduled. * Your JP drain will be removed within 10 days from your surgery. This appointment will be made for you. However please call if you do not hear from the office in the next week. * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. 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. *** 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. *** Home with foley: You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ on ___ for catheter removal. An appointment has been requested for you. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. WHEN YOU ARE DISCHARGED WITH A FOLEY CATHETER: -Please also reference the nursing handout and instructions on routine care and hygiene -Your Foley should be secured to the catheter secure on your thigh at ALL times until your follow up with the surgeon. -DO NOT allow anyone outside your urologist/team representative remove your Foley for any reason. -Wear Large Foley bag for majority of time. The leg bag (if provided) is for short-duration periods and the bag must be emptied frequently. -Do NOT drive if you have a Foley in place (for your safety-but of course you may be a passenger
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Ms. ___ was admitted to the gynecologic oncology service after undergoing total abdominal trachelectomy, bilateral salpingo-oophorectomy, appendectomy, radical resection of pelvic tumor, left pelvic lymph node dissection, partial cystectomy, sigmoid colectomy, and mobilization of splenic flexure for uterine sarcoma vs. ovarian cancer. Please see the operative report for full details. *) Post-op: Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural. Her diet was slowly advanced from NPO to sips on ___. She was advanced to clears on ___. She was then advanced to a regular diet on ___ without difficulty. She was transitioned to PO oxycodone/iburpofen with scheduled PO Tylenol on ___. Given her partial cystectomy, she remained on prolonged bladder rest with plan for her Foley to remain in place until post-operative day #14. Her JP drain had appropriate serosanguinous output with ascites Cr 0.4 (___) with no evidence of urinoma formation. By post-operative day #4, she was tolerating a regular diet, voiding via Foley. ambulating independently, and pain was controlled with oral medications. *) OSA She was maintained on telemetry with continuous SpO2 monitoring and provided a CPAP to where while sleeping. She was then discharged home in stable condition with prophylactic Macrobid while Foley in place and outpatient follow-up scheduled for JP drain removal, voiding cystogram, and Foley removal with Urology on post-operative day #14.
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11355674-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> doxycycline / surgical bandage <ATTENDING> ___. <CHIEF COMPLAINT> Infertility, fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> Abdominal myomectomy <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> ___ 10: 33AM BLOOD WBC-9.2 RBC-3.26* Hgb-9.1* Hct-28.5* MCV-87 MCH-27.9 MCHC-31.9* RDW-13.7 RDWSD-43.8 Plt ___ ___ 07: 53AM BLOOD WBC-15.7*# RBC-3.67*# Hgb-10.1*# Hct-31.3*# MCV-85 MCH-27.5 MCHC-32.3 RDW-13.6 RDWSD-41.9 Plt ___ ___ 12: 20PM BLOOD WBC-5.6 RBC-5.17 Hgb-14.0 Hct-44.1 MCV-85 MCH-27.1 MCHC-31.7* RDW-13.7 RDWSD-41.9 Plt ___ ___ 10: 08PM BLOOD UreaN-7 Creat-0.6 <MEDICATIONS ON ADMISSION> Active Medication list as of ___: Medications - Prescription MEDROXYPROGESTERONE - medroxyprogesterone 10 mg tablet. 1 tablet(s) by mouth once a day Medications - OTC IRON-VITAMIN C [VITRON-C] - Vitron-C 65 mg iron-125 mg tablet,delayed release. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) PNV ___ FUMARATE-FA - prenatal vit ___ fumarate 28 mg-folic acid ___ mcg tablet. 1 tablet(s) by mouth once a day - (OTC) <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 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: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate may cause sedation. do not drink alcohol or drive while taking oxycodone RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing an abdominal myomectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid 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 and she was transitioned to PO Oxycodone, Ibuprofen, and Acetaminophen PRN. On post-operative day ___, pt experienced nausea and several episodes of emesis. Her vital signs and urine output remained within normal limits, and her abdominal exam was appropriate. There was low concern for ileus or any other acute intra-abdominal process. On post-operative day ___ her nausea improved and she was able to tolerate a regular diet. Of note, estimated blood loss from the procedure was 800cc. Pt experienced a drop in hematocrit from 44 (pre-operative) to 31.8 (post-operative day 1). On post-operative day 2, her hematocrit was relatively stable at 28.5. Given that she had no evidence of ongoing vaginal or intra-abdominal bleeding, and that pt's vital signs remained stable, her hematocrit was not trended during the remainder of her hospitalization. By post-operative day 4, Ms. ___ 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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11355691-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Tetracycline Analogues / Aspirin / Percocet / Darvon / Erythromycin Base / Compazine / Codeine / Doxepin / Naprosyn / Zantac / Ceclor / Antivert / MS ___ / Zoloft / Colchicine / Allopurinol / lisinopril / latex <ATTENDING> ___ <CHIEF COMPLAINT> thigh pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ guided drainage of L thigh abscess <HISTORY OF PRESENT ILLNESS> HPI: ___ P2 recently discharged from GYN service on ___ after treatment for bilateral groin abscesses requiring I&D and ___ drainage presenting to ED tonight with worsening left leg pain. Patient's recent hospital course as follows: Admitted from clinic with bilateral groin abscesses (left >right) with intramuscular involvement.Started on levofloxacin and flagyl. Underwent I&D of abscesses followed by worsening pain and elevated WBC, prompting ___ guided drainage of residual left sided abscess. Patient was discharged on IV aztreonam, vancomycin, and flagyl. Ultrasound prior to discharge with marked reduction in size of collection. Patient referred to ED from rehab due to worsening left leg pain that patient describes as constant, mostly in thigh, and being ___ in severity. No fever/chills/vaginal discharge/abdominal pain/vaginal bleeding/dysuria/discharge from incision site. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. COPD (Asthma) 2. Depression 3. H.o PE (___) 4. HTN 5. Hypercholesterolemia 6. GERD 7. Chronic back pain PAST SURGICAL HISTORY 1. Gastric bypass 2. Abdominoplasty 3. Cholecystectomy 4. TAH 5. Bladder suspension 6. Dental PAST OB HISTORY ___ Vaginal: 2 PAST GYN HISTORY She denies ever having Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV She denies having an abnormal Pap test She denies having an abnormal Mammogram Her last colonoscopy was in ___ She is Postmenopausal and denies any post-menopausal bleeding. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Breast/Ovarian or Colon cancer. <PHYSICAL EXAM> On day of discharge AFVSS CTAB RRR abd: s, nt, nd, +BS GU: incontinent of urine, L groin swelling improved, L groin packing in place, skin with mild erythema and mild breakdown L thigh and groin ___: L thigh JP drain in place with serosangenous drainage, nt, ne <PERTINENT RESULTS> ___ 06: 08AM BLOOD WBC-11.5* RBC-3.15* Hgb-8.8* Hct-29.2* MCV-93 MCH-27.8 MCHC-30.1* RDW-16.9* Plt ___ ___ 06: 30AM BLOOD WBC-8.8 RBC-3.28*# Hgb-9.2*# Hct-30.7*# MCV-94 MCH-28.0 MCHC-29.9* RDW-16.4* Plt ___ ___ 06: 14AM BLOOD WBC-12.3* RBC-2.38* Hgb-6.4* Hct-22.6* MCV-95 MCH-26.9* MCHC-28.4* RDW-17.2* Plt ___ ___ 03: 50PM BLOOD WBC-9.3 RBC-2.46* Hgb-6.5* Hct-23.3* MCV-95 MCH-26.3* MCHC-27.7* RDW-17.1* Plt ___ ___ 06: 30AM BLOOD WBC-9.9 RBC-2.51* Hgb-6.9* Hct-24.1* MCV-96 MCH-27.4 MCHC-28.5* RDW-16.6* Plt ___ ___ 10: 40AM BLOOD WBC-8.9 RBC-3.25* Hgb-9.1* Hct-31.4* MCV-96 MCH-28.1 MCHC-29.1* RDW-16.5* Plt ___ ___ 10: 20PM BLOOD WBC-14.0* RBC-2.78* Hgb-7.4* Hct-27.0* MCV-97 MCH-26.8* MCHC-27.5*# RDW-16.7* Plt ___ ___ 06: 08AM BLOOD Neuts-78.7* Lymphs-10.6* Monos-5.5 Eos-4.8* Baso-0.4 ___ 06: 30AM BLOOD Neuts-60 Bands-0 ___ Monos-9 Eos-7* Baso-3* Atyps-1* ___ Myelos-0 ___ 06: 14AM BLOOD Neuts-80.3* Lymphs-10.7* Monos-5.1 Eos-3.7 Baso-0.2 ___ 10: 40AM BLOOD Neuts-84* Bands-1 Lymphs-12* Monos-3 Eos-0 Baso-0 ___ Myelos-0 ___ 10: 20PM BLOOD Neuts-81.1* Lymphs-10.6* Monos-4.0 Eos-3.9 Baso-0.4 ___ 06: 30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL Ellipto-OCCASIONAL ___ 06: 30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ ___ 10: 40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 06: 08AM BLOOD Plt ___ ___ 06: 08AM BLOOD ___ PTT-42.7* ___ ___ 06: 30AM BLOOD Plt Smr-NORMAL Plt ___ ___ 06: 30AM BLOOD ___ PTT-40.5* ___ ___ 06: 14AM BLOOD Plt ___ ___ 05: 45AM BLOOD ___ PTT-36.1 ___ ___ 03: 50PM BLOOD Plt ___ ___ 06: 30AM BLOOD Plt Smr-NORMAL Plt ___ ___ 06: 30AM BLOOD ___ PTT-37.2* ___ ___ 10: 40AM BLOOD Plt Smr-NORMAL Plt ___ ___ 10: 40AM BLOOD ___ PTT-37.6* ___ ___ 10: 20PM BLOOD Plt ___ ___ 06: 08AM BLOOD ___ ___ 06: 30AM BLOOD ___ ___ 05: 45AM BLOOD ___ ___ 06: 30AM BLOOD ___ ___ 10: 40AM BLOOD ___ ___ 06: 08AM BLOOD Glucose-80 UreaN-16 Creat-1.0 Na-143 K-3.9 Cl-117* HCO3-17* AnGap-13 ___ 06: 30AM BLOOD Glucose-87 UreaN-18 Creat-1.0 Na-146* K-3.6 Cl-116* HCO3-19* AnGap-15 ___ 05: 45AM BLOOD Glucose-90 UreaN-22* Creat-1.2* Na-146* K-3.3 Cl-117* HCO3-18* AnGap-14 ___ 06: 30AM BLOOD Glucose-80 UreaN-23* Creat-1.1 Na-142 K-3.9 Cl-114* HCO3-18* AnGap-14 ___ 10: 40AM BLOOD Glucose-86 UreaN-26* Creat-1.2* Na-142 K-3.7 Cl-114* HCO3-19* AnGap-13 ___ 10: 20PM BLOOD Glucose-87 UreaN-28* Creat-1.5* Na-140 K-3.9 Cl-112* HCO3-16* AnGap-16 ___ 06: 08AM BLOOD Calcium-7.7* Phos-4.1 Mg-2.1 ___ 06: 30AM BLOOD Calcium-7.4* Phos-4.5 Mg-1.3* ___ 05: 45AM BLOOD Calcium-6.9* Mg-1.4* ___ 06: 30AM BLOOD Albumin-2.2* Calcium-7.6* Phos-4.4 Mg-1.5* ___ 10: 40AM BLOOD Calcium-7.4* Phos-4.6* Mg-1.6 ___ 10: 20PM BLOOD Vanco-24.8* ___ 10: 20PM BLOOD HoldBLu-HOLD <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Docusate Sodium 100 mg PO BID: PRN Constipation 2. Bisacodyl ___AILY: PRN Constipation 3. Milk of Magnesia 30 mL PO PRN Constipation 4. Senna 1 TAB PO BID: PRN Constipation 5. Acetaminophen 325 mg PO Q4H: PRN pain or fever 6. Aztreonam ___ mg IV Q8H 7. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN Pain 9. HYDROmorphone (Dilaudid) 4 mg PO Q4H: PRN Severe pain 10. Cyclobenzaprine 5 mg PO TID: PRN spasms 11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 12. Meclizine 25 mg PO BID 13. Pantoprazole 40 mg PO Q24H 14. Norco (HYDROcodone-acetaminophen) ___ mg oral Q4H: PRN pain 15. desvenlafaxine succinate 50 mg oral Daily 16. Lorazepam 0.5 mg PO HS 17. Ondansetron 4 mg PO BID: PRN nausea 18. Meladox (melatonin) 10 mg oral daily 19. Vancomycin 750 mg IV Q 24H 20. Probiotic Acidophilus Biobeads (L.acidoph-L.rhamn-B.bif-B.long) 2.5 billion cell oral TID 21. Vitamin D ___ UNIT PO DAILY 22. Cyanocobalamin 1000 mcg PO DAILY <DISCHARGE MEDICATIONS> 1. Aztreonam ___ mg IV Q8H 2. Cyclobenzaprine 5 mg PO TID: PRN spasms 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Lorazepam 0.5 mg PO HS 5. Meclizine 25 mg PO BID 6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 7. Pantoprazole 40 mg PO Q24H 8. Vancomycin 750 mg IV Q 24H 9. Probiotic Acidophilus Biobeads (L.acidoph-L.rhamn-B.bif-B.long) 2.5 billion cell oral TID 10. Milk of Magnesia 30 mL PO PRN Constipation 11. Senna 1 TAB PO BID: PRN Constipation 12. Meladox (melatonin) 10 mg oral daily 13. Docusate Sodium 100 mg PO BID: PRN Constipation 14. desvenlafaxine succinate 50 mg oral Daily 15. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H: PRN pain do not drive. take w food. do not exceed 4000mg acetaminophen in 24 hours. RX *hydrocodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 16. Cyanocobalamin 1000 mcg PO DAILY 17. Vitamin D ___ UNIT PO DAILY 18. Acetaminophen 325 mg PO Q4H: PRN pain or fever 19. Bisacodyl ___AILY: PRN Constipation 20. Ondansetron 4 mg PO BID: PRN nausea 21. Amlodipine 5 mg PO DAILY 22. Phytonadione 10 mg PO DAILY Duration: 3 Days RX *phytonadione [Mephyton] 5 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills: *0 <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> thigh/groin abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure caring for you while you were here a ___. You appear to be recovering well and thus were felt to be safe to discharge. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * The incision in the L groin requires daily packing change and please place a loose barrier dressing (only dressing that allow air flow) over the area for skin protection Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms ___ was readmitted to the gynecology service on ___ for treatment of her worsening leg pain. She was found to have reaccumulation of her L thigh abscess cavity. General surgery and interventional radiology was consulted and the decision was made to proceed with ___ guided drainage, which was successful. Please see operative report for full details. A drain was left in place and she was discharged with the drain at it continued to drain 70 or more ml of serogsangenous fluid per day out of concern for possibility of reaccumulation. She recovered well after the procedure and remained afebrile throughout the course of her admission. Her mobility and pain improved throughout the course of her admission on IV antibiotics. Hematology was consulted for a mild coagulopathy and she was felt to be vitamin K deficient. She was put on replacement therapy and she will have follow up labs drawn on ___ as an outpatient.
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11355691-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Tetracycline Analogues / Aspirin / Percocet / Darvon / Erythromycin Base / Compazine / Codeine / Doxepin / Naprosyn / Zantac / Ceclor / Antivert / MS ___ / Zoloft / Colchicine / Allopurinol / lisinopril / latex <ATTENDING> ___ <CHIEF COMPLAINT> vaginal prolapse, dyspareunia <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Monarc suburethral sling procedure. 2. Bilateral sacrospinous ligament vault suspension (Elevate). 3. Posterior colporrhaphy. 4. Insertion of biologic graft in the posterior compartment. 5. Cystoscopy. <HISTORY OF PRESENT ILLNESS> On initial consultation at Urogynecology: Mrs. ___ is a ___ yo Gravida 2 Para ___ who presents today in the office for a consultation requested by ___, NP regarding vaginal prolapse and dyspareunia. She is complaining of significant perineal discomfor when having intercourse. Her symptoms have been present for approximately ___ year and are persistent. She also reports fecal incontinence episodes ___ /week and has not mentioned this to her primary care physician ___. She reports ___ urinary incontinence events per day characterized as urge. 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 hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ admits to some vaginal pressure and palpable prolapse. She denies any splinting She also denies any constipation. She is sexually active and does experience dyspareunia. She admits to vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. COPD (Asthma) 2. Depression 3. H.o PE (___) 4. HTN 5. Hypercholesterolemia 6. GERD 7. Chronic back pain PAST SURGICAL HISTORY 1. Gastric bypass 2. Abdominoplasty 3. Cholecystectomy 4. TAH 5. Bladder suspension 6. Dental PAST OB HISTORY G2P2002 Vaginal: 2 PAST GYN HISTORY She denies ever having Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV She denies having an abnormal Pap test She denies having an abnormal Mammogram Her last colonoscopy was in ___ She is Postmenopausal and denies any post-menopausal bleeding. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Breast/Ovarian or Colon cancer. <PHYSICAL EXAM> INITIAL PHYSICAL EXAMINATION Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Normal sounds, no murmurs Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Ext: No edema or varicosities. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skin & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: absent-hysterectomy Uterus: absent-hysterectomy Adnexa: no masses non tender. POP-Q Exam: Aa: -2.5 Ba: -2.5 TVL: 7.5 D: C: -6 ___: 3 PB: 2 Ap: +1.5 Bp: +1.5 ___ Exam: Cystocele: Uterus/Cervix: Vault: Ant enterocele: Post enterocele: 3 Rectocele: 3 VAGINAL EXAM - There was severe vaginal atrophy: Ulcerations were absent ON DAY OF DISCHARGE GEN: NAD CV: RRR LUNGS: CTAbl ABD: soft, NT, ND EXT: wnl <MEDICATIONS ON ADMISSION> ADVAIR DISKUS - 500-50MCG Disk with Device. USE ONE PUFF BY MOUTH TWICE A DAY DESVENLAFAXINE SUCCINATE [PRISTIQ] - Pristiq 50 mg daily HYDROCODONE-ACETAMINOPHEN [VICODIN] LOVASTATIN - MECLIZINE - MVI - PANTOPRAZOLE TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - Dyazide 37.5 mg-25 mg capsule. 1 capsule(s) by mouth twice a day <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H pain do not take over 4000mg tylenol in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6H: PRN Disp #*60 Tablet Refills: *0 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H: PRN shortness of breath 3. desvenlafaxine succinate 50 mg Oral daily 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain RX *hydromorphone 2 mg ___ tablets by mouth Q4H: PRN Disp #*25 Tablet Refills: *0 7. Meclizine 25 mg PO BID 8. Pantoprazole 40 mg PO Q24H 9. Triamterene-Hydrochlorothiazide 1 CAP PO BID 10. Nitrofurantoin (Macrodantin) 100 mg PO HS while foley catheter is in place RX *nitrofurantoin macrocrystal [Macrodantin] 100 mg 1 capsule(s) by mouth at night Disp #*10 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> Dear Ms. ___, You were admitted into the GYN service following the procedures listed below. The team now feels that you're safe to be discharged home. Please follow the instructions listed below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet * You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ on ___ for catheter removal. Please call for an appointment. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing: 1. Monarc suburethral sling procedure. 2. Bilateral sacrospinous ligament vault suspension (Elevate). 3. Posterior colporrhaphy. 4. Insertion of biologic graft in the posterior compartment. 5. Cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 120 mL with some incontinence with 120 mL residual. 2. Instilled 300 mL, voided 60 mL with incontinence with 150 mL residual. Her Foley catheter was replaced and she was instructed in its care. Her diet was advanced without difficulty and she was transitioned to PO dilaudid and tylenol.
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Tetracycline Analogues / Aspirin / Percocet / Darvon / Erythromycin Base / Compazine / Codeine / Doxepin / Naprosyn / Zantac / Ceclor / Antivert / MS ___ / Zoloft / Colchicine / Allopurinol / lisinopril / latex <ATTENDING> ___ <CHIEF COMPLAINT> L thigh pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploration/evacuation of right and left groin abscess, sling excision Ultrasound guided drainage of L thigh abscess <HISTORY OF PRESENT ILLNESS> . Monarc suburethral sling procedure. 2. Bilateral sacrospinous ligament vault suspension (Elevate). 3. Posterior colporrhaphy. 4. Insertion of biologic graft in the posterior compartment. 5. Cystoscopy. She returns today stating that her perineal pain had improved with Vicodin and flexeril until 3 days ago. She reports b/l thigh pain L>R, difficulty ambulating. She denies any issues with BM, no bulging, no constipation. + urinary incontinence She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. COPD (Asthma) 2. Depression 3. H.o PE (___) 4. HTN 5. Hypercholesterolemia 6. GERD 7. Chronic back pain PAST SURGICAL HISTORY 1. Gastric bypass 2. Abdominoplasty 3. Cholecystectomy 4. TAH 5. Bladder suspension 6. Dental PAST OB HISTORY G2P2002 Vaginal: 2 PAST GYN HISTORY She denies ever having Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV She denies having an abnormal Pap test She denies having an abnormal Mammogram Her last colonoscopy was in ___ She is Postmenopausal and denies any post-menopausal bleeding. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Breast/Ovarian or Colon cancer. <PHYSICAL EXAM> Admission PE Gen: Denies fever, significant weight change or weakness Neuro: Denies headache, syncope, seizures or abnormal sensations CV: Denies chest pain, palpitations, orthopnea Resp: Denies cough, dyspnea, hempotysis Vital Signs : per OMR VAGINAL EXAM - Left obturator incision opened + purulent discharge, + 2 tenderness extending to her thigh Posterior vaginal wall incision opened for 2-3 cm Musculoskeletal: No clubbing, cyanosis or edema. No cords bilaterally Empty Supine Stress Test was: positive Her (PVR) post void residual was 50 ml assessed by straight catheterization Exam on day of discharge AFVSS CTAB RRR abd s, nt, nd +BS GU: L groin swelling >R, wick in place, no overlying erythema or drainage noted, moderate ttp ___: ne, nt <PERTINENT RESULTS> ___ 06: 45AM BLOOD WBC-10.0 RBC-2.72* Hgb-7.6* Hct-24.7* MCV-91 MCH-27.8 MCHC-30.6* RDW-16.1* Plt ___ ___ 07: 50AM BLOOD WBC-11.2* RBC-2.85* Hgb-7.7* Hct-26.1* MCV-92 MCH-26.9* MCHC-29.3* RDW-16.3* Plt ___ ___ 06: 50AM BLOOD WBC-13.8* RBC-2.76* Hgb-7.7* Hct-24.8* MCV-90 MCH-27.9 MCHC-31.0 RDW-16.1* Plt ___ ___ 06: 45AM BLOOD WBC-15.4* RBC-2.88* Hgb-7.8* Hct-26.1* MCV-91 MCH-27.1 MCHC-29.9* RDW-16.3* Plt ___ ___ 12: 45PM BLOOD WBC-13.7* RBC-2.96* Hgb-8.3* Hct-26.7* MCV-90 MCH-28.1 MCHC-31.3 RDW-16.2* Plt ___ ___ 08: 25AM BLOOD WBC-10.1 RBC-3.02* Hgb-8.5* Hct-27.4* MCV-91 MCH-28.1 MCHC-31.0 RDW-16.2* Plt ___ ___ 07: 35AM BLOOD WBC-7.3 RBC-3.14* Hgb-8.5* Hct-28.9* MCV-92 MCH-27.1 MCHC-29.4* RDW-16.3* Plt ___ ___ 07: 10AM BLOOD WBC-8.0 RBC-2.88* Hgb-8.1* Hct-27.0* MCV-94 MCH-28.2 MCHC-30.1* RDW-16.0* Plt ___ ___ 04: 10PM BLOOD WBC-9.0 RBC-3.02* Hgb-8.6* Hct-27.9* MCV-92 MCH-28.6 MCHC-30.9* RDW-16.0* Plt ___ ___ 06: 45AM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND Baso-PND ___ 07: 50AM BLOOD Neuts-69 Bands-2 Lymphs-12* Monos-9 Eos-3 Baso-0 ___ Metas-4* Myelos-1* ___ 06: 50AM BLOOD Neuts-84.4* Lymphs-8.0* Monos-2.8 Eos-4.7* Baso-0.2 ___ 06: 45AM BLOOD Neuts-84.0* Lymphs-8.2* Monos-2.7 Eos-4.8* Baso-0.3 ___ 12: 45PM BLOOD Neuts-86.6* Lymphs-5.6* Monos-2.8 Eos-4.6* Baso-0.4 ___ 08: 25AM BLOOD Neuts-84.4* Lymphs-7.9* Monos-4.7 Eos-2.7 Baso-0.4 ___ 07: 35AM BLOOD Neuts-74.3* Lymphs-12.3* Monos-7.0 Eos-5.9* Baso-0.4 ___ 07: 10AM BLOOD Neuts-77.8* Lymphs-11.6* Monos-7.2 Eos-3.2 Baso-0.3 ___ 04: 10PM BLOOD Neuts-80.7* Lymphs-10.4* Monos-6.5 Eos-2.1 Baso-0.4 ___ 07: 50AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Burr-OCCASIONAL Tear Dr-OCCASIONAL ___ 06: 45AM BLOOD Plt ___ ___ 07: 50AM BLOOD Plt Smr-NORMAL Plt ___ ___ 06: 45AM BLOOD Glucose-84 UreaN-18 Creat-1.1 Na-143 K-4.5 Cl-114* HCO3-21* AnGap-13 ___ 07: 50AM BLOOD Glucose-96 UreaN-17 Creat-1.2* Na-143 K-4.1 Cl-114* HCO3-21* AnGap-12 ___ 06: 50AM BLOOD Glucose-95 UreaN-14 Creat-1.2* Na-141 K-4.8 Cl-111* HCO3-23 AnGap-12 ___ 06: 45AM BLOOD Glucose-86 UreaN-16 Creat-1.2* Na-142 K-4.5 Cl-111* HCO3-23 AnGap-13 ___ 12: 45PM BLOOD Glucose-109* UreaN-16 Creat-1.4* Na-142 K-5.0 Cl-113* HCO3-22 AnGap-12 ___ 08: 02AM BLOOD Glucose-105* UreaN-18 Creat-1.4* Na-137 K-7.2* Cl-111* HCO3-18* AnGap-15 ___ 08: 25AM BLOOD Glucose-84 UreaN-20 Creat-1.3* Na-141 K-5.4* Cl-111* HCO3-21* AnGap-14 ___ 07: 35AM BLOOD Glucose-89 UreaN-30* Creat-1.5* Na-140 K-4.8 Cl-113* HCO3-19* AnGap-13 ___ 06: 20PM BLOOD Glucose-84 UreaN-36* Creat-1.6* Na-136 K-4.6 Cl-109* HCO3-19* AnGap-13 ___ 07: 10AM BLOOD Glucose-80 UreaN-46* Creat-1.8* Na-136 K-4.9 Cl-109* HCO3-18* AnGap-14 ___ 04: 10PM BLOOD Glucose-94 UreaN-48* Creat-1.9* Na-136 K-5.4* Cl-110* HCO3-16* AnGap-15 ___ 07: 50AM BLOOD Calcium-7.3* Phos-3.7 Mg-1.7 ___ 06: 50AM BLOOD Calcium-7.6* Phos-3.4 Mg-1.9 ___ 06: 45AM BLOOD Calcium-7.5* Phos-3.6 Mg-1.4* ___ 12: 45PM BLOOD Calcium-7.4* Phos-4.0 Mg-1.4* ___ 08: 02AM BLOOD Calcium-7.3* Phos-4.4 Mg-1.4* ___ 08: 25AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.4* ___ 07: 35AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.8 ___ 06: 20PM BLOOD Calcium-8.2* Phos-4.6*# Mg-1.8 ___ CT: HISTORY: Three weeks postop with mesh in place. Query left groin abscess amenable to drainage? TECHNIQUE: Axial helical MDCT of the pelvis was performed with oral contrast only (the patient's creatinine was elevated and the study was performed without intravenous contrast). Multiplanar coronal and sagittal reformatted images were also generated. DLP: 496.26 mGy-cm. COMPARISON: This study is compared to previous CT abdomen and pelvis from ___. FINDINGS: CT PELVIS: Assessment is limited given the lack of intravenous contrast. There has been previous total hysterectomy. There is a small fluid collection with several small pockets of gas seen posterior and to the right of the vagina in the pre-sacral space, measuring 4.6 x 1.9 cm (transverse x AP dimension). There is a second small fluid collection in the right pre-sacral space superior to the first collection measuring 1.9 x 2.9 cm (transverse x AP ___, 2: 34). There is increased density posterior to the lower vagina and fat stranding in the perineum. There is thickening along the labia majora posteriorly, however it is not well delineated on this study. In addition, the adductor muscle group is enlarged within the left anterior medial thigh and contains a pocket of gas and surrounding increased density/fat stranding; the findings are suspicious for an abscess, however this area is not fully imaged on this study. There are surgical sutures and staples in the anterior abdominal wall. The a 1.3-cm fat-containing lesion within the transverse colon (2: 1), which represents a small intraluminal lipoma. There has been previous surgical anastomosis of the small bowel, similar to previous. There is no pelvic or inguinal lymphadenopathy. There are moderate atherosclerotic changes of the abdominal aorta and iliac arteries, however assessment of the vessels is limited on this non-contrast study. The bladder appears mildy distended. OSSEOUS STRUCTURES: There are mild degenerative changes of the lumbar spine with grade I anterolisthesis of L4 over L5. IMPRESSION: 1. Gas containing fluid collections in the pre-sacral space and diffuse thickening of tissue planes about vagina and perineum, poorly delineated at noncontrast CT. In addition, there is suspected abscess formation within the adductor muscle group of the left anterior thigh, although this area is not fully imaged on this study. Further evaluation could be obtained with MRI. 2. Moderate atherosclerotic disease. 3. Degenerative changes of the lumbar spine. 4. Colonic lipoma. ___ EKG Sinus rhythm. Normal tracing. Compared to the previous tracing of ___ the premature atrial contractions are absent. US ___: FINDINGS: Please note that the scanning was limited by extreme tenderness in the left inguinal region. There is an intramuscular collection involving the adductor muscle group in the left anterior thigh measuring 5.1 x 3 cm and containing a small pocket of gas within the collection. This is consistent with abscess and diffuse intramuscular phlegmonous change. In addition, the skin is edematous and there is profuse mucopurulent discharge at the skin surface of the site of previous incision in the medial left inguinal region. There are also meandering tracks seen coursing inferior to the skin surface within the subcutaneous tissues, however the course of these tracts and the intramuscular collection are difficult to define with ultrasound given significant patient tenderness with scanning. However, tracks appear to course medial to the inguinal crease suggesting a more extensive infectious process than the abscess seen in the left upper thigh/adductor musculature. IMPRESSION: 1. Intramuscular collection consistent with abscess within the adductor muscle group of the left anterior thigh muscles. 2. Meandering tracts coursing inferior from the skin incision site, with mucopurulent discharge arising from the skin surface. Given prior CT with additional collection seen in deep pelvis, and the apparently widespread infectious/inflammatory change in the left inguinal region, recommend an MRI of the pelvis to more definitively assess the extent of the collections and tracts prior to drainage. MRI ___ INDICATION: ___ woman status post a suburethral sling procedure, colporrhaphy with bilateral sacrospinous ligament wall suspension with placement of biological graft, is here with a left thigh abscess. COMPARISON: CT pelvis without contrast ___. TECHNIQUE: Multiplanar T1- and T2-weighted MR images of the pelvis were performed prior to and after uneventful intravenous administration of 13 mL of ProHance. FINDINGS: Two linear rim-enhancing tracts originating from the anterolateral aspect of the vagina, traversing laterally on either direction, (1101: 82) are seen along the course of the sub-urethral sling. On the right, the tract extends through the obturator internus/ externus muscles and terminates in a rim-enhancing fluid collection centered in the adductor magnus muscle, measuring approximately 6 x 2.9 x 1.0 cm (1101: 63). A linear tract extending to the right vulva (1101: 60), likely represents the percutaneous access site. On left, the abscess tract extends through the left obturator internus/externus muscles terminating in a multiloculated rim-enhancing abscess within the left adductor magnus/obturator externus muscles, measuring approximately 8 x 7.1 x 1.8 cm. A smaller track with an associated abscess is seen in the left gracilis muscle (1101: 35), measuring 11 x 7 mm. A curvilinear rim enhancing fluid collection posterosuperior to the posterior wall of the vagina extending between the sacrospinous ligaments, represents fluid collection within the biological graft. This may possibly communicate with the posterior wall of the vagina (1102: 77). On right, the largest pocket of fluid collection measures 14 x 12 mm (1101: 94) and on the left this measures 15 x 9 mm (1101: 85). This collection extends to involve the left levator ani muscle (5: 34). Inflammatory changes are seen in both sacrospinous ligaments. T2-hypointense rounded structure seen within the lateral most aspect of this collection (3: 20 and 3: 34) likely represents post-surgical material. Tiny locules of air are seen within this collection as well as the collection in the left thigh. The rectum and anal canal are normal. The urinary bladder is unremarkable. No marrow signal abnormality is evident. Multiple enlarged lymph nodes in bilateral internal iliac and inguinal regions (5: 32) are likely reactive. There is no pelvic free fluid. IMPRESSION: 1. Rim-enhancing fluid tracts along the course of the suburethral sling extending from the anterior vagina, through the obturator/adductor muscles into bilateral proximal thighs, associated with intramuscular abscesses, left larger than right. 2. Additional rim-enhancing fluid collection along the biologic graft in the posterior compartment extending between the sacrospinous ligaments, worrisome for an abscess. This may communicate with the posterior wall of the vagina. 3. Reactive internal iliac and inguinal adenopathy. ___ ___ Dopplers HISTORY: ___ female with left upper thigh pain and swelling. Evaluate for DVT. COMPARISON: None. FINDINGS: Grayscale, color, and spectral Doppler evaluation was performed of the left lower extremity veins. There is normal phasicity of the common femoral veins bilaterally. There is normal compression and augmentation of the left common femoral, proximal femoral, mid femoral, distal femoral, popliteal, posterior tibial, and peroneal veins. Small nonpathologically enlarged lymph nodes are present along the upper thigh. An 11 x 8 x 8 ___ cyst is present in the popliteal fossa. IMPRESSION: No evidence of DVT in the left lower extremity. Small left sided medial popliteal fossa cyst. Further imaging on ___ an ___ was done however, only preliminary documentation was available and is not included in this report. Please obtain final reports for reference as needed. ___ 10: 30 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 3: 05 pm ABSCESS Source: L thigh abscess. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 9: 20 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 1: 00 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 10: 49 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY NOT S. SAPROPHYTICUS. 10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY | GENTAMICIN------------ 8 I LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S ___ 9: 25 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7: 30 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 11: 40 am URINE Site: CATHETER PREVIOUSLY LOGGED AS PROBLEM # ___. SPECIMEN IDENTIFIED AND TESTING AUTHORIZED BY ___. ___ @ 1726, ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Time Taken Not Noted Log-In Date/Time: ___ 3: 34 pm SWAB Source: left groin. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 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 in this culture.. ANAEROBIC CULTURE (Final ___: PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE POSITIVE. <MEDICATIONS ON ADMISSION> Medications - Prescription ADVAIR DISKUS - 500-50MCG disk with device. USE ONE PUFF BY MOUTH TWICE A DAY CONJUGATED ESTROGENS [PREMARIN] - Premarin 0.625 mg/gram vaginal cream. 1 gm inserted vaginally twice a week @ hs CYCLOBENZAPRINE - cyclobenzaprine 10 mg tablet. 1 tablet(s) by mouth three times a day CYCLOBENZAPRINE - cyclobenzaprine 5 mg tablet. ___ Tablet(s) by mouth three times a day as needed for spasms DESVENLAFAXINE SUCCINATE [PRISTIQ] - Pristiq 50 mg tablet,extended release. 1 tablet extended release 24 hr(s) by mouth once a day - (Prescribed by Other Provider) HYDROCODONE-ACETAMINOPHEN - hydrocodone 10 mg-acetaminophen 500 mg tablet. 1 tablet(s) by mouth every four (4) to six (6)hours as needed for pain do not exceed 6 tablets in 24 hours HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. apply to affected area twice a day LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth at bedtime LOVASTATIN - lovastatin 40 mg tablet. 1 tablet(s) by mouth at bedtime - (Prescribed by Other Provider) MECLIZINE - meclizine 25 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) MVI - Dosage uncertain - (Prescribed by Other Provider: ??) PANTOPRAZOLE - pantoprazole 40 mg tablet,delayed release. 1 tablet,delayed release (___) by mouth once a day - (Prescribed by Other Provider) TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - Dyazide 37.5 mg-25 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) Medications - OTC BIOTIN - biotin 2,500 mcg capsule. 2 capsule(s) by mouth once a day - (Prescribed by Other Provider) CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain - (Prescribed by Other Provider) CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000 mcg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Cyclobenzaprine 5 mg PO TID: PRN spasms 2. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H: PRN pain take 30 minutes prior to dressing change. do not drive or take more than prescribed. RX *hydrocodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *1 3. Pantoprazole 40 mg PO Q24H 4. Aztreonam ___ mg IV Q8H RX *aztreonam in dextrose(iso-osm) [Azactam in dextrose (iso-osm)] 2 gram/50 mL ___ mg IV q8 hours Disp #*84 Gram Refills: *0 5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H RX *metronidazole in NaCl (iso-os) 500 mg/100 mL 500 mg IV q 8 hours Disp #*21 Gram Refills: *0 7. Vancomycin 1000 mg IV Q 24H RX *vancomycin 1 gram 1 gram IV 24 hours Disp #*42 Gram Refills: *0 8. Pristiq (desvenlafaxine succinate) 50 mg oral daily 9. Meclizine 25 mg PO BID <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> post-operative groin/thigh infection <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 * 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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___ F readmitted with a post-operative infection for IV antibiotics and I&D of bilateral groin abscesses (L>R), suburethral sling excision, revision of ant/post vaginal incisions, cysto on ___. Please see operative report for full details. *) Abscess: She was given levofloxacin and metronidazole from ___ and remained afebrile and without a leukocytosis. On ___ she developed a leukocytosis desipte levofloxacin and metronidazole. She was transitioned to IV aztreonam, vancomycin and metronidazole with the consultation of the ID team. She was then followed with imaging which showed residual abscess collection on ___ which was drained by US guidance. She had several blood cultures on this admission and all had no growth to date. Her leukocytosis continued to improve over the course of her hospital admission and she clinically improved with reduced pain. A PICC line was placed for ___ for long term access in anticipation of need for IV antibiotic therapy. Final ultrasound on ___ showed marked reduction in size of collection on IV antibiotics with maximum abscess diameter in L thigh collection of 5.9cm. Thus the decision was made that she was safe for discharge on IV antibiotics with ID and urogyn adn 2 week interval MRI follow-up scheduled. Her pain was well controlled on po dilaudid, she was voiding but incontinent of urine, moving her bowels and tolerating a regular diet on day of discharge. *) ___: Of note, on admission she has ___ with a Cr of 1.9 and a mild hyperkalemia which improved over the course of her admission with IV fluids and hodling of nephrotoxic medications, including NSAIDS. HEr Creatitine on day of discharge was 1.1. *) UTI Coag neg staph was found, however sensitivities showed sensitivity to vancomycin which patient was already recieving. *) Diarrhea: She had several episodes of diarrhea after receiving colace and miralax on ___. Diarrhea resolved with discontinuation of bowel regimen and c diff assay was negative.
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11361376-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> aspirin <ATTENDING> ___. <CHIEF COMPLAINT> uterine fibroids and possible ovarian mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Abdominal myomectomy, right salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 with known uterine fibroids and ? ovarian mass vs extrauterine fibroid now scheduled for abdominal myomectomy and possible RSO. Patient initially seen in consultation on ___ at which time she reported a longstanding history of menorrhagia which had been managed on OCPs. Symptoms were well controlled until recently when she began to experience significant abdominal pain that resulted in her presenting to the ED on ___. She was then diagnosed with degeneration of her fibroids. She has been using Motrin with some relief of pain. She now desires definitive surgical management with removal of fibroids. She still desires future fertility and is not interested in hysterectomy at this time. Pelvic ultrasound ___: Impression 1. Fibroid uterus with the largest fibroid in the posterior left midline distorting the endometrium 2. Soft tissue lesion adjacent tot eh ovary in the right adnexa of unclear etiology; this could be part of the ovary or an exophytic fibroid. Pelvic MRI ___: There is a 3.3 x 3.1 x 2.8 cm T2 hypointense lesion within the right adnexa immediately medial to the right ovary (sequence 5 image 13 and sequence 6 image 9). This lesion is heterogenous in appearance and demonstrates avid enhancement post-contrast (sequence 1002 image 90). It correlates with the previously identified lesion at ultrasound. The right ovary is otherwise unremarkable. The left ovary is within normal limits. Multiple T2 hypointense lesions are noted within the uterus in a subserosal, intramural and submucosal location. The largest lesion is intramural within the body of the uterus posterior to the endometrial cavity and measures 7.9 x 6.8 x 6.4 cm (sequence 5 image 20). Note is also made of a 1.1 cm submucosal lesion (sequence 6 image 22). Some of these lesions contain foci of T1 hypointensity (for example, sequence 8 image 44) consistent with calcification. Most of the lesions demonstrate avid enhancement post-contrast. These lesions are consistent with fibroids. There is a small amount of free fluid within the pelvis. The bladder is within normal limits. The sigmoid colon and rectum are unremarkable. No pelvic adenopathy. Bone marrow signal is normal. No destructive osseous lesions. IMPRESSION: 1. 3.3 x 3.1 x 2.8 cm T2 hypointense lesion within the right adnexa which is immediately medial to the right ovary. The most likely differential diagnosis is an extrauterine fibroid, although differential considerations such as a ___ tumor, ovarian fibroma or fibrothecoma are not completely outruled. 2. Multiple uterine fibroids in a subserosal, intramural and submucosal location. <PAST MEDICAL HISTORY> PMH: Menorrhagia, anemia, childhood asthma PSH: Wisdom teeth extraction ___ GYNHx: last pap smear ___ negative. Not currently sexually active. Remote h/o abnl paps in early ___. Remote h/o chlamydia OBHx: G1P0, medical abortion x 1 <ALLERGIES> aspirin -> stomach upset <SOCIAL HISTORY> ___ <FAMILY HISTORY> No known breast, gyn, or gi cancers <PHYSICAL EXAM> Pre-op exam: BP 112/62 Gen: NAD CV: RRR, normal S1S2, no murmur, rub, or gallop Lungs: CTAB, no wheezes, rhonchi, rales Abd: soft, ND, NT, uterus with multiple fibroids palpated to 4cm above umbilicus Ext: wwp, no clubbing Exam on discharge: T 98.3, BP 93/45, HR 79 O2sat 100% RA Gen: NAD CV: RRR Lungs: CTAB Abd: soft, mildly distended, no rebound/guarding, incision C/D/I Ext: no edema, non-tender to palpation <PERTINENT RESULTS> PATHOLOGY: - Pelvic washings: Negative for malignant cells - Fibroids, right ovary: PENDING <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) to six (6) hours Disp #*45 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 <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. * 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 Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing an abdominal myomectomy and right salpingo-oophorectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with a dilauid PCA. 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 pain medication. 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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11363199-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bulge <MAJOR SURGICAL OR INVASIVE PROCEDURE> Sacrospinous suspension Anterior/posterior repair TVT Cystoscopy <HISTORY OF PRESENT ILLNESS> She complains of bilateral lower abdominal cramps pain. A recent CT was negative for significant findings other than renal cyst and calcified fibroids. She also has low back pain. She had an accidental fall on to her lower back recently. She continues to have occasional urge incontinence. The incontinence began 3 months ago. Her daytime frequency is every 2 or 3 hours. She does not leak with coughing or sneezing. She has no difficulty starting or maintaining a urine stream. She has no nocturia x2 or 3. She has no recent history of UTI. She does have not have constipation or fecal incontinence. She has not been sexually active. <PAST MEDICAL HISTORY> OB history: G3P2, vaginal birth x 2, Largest baby 9lbs Gyn history: abnl pap smear, ascus negative high risk HPV, urge incontinence, cystocele, rectocele PMH: - HTN - HL - Disc disorder of cervical region - OA - HIV - monoclonal gammopathy - OA knee - breast cancer PSH - s/p total knee replacement - s/p lumpectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> - family history of colon cancer requiring screening colonoscopy - no known bladder problems or prolapse <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <MEDICATIONS ON ADMISSION> - HCTZ 50mg - Lisinopril 10mg - Tramadol 50mg - Atripla - vitamin D <DISCHARGE MEDICATIONS> received prescriptions in the office <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Uterine prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. 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 sacrospinous suspension, anterior and posterior repair, and tension free vaginal tape surgery for correction of stress urinary incontinence, cystocele, and uterine prolapse. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV morphine and acetaminophen. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 350 mL with 0 mL residual. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11363621-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ceclor / amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> Endometritis Retained products of conception <MAJOR SURGICAL OR INVASIVE PROCEDURE> D&C <HISTORY OF PRESENT ILLNESS> ___ G1P0100 4 weeks s/p preterm vaginal delivery of di-di twins at 24 weeks in the setting of abruption, delivery complicated by ___ requiring D&C for retained placenta. Unfortunately, both twins passed away due to complications of prematurity. She presented to ___ ___ after report of fever to 103 at home (vs. 100.2 in transfer notes) and blood cultures were obtained, one of which came back positive for gram negative rods per our ED team. The patient was called back in and pelvic ultrasound performed at ___ which showed a 2.3cm area of vascularized retained products of conception. She was started on ceftriaxone and flagyl and transferred to ___ for continued management. Upon arrival, patient was afebrile and denied any physical complaints other than general achiness. She specifically denied headache, chest pain, shortness of breath, breast tenderness or redness, back pain, abdominal pain, dysuria, abnormal lochia, constipation or diarrhea. Her lochia was mostly pink mucous discharge at time of presentation. <PAST MEDICAL HISTORY> POB: - G1 SVD of di-di twins at 24 weeks c/b abruption, PPH requiring D&C, with subsequent neonatal demise of both twins due to prematurity PGYN: - Denies abnormal Pap or cervical procedures - Denies fibroids/endometriosis/cysts - Denies STIs, including HSV PMH: Denies PSH: Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> T 97.9 (last febrile on ___ at 0947) HR 65, BP 115/79, O2sat 100% on RA Gen: NAD, appears well CV: RRR Abd: soft, nontender, no rebound/guarding Ext: nontender, no edema <PERTINENT RESULTS> ___ 04: 25AM BLOOD WBC-4.4# RBC-3.94# Hgb-11.2 Hct-34.8# MCV-88 MCH-28.4 MCHC-32.2 RDW-12.5 RDWSD-40.1 Plt ___ ___ 04: 25AM BLOOD Neuts-76.8* Lymphs-15.6* Monos-6.4 Eos-0.0* Baso-0.5 Im ___ AbsNeut-3.34 AbsLymp-0.68* AbsMono-0.28 AbsEos-0.00* AbsBaso-0.02 ___ 04: 25AM BLOOD Glucose-103* UreaN-4* Creat-0.6 Na-139 K-4.1 Cl-106 HCO3-20* AnGap-13 ___ 04: 25AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7 ___ 04: 46AM BLOOD Lactate-1.5 K-3.8 <MEDICATIONS ON ADMISSION> ___ 81mg <DISCHARGE MEDICATIONS> 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily Disp #*28 Tablet Refills: *0 2. Acetaminophen ___ mg PO Q6H: PRN Mild Pain 3. Docusate Sodium 100 mg PO BID: PRN Constipation 4. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometritis E.coli bacteremia Retained products of conception <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 an infection of the lining of your uterus. You had a procedure to remove some infected products of conception (likely part of the pregnancy tissue that had been retained for some reason). There was also bacteria that grew out in the blood culture. For this reason, you need to be on antibiotics for 14 days. Additional recommendations: Nothing in the vagina for 4 weeks (No sex, douching, tampons) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, nausea/vomiting, heavy vaginal bleeding soaking >1 pad/hr, or any other concerns.
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On ___, Ms. ___ underwent a D&C which removed retained products of conception. She was afebrile following the procedure with no fevers, chills, or abdominal pain. She was advanced to a regular diet with no nausea or vomiting. She had minimal vaginal bleeding. She received 24 hours of IV ceftriaxone and flagyl. She was discharged home in stable condition with follow up in ___ weeks. Of note, gram negative rods in 1 culture bottle at ___ grew out E.coli, which was pan-sensitive.
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11363621-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ceclor / amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal birth with breech extraction twin B Retained placenta requiring D&C postpartum <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at ___ with di-di twins who presents with vaginal bleeding. She states that she had small spots of dark red blood with wiping this morning. Nothing in the toilet. She was evaluated by CNM at ___ and on speculum exam was noted to have a concerning amount of bleeding and was therefore transferred to ___ for management. She also reports some intermittent tightening but overall comfortable. No LOF, active FM x 2. ROS: Denies fevers/chills or recent illness. Denies HA, vision changes. Denies chest pain/shortness of breath/palpitations. Denies abdominal pain. Denies recent falls or abdominal trauma. <PAST MEDICAL HISTORY> PNC: - ___: ___ - Labs: Rh-/Abs-/RI/RPR nr/HBsAg-/HIV-/GBS unknown - Screening: LR ___ 2, CF negative - FFS: wnl, lowing placenta for twin A, succenturiate lobe for twin B - U/S: ___ A: anterior, low lying (1.4 cm from internal cervical os on ___, cephalic B: anterior placenta with posterior succenturiate lobe, connecting vessels fundal lateral left, transverse upper uterus - Issues: *) Low lying placenta: Twin A - most recently noted on US ___ *) Twin pregnancy: s/p MFM consult, on baby aspirin *) Elevated BPs: elevated at initial 159/91 -> 123/82 at 9wks, ___ at 16wks -> rpt wnl *) Rh negative OBHx: GP10 - G1: Current, di-di twins, spontaneous GynHx: - Denies abnormal Pap or cervical procedures - Denies fibroids/endometriosis/cysts - Denies STIs, including HSV PMH: Denies PSH: Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Lungs: breathing comfortably on room air Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ WBC-25.1 RBC-2.87 Hgb-9.0 Hct-25.5 MCV-89 Plt-206 ___ WBC-20.5 RBC-3.33 Hgb-10.5 Hct-29.3 MCV-88 Plt-232 ___ WBC-15.1 RBC-4.29 Hgb-13.5 Hct-37.7 MCV-88 Plt-238 ___ ___ PTT-24.1 ___ ___ ___ PTT-19.8 ___ ___ ___ PTT-24. ___ ___ BLOOD FetlHgb-0 ___ URINE Color-Yellow Appear-Hazy Sp ___ ___ URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 ___ URINE AmorphX-OCC ___ URINE Mucous-RARE ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG <MEDICATIONS ON ADMISSION> PNV, aspirin 81 mg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Mild Pain RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*60 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Preterm labor at 24 weeks Vaginal birth with breech extraction twin B Retained placenta requiring D&C postpartum Neonatal demise twin A Acute postop anemia, asymptomatic <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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___ yo G1P0 with di-di twins transferred at 23w5d with vaginal bleeding and preterm contractions concerning for abruption. On arrival, she was hemodynamically stable without any active bleeding. Her cervix was visually 1cm dilated (external os), and the internal os appeared closed by transvaginal ultrasound. She was noted to have contractions on toco, however, was not feeling them. Fetal testing was reassuring. Given her periviable gestational age, she met with both NICU and MFM and initially opted to defer betamethasone. She was transferred to the antepartum floor for observation. On HD#2, she developed painful contractions and changed her cervix to 2cm dilated. She was transferred back to labor and delivery where she was counseled again and opted for Magnesium for neuroprotection and betamethasone for fetal lung maturity. She remained clinically stable on Magnesium for approximately 24 hours. The Magnesium was discontinued given her stability. Shortly after, she had a precipitous vaginal delivery of Twin A (at 24w0d) followed by a postpartum hemorrhage (EBL 1000cc). She subsequently had a breech delivery of Twin B. Neonatology staff was present for delivery and transferred both neonates immediately for prematurity. . Her postpartum course is as follows: *) Post partum hemorrhage Ms. ___ had ___ partum hemorrhage secondary to retained placenta, and underwent dilation and curettage in the operating room following delivery. Her hematocrit was 37 (pre delivery) -> 29 (post delivery of twin A) -> 25 (post delivery of twin B). Her vital signs and vaginal bleeding were stable following her D&C. There was a neonatal demise of Twin A on ___ and of Twin B on ___. Her post partum course was otherwise uncomplicated. By ___, 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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11364479-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Lamisil / Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___ <CHIEF COMPLAINT> fevers, pelvic abcess <MAJOR SURGICAL OR INVASIVE PROCEDURE> CT guided drainage of pelvic abcess <HISTORY OF PRESENT ILLNESS> ___ G0P0 ___ ___ Female w/ newly dx'd endometriosis, now ~2wks post-op s/p Op LSC R ov cystectomy (endometrioma), fulg/exc of endometriosis (including bladder serosal exc w/ LSC reinforcement), and LSC enterolysis (___) w/ psoriasis flare, being treated for presumptive inc infxn, here today for inc check and f/u for c/o persistent fever. Pt here today for f/u for inc check for tx of presumed inc infxn and c/o unexplained fever. Pt eval'd in clinc last week ___ for c/o inc tenderness, fever, & URI sx's w/ cough, congestion & sore throat. Reported fever T100-101 initally thought to be related to URI. URI sx's have since spontaneously resolved, but pt still w/ c/o fever that responds to ibuprofen tx. Pt was also started on abs tx for presumed inc infxn due to c/o umb & suprapubic inc tenderness. Since initiating Keflex po abx tx last ___, pt reports improved inc pain (still w/ some inc tenderness at ___) but still cont's to have unexplained low grade fevers BID in AM & ___. Abd/inc exam somewhat obscured by flare of psoriasis manifesting throughout, including on pt's abd & inc's. Careful inspection of inc after unroofing the psoriatic lesions show intact umb inc w/o obvious collections, wd separation, induration, or drainage for culture. Pt has declined a pelvic/BME to date (she is virginal). She was not using topical steroids for her abd psoriasis and was encouraged to do so at the last visit & has been compliant. Pt tested neg for H1Ni flu (___), CXR neg (___) however ___ elevated 118 w/ left shift N 86.4, plts 550, elevated ESR 130, CRP 253.4. Prior to today's visit, pt c/o inc tenderness only. On today's visit she c/o new onset lower abd discomfort and persistent fever as high as T101. On visits at our ___ clinic pt has been afebrile. T 98.6 today, but pt has taken ibuprofen before each gyn vist (last dose at 6am, ~4.5 hrs prior to today's visit). She otherwise denies any other sx's such as CP/SOB/n/v/d/GU or GI sx's. <PAST MEDICAL HISTORY> OB History: G0, P0. GYN History: Menarche at age ___, LMP ___, regular menses every 26 days with 8 days of heavy flow, significant dysmenorrhea as noted above. Both midline and right lower quadrant pain, see above. She complains of dyspareunia with vaginismus. No successful vaginal intercourse to date. Denies any pain with full bladder or bowel movement. She denies abnormal Pap smear, but has never had successful Pap smear in the past. She is virginal to date but is intimate with her husband, prefers opposite sex and reports only one sexual partner throughout life. Does not currently require any birth control. Denies any history of STDs. - GYN Problems: 1. Persistent complex 2.8 cm right ovarian cyst. 2. Vaginismus and dyspareunia, using vaginal dilators. Medical Problems: Psoriasis, otherwise negative, see GYN problem list. Surgical History: On ___, laparoscopic cholecystectomy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Reports a maternal aunt with colon cancer, but denies any GYN female cancers such as breast, ovarian, uterine, cervical, vaginal, colon, or other cancers. She reports mother with hypertension and heart disease, but denies any diabetes or hypercholesterolemia or any other family medical conditions. <PHYSICAL EXAM> Pleasant, ___ female in no acute distress. BP is 114/70, weight 152 pounds, height 5 feet ___ inches. HEENT: Normocephalic, atraumatic, anicteric sclerae. Neck: Supple, full range of motion, no thyromegaly. Lymph Nodes: No cervical or supraclavicular lymphadenopathy. Back: No CVA tenderness. Lungs: Clear to auscultation bilaterally. CV: Regular rate and rhythm. Abdomen: Soft, nontender, nondistended, positive bowel sounds. No rebound or guarding. Well-healed infraumbilical laparoscopic incision. Extremities: No clubbing, cyanosis, or edema. Pelvic exam: There is grossly normal external female genitalia. On touch of the external surface, the patient demonstrates findings consistent with vaginismus with a very tight voluntary pelvic floor and introitus. Attempted speculum exam was unsuccessful due to the patient's inability to tolerate the insertion of the speculum. Bimanual exam attempted; however, limited due to the patient's inability to tolerate. One finger was inserted and a voluntary tight introitus was recognized, but no identifiable pathology, patent vaginal vault noted. Uterus and adnexa are not easily palpated. <PERTINENT RESULTS> ___ 11: 08AM UREA N-13 CREAT-0.7 ___ 11: 08AM estGFR-Using this ___ 11: 08AM WBC-11.2* RBC-3.62* HGB-10.0* HCT-29.8* MCV-83 MCH-27.6 MCHC-33.5 RDW-14.4 ___ 11: 08AM NEUTS-87.0* LYMPHS-9.3* MONOS-3.1 EOS-0.4 BASOS-0.2 ___ 11: 08AM PLT COUNT-516* ___ 04: 00PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 04: 00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG ___ 04: 00PM URINE RBC-172* WBC-16* BACTERIA-FEW YEAST-NONE EPI-10 ___ 04: 00PM URINE MUCOUS-RARE ___ 03: 15PM CRP-253.4* ___ 03: 15PM WBC-11.8*# RBC-3.74* HGB-10.2* HCT-32.0* MCV-86 MCH-27.4 MCHC-32.0 RDW-14.0 ___ 03: 15PM NEUTS-86.4* LYMPHS-9.4* MONOS-3.5 EOS-0.4 BASOS-0.2 ___ 03: 15PM PLT COUNT-550*# ___ 03: 15PM SED RATE-130* <MEDICATIONS ON ADMISSION> Dovonex ointment for psoriasis b.i.d. <DISCHARGE MEDICATIONS> 1. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for fever, HA, pain. 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 3. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous twice a day for 14 days. Disp: *QS * Refills: *0* 4. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 14 days. Disp: *QS * Refills: *0* 5. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours. Disp: *20 Tablet, Rapid Dissolve(s)* Refills: *0* 6. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical BID (2 times a day). 7. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 8. Heparin Flush 10 unit/mL Kit Sig: 100u/ml flush Intravenous twice a day for 1 months: heparin 100u/mL flush picc with 3cc after each administration of antibiotic. Disp: *QS * Refills: *3* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> post-op pelvic abcess medication-induced nausea <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> please call Dr. ___ you have fever (greater than 101 degrees), increasing abdominal/pelvic pain, drainage/redness/swelling at your incision sites/drain site. please take all of your antibiotics as directed.
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Ms. ___ was admitted for IV antibiotics and CT guided drainage of a pelvic abcess s/p an operative laparoscopy on ___. She presented with post-op fevers and lower abdominal/pelvic pain. She was admitted ___ for IV antibiotuc treatment. On ___, she underwent CT-guided drainage of her pelvic abcess by ___ left a pigtail catheter in place for further drainage of the abcess. On admission, she was started on IV levofloxacin and flagyl. The following day, on ___, IV vanco was also started for broader coverage. Her pain was well-controlled with tylenol and ibuprofen. Her WBC count was trended: it was 11.2 on admission, then 12 -> 12.4 -> 11.3 on ___ with one band on the differential, then further trended down to 8 throughout her hospital stay. She remained afebrile since ___. Her CBC was also notable for anemia, explained by onset of expected menses. Her pre-op Hct was 34, then 32 in the office prior to admission, then 28 on admission, then 26.3, then stable at 26.4. The CT scan results were reviewed with the radiologist and no other sources of bleeding were seen on the scan. An anemia workup was done, which showed a low transferrin level but the rest of the panel was normal. A peripheral smear was also done to check for lysis of RBCs but also came back normal. The patient was also admitted with a UTI- Urine culture grew out E.Coli- she was never symptomatic from the UTI and it was treated simulataneously with the IV Levofloxacin antibiotics she was on. Throughout her hospital stay, her main complaint of pelvic pain transitioned to nausea. The onset of nausea occurred with initiation of the antibiotics. It was felt that the nausea was most likely secondary to flagyl. Although the nausea was somewhat treated with anti-emetics, it progressively got worse. A repeat CT scan was performed to look for other causes of nausea. CT abd/pelvis on ___ revealed that the abscess had decreased in size appropriately and the catheter was in the correct location. There was no evidence of bowel injury. LFTs were assessed and wnl. WBC normalized from 12 --> 8. Pt remained afebrile on IV abx treatment. Although the patient's abscess appeared to be responding to conservative management, the patient's nausea persisted and she was unable to tolerate PO intake. Since the abscess cultures did not grow anything (patient was on Keflex for presumed wd infection prior to admission on ___, the Infectious Diseases service was consulted for advice regarding an appropriate antibiotic regimen with broad coverage given her psoriasis and less GI side effects- their input was greatly appreciated. ID also felt her nausea was due to her antibiotics and her antibiotics were changed to IV Meropenem, Vancomycin was continued, and Levo and flagyl were discontinued. Her nausea resolved and she began to tolerate a regular diet on ___. On ___, a PICC line was placed for anticipation of discharge home on IV antibiotics. On ___, her pigtail catheter was removed given minimal output and clinical improvement. She was discharged home on ___ with ___ services on IV Ertapenem and vancomycin. She will have a repeat CT scan as an outpatient with follow-up with Dr. ___.
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| 714
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11366626-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> ___ PPROM <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <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> ___ 02: 56PM BLOOD WBC-15.1* RBC-4.62 Hgb-10.7*# Hct-34.3 MCV-74*# MCH-23.2*# MCHC-31.2*# RDW-28.6* RDWSD-71.5* Plt ___ ___ 02: 56PM BLOOD Neuts-81.0* Lymphs-9.4* Monos-7.3 Eos-1.5 Baso-0.3 Im ___ AbsNeut-12.24* AbsLymp-1.42 AbsMono-1.11* AbsEos-0.22 AbsBaso-0.04 ___ 02: 56PM BLOOD Plt ___ GBS + GC/CT negative <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Labetalol 200 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Premature rupture of membranes at 19 weeks. Vaginal Delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call for heavy vaginal bleeding, temperature greater than 101, severe abdominal pain
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___ gravida 6 para 0 status post a spontaneous vaginal delivery after induction of labor for ___ PPROM. She was admitted on ___ after PPROM on ___ at 19 weeks gestational age. She presented to OB/GYN triage and was found to also have advanced cervical dilation of 3 cm. ___ was consulted regarding the poor prognosis given the gestational age. Given the high risk of multiple complications including chorioamnionitis, maternal sepsis, hysterectomy, or death if the pregnancy were to continue, the patient opted for induction of labor. She had an uncomplicated spontaneous vaginal delivery on ___. The patient had an uncomplicated postpartum course. She was discharged on postpartum day 1 afebrile with stable vital signs.
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11366626-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Elevated blood pressures <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <PHYSICAL EXAM> On day of discharge VSS Gen - NAD CV - regular rate Pulm - nl respiratory effort Abd - soft, NT/ND Ext - no calf tenderness <PERTINENT RESULTS> ___ 04: 56PM BLOOD WBC-9.5 RBC-3.88* Hgb-8.7* Hct-28.5* MCV-74* MCH-22.4* MCHC-30.5* RDW-20.9* RDWSD-55.7* Plt ___ ___ 04: 56PM BLOOD Plt ___ ___ 04: 56PM BLOOD Glucose-87 UreaN-6 Creat-0.6 Na-136 K-3.7 Cl-99 HCO3-22 AnGap-19 ___ 04: 56PM BLOOD ALT-11 AST-16 ___ 04: 56PM BLOOD Calcium-9.5 Phos-2.8 Mg-2.2 UricAcd-3.6 <MEDICATIONS ON ADMISSION> Labetalol 200mg BID <DISCHARGE MEDICATIONS> 1. Lisinopril 20 mg PO DAILY RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills: *1 2. Hydrochlorothiazide 25 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with very high blood pressures which required IV blood pressure medications to control. You were seen by a medicine doctor and started on new blood pressure medications. We have monitored you in the hospital and your blood pressures have improved. Having very high blood pressures for long periods of time can result in health problems, including stroke, heart problems, and kidney problems. For these reasons, it is very important that you follow-up with your primary care doctor and find a medical regimen which helps you control your blood pressures. We have made a follow-up appointment with your primary care team for next week. At home, please take your blood pressure medications as prescribed and call your doctor if you experience any symptoms described below or have any concerns.
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Ms. ___ is a ___ yo G6P0 w/ hx of chronic hypertension who was admitted on postpartum day ___ s/p spontaneous vaginal delivery complicated by intrauterine fetal demise s/p preterm premature rupture of membranes. At initial presentation, pt's BP were in the severe range. Her BP (and HR) and subsequent antihypertensive medication administration is detailed below: 1700: ___: 186/132, 80, 18 1720: 201/117, 73 -> 20mg IV labetalol given 1730: 187/120, 66, 18 -> 40mg IV labetalol given 1740: 185/111, 68 1750: 160/110, 68 1800: 179/109, 65 1815: 167/108, 67 -> 80mg IV labetalol given 1830: 155/98 1850: 171/107 -> 10mg IV hydralazine given ___: 10mg IV hydralazine ___: 166/10 ___: 144/60 Given her severe range blood pressures despite high dose antihypertensive medications, she underwent an EKG which was within normal limits. Her preeclampsia labs were also repeated and were normal limits on ___. Once her blood pressures were stabilized, she was admitted for continued BP monitoring. Pt was evaluated by the Hospitalist Medicine Service who recommended that she be started on lisinopril 20mg QD and HCTZ 25mg QD. During her admission, her blood pressures remained within goal range on these medications On hospital day #1, she was discharged to home in good condition with outpatient follow-up as scheduled.
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11366626-DS-4
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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> ___ is a ___ gravida 6 para 0 with a known fibroid uterus and presents after thinking about options for treatment, requesting multiple myomectomy. She endorses irregular heavy bleeding which varies in length, she can bleed up to 2 weeks at a time. She has not had sampling of the endometrial lining which I recommend and that procedure will be scheduled. On ___ ultrasound which showed an anteverted uterus that measured 16.7 x 10.9 x 13.8 cm. The overall size of the uterus is stable compared to ultrasound of ___. There are multiple masses consistent with fibroids. The largest fibroid is located on the left and measured 5.7 x 5.7 x 6.1 cm. The second largest fibroid located on the right measured 4.4 x 3.0 x 4.8 cm. Both of these dominant fibroids are rim calcified. The endometrium was homogenous and measured 17 mm, partially distorted by fibroids. The ovaries were normal and there was no free pelvic fluid. These findings were discussed with the patient and her questions were answered to her satisfaction. Of note, in ___ she experienced an intrauterine fetal demise secondary to pre-PROM at 19 weeks with advanced cervical dilation. <PAST MEDICAL HISTORY> OB GYN history: 5 TABs / 1 SVD c/b IUFD s/p PPROM at 19 weeks (___) She denies any sexually transmitted infection/PID. Her last Pap was ___ and normal/she denies any history of abnormal Pap smears. Medical history: ANEMIA ECZEMA HYPERTENSION FIBROID UTERUS ALPHA THALASSEMIA TRAIT H/O OBESITY Surgical History: HYSTEROSCOPY ___ MMY - 4CM SM FIBROID DILATION AND EVACUATION ___ D&C x 5 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family History : no cancer, heart attack, stroke or DM <PHYSICAL EXAM> <PHYSICAL EXAM> General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, mildly-distended, appropriately tender to palpation without rebound or guarding, incision clean/dry/intact GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 04: 05PM BLOOD WBC-21.8* RBC-4.06 Hgb-8.8* Hct-29.3* MCV-72* MCH-21.7* MCHC-30.0* RDW-22.1* RDWSD-57.2* Plt ___ ___ 04: 05PM BLOOD Glucose-193* UreaN-10 Creat-0.7 Na-139 K-3.5 Cl-99 HCO3-23 AnGap-17 ___ 04: 05PM BLOOD Calcium-9.3 Phos-2.4* Mg-1.5* ___ 11: 29AM BLOOD Glucose-139* Lactate-1.7 Na-135 K-2.8* Cl-101 calHCO3-27 <MEDICATIONS ON ADMISSION> Medications (Last Review: ___ by ___, MD): Active Medication list as of ___: Medications - Prescription CHLORTHALIDONE - chlorthalidone 25 mg tablet. 1 tablet(s) by mouth qam ERYTHROMYCIN WITH ETHANOL - erythromycin with ethanol 2 % topical gel. Apply to face twice a day HYDROCORTISONE - hydrocortisone 2.5 % topical cream. apply to the chin once a day for ___ days Medications - OTC FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth twice per day bid, take with food <ALLERGIES> Patient recorded as having no known allergies to drugs <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your follow-up 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 abdominal myomectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV pain medications. 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 pain medications. 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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11368344-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal bleeding, fevers in the setting of a recent SAB <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound guided dilation and currettage Echocardiogram Lupron Injection <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p SAB at 9w2d by ___ tri US presents from ___'s office with fever to 101.2 in the office and 104 at home, ongoing VB, saturating ___ pads per day, and malodorous discharge. Also reports syncopal events x 2 on ___ and ___. Remembers passing out but did not hit her head. Last PO's 4pm today. + Decreased appetite and N/V, which was attributed to early pregnancy with the most recent emesis today in the am. Has had chills at home. Denies chest pain or palpitations. Has noted abdominal distention. <PAST MEDICAL HISTORY> GynHx: - LMP Irregular, ___ - irregular cycles with heavy bleeding x7-15d, +cramping - denies h/o abnl pap; last pap ___ with PCP (___) - had Gonorhea in ___ and Chlamydia in high school - h/o fibroids - sexually active with husband, using no contraception, monogamous - + h/o HSV OBhx: G3P___ - ___ TABx1 - ___ SABx1 - ___ SAB as above PAST MEDICAL HISTORY: 1. Tonic Clonic seizures and migraine HA, followed by neurology. No seizure since ___. 2. Fibroid uterus 3. Hypercholesterolemia 4. SLE 5. T2DM 6. H/o MRSA skin abscess PAST SURGICAL HISTORY: 1. Hysteroscopy ___ at ___ 2. D+C ___. Abdominal myomectomy ___ requiring ICU admission but no blood transfusion 4. Hysteroscopic polypectomy ___ (Prior surgeries at ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Parents living- Mom with DM, dad with HTN/ DM. Twin sister also with DM ans SLE. GM died at ___ MI <PHYSICAL EXAM> Admission Exam: VS: 100.4 150/99 98 18 100%RA Gen: Tired appearing woman, laying on her side covered under 4 blankets because she feels very cold. Appears uncomfortable but engaged in conversation, able to move with discomfort. Neuro: A&O self, place, date. grossly nl strength Abd: Distended without tympany, obese, + palpable fibroid uterus extending above the umbillicus. + TTP difusely with midline umbilical TTP and most pronounced RLQ TTP. No rebound. No guarding. SSE: + 9 scoppetes of foul odorous blood in the vault. + Minimal bleeding. No other discharge. BME: Limited by body habitus and pt discomfort, but patient becomes very uncomfortable on palpation of the bulky uterus. Again RLQ TTP is seen. Ext: NT, NE <PERTINENT RESULTS> ___ 06: 20PM WBC-15.5* RBC-4.17* HGB-10.6* HCT-33.5* MCV-80* MCH-25.3* MCHC-31.5 RDW-15.9* ___ 06: 20PM NEUTS-71.3* ___ MONOS-5.3 EOS-1.7 BASOS-0.4 ___ 06: 20PM PLT COUNT-475* ___ 06: 20PM GLUCOSE-79 UREA N-9 CREAT-0.9 SODIUM-138 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17 <MEDICATIONS ON ADMISSION> Clindamycin lotion folic acid lasix (dc'd by PCP once found out she is pregnant) Neurontin Hydroxychloroquine ketoconazole metformin (dc'd in early pregnancy) Trileptal <DISCHARGE MEDICATIONS> 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *0* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constiptation. 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: at 4pm every day. Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Post-miscarriage endometritis Right main pulmonary embolus Large 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 > 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.
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Ms. ___ was admitted to the GYN service for presumed endometritis. She was taken for a D&C under ultrasound guidance for evacuation of the presumed endometritis. Please see operative note for full details. Cultures were sent as well as pathology. Pt was offered and accepted social work consult for support. . GYN: Ms. ___ was stable on IV antibiotics. These were discontinued after remaining afebrile for 48 hours. She had a benign abdominal exam and her endometritis was considered resolved on hospital day 3. She received an injection of lupron on ___ for treatment of her fibroid uterus. . Resp: On POD 1, pt developed tachycardia associated with fevers. Full examination was significant for decreased left breath sounds. Pt was sent for a CTA which was positive for right main pulmonary embolus. She was immediately started on a heparin drip and Coumadin for anticoagulation. She was placed on telemetry with continuous oxygen saturation monitoring. Pt became therapeutic on Coumadin two days later and Coumadin and heparin was overlapped by 24 hours when her heparin drip was discontinued on hospital day 6. . Card: On hospital day 4, pt had chest tightening and was evaluated by the night team. Her EKG was noted to be unchanged (reviewed by cardiology) and she was sating well on room air. She was given aspirin 325 mg po x 1 and supplementary oxygen. She was seen urgently by hematology who recommended TTE. Her TTE was notable for an EF of 50-55%, mild LVH, and mild right ventricular dilation consistent with pulmonary embolus. This was reviewed by cardiology in formal consultation, who agreed with management of anticoagulation and recommended continuing her current regimen. They concluded that she was stable for discharge given her stable vitals and TTE results. . Renal: On hospital day 1 she was noted to have increased creatine (1.4 up from 0.9 on admission) consistent with acute renal failure. This level resolved with hydration and returned to 0.9. . GI: Ms. ___ was noted to have intermittent emesis on hospital day 1 and 2. She had an abdominal CT with her CTA which was remarkable only for a fibroid uterus. Her diet was restricted to sips and slowly advanced without difficulty. She had no further episodes of emesis. . Neuro: On hospital day 6, patient had seizure-like activity. She was evaluated by the chief resident to be alert and oriented within ten minutes of seizure activity. Neurology was urgently consulted, they recommended a CT head and MRV head. Both studies were normal. Her previous neuroleptic levels at the beginning of ___ were normal. Neurology concluded that she was stable for discharge on her home dose of AEDs. . She was discharged home on hospital day ___ in stable condition.
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11368344-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> menorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy PICC placement, removal Wound vac placement <HISTORY OF PRESENT ILLNESS> The patient is a ___ G3, P0-0-3-0 who has symptomatic fibroid uterus causing vascular compression of the pelvic vasculature leading to a thromboembolic event as well as menorrhagia requiring Lupron therapy. The patient strongly desired fertility sparing measures and elected to undergo an abdominal myomectomy. Risks and benefits of the procedure were discussed with the patient in great detail and all questions were answered. <PAST MEDICAL HISTORY> OBhx: ___ - ___ TABx1 - ___ SABx1 - ___ SAB . PMH: Type 2 diabetes mellitus, systemic lupus erythematosis, epilepsy, h/o PE, MRSA+, focal hepatic nodular hyperplasia. . PSH: 1. Hysteroscopy ___ at ___ 2. D+C ___. Abdominal myomectomy ___ requiring ICU admission but no blood transfusion 4. Hysteroscopic polypectomy ___ (Prior surgeries at ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> DM, SLE <PHYSICAL EXAM> On admission (post-op): VS 99.2 104/78 HR125 16 96%RA FS145 NAD tachy, reg rhythm CTAB Abd soft, NT, diffuse TTP, no rebound Inc dressing c/d/i, no swelling/drainage No VB Ext NT NE <PERTINENT RESULTS> ___ 06: 35AM BLOOD WBC-16.4* RBC-3.61* Hgb-9.5* Hct-29.8* MCV-82 MCH-26.4* MCHC-32.0 RDW-16.5* Plt ___ ___ 06: 35AM BLOOD ___ PTT-32.8 ___ ___ 06: 35AM BLOOD Glucose-78 UreaN-10 Creat-1.1 Na-134 K-4.9 Cl-101 HCO3-20* AnGap-18 ___ 06: 55AM BLOOD ALT-13 AST-18 AlkPhos-72 Amylase-40 TotBili-0.2 ___ 06: 35AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1 ___ LUE U/S: DVT involving the left subclavian, left axillary, and left cephalic veins with slowed flow in the left basilic and left brachial veins. ___ CT A/P: 1. Either early complete or partial small-bowel obstruction. Fluid-filled loops of small bowel are seen extending through the jejunum to the terminal ileum. The ascending colon, transverse colon are not decompressed suggesting this could be an early small-bowel obstruction. 2. No definitive transition point can be identified explaining the etiology of this small-bowel obstruction. 3. No evidence of free air within the bowel. 4. Heterogenous large uterus without any evidence of hemorrhage in the region of known prior myomectomy. ___ CTA: 1. No evidence of pulmonary embolism. 2. Bilateral lower lobe atelectasis, slightly worsened since the CT of six hours prior (which was non-diagnostic). <MEDICATIONS ON ADMISSION> Gabapentin 300mg BID Hydroxychloroquine 200mg BID Trileptal 600mg BID <DISCHARGE MEDICATIONS> 1. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 3. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24 Hours). Disp: *30 Tablet(s)* Refills: *0* 8. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg/mL Subcutaneous Q12H (every 12 hours). Disp: *QS 1 week mg/mL* Refills: *0* 9. Outpatient Lab Work pls draw CBC, ___, PTT, INR and fax results to ___, attn: Dr. ___ on ___ 10. Iron (ferrous sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp: *30 Tablet(s)* Refills: *2* 11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp: *14 Tablet(s)* Refills: *0* 12. Outpatient Lab Work pls draw CBC, ___, PTT, INR on ___ and fax results to ___, attn: Dr. ___ ___ 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> 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. Please follow up with your PCP regarding your coumadin therapy.
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Ms. ___ was admitted after an abdominal myomectomy of numerous fibroids; see operative report for details. Recovery was complicated by the following issues: 1. Anemia: Postoperatively, Hct drifted to 21.5 (from 37.8). Transfused 2 units of packed red blood cells, and Hct stabilized at ___. 2. Postoperative ileus and possible partial SBO: POD 6 bilious emesis. Made NPO, started IVF, NGT placed. Daily electrolytes remained WNL and begun on TPN. Ileus/SBO slowly resolved, return of bowel function noted, and had advanced to regular diet by POD 12. 3. Wound infection: POD 10, fever to 101.2 and incision opened with purulent drainage. Wound vac placed, and pt was d/c'ed on Bactrim, with home nurse wound vac care orders. Remained afebrile through remainder of admission. Wound cultures pending. 4. LUE DVT: Postop tachycardic to 125 w/pleuritic CP, work up negative for PE. POD 8, L PICC placed to administer TPN. POD 11, c/o L arm pain, U/S showed LUE DVT. PICC d/c'ed, Lovenox started, d/c'ed with Coumadin bridge and serial lab draws. Arranged for PCP to manage anticoagulation. 5. Left arm weakness: Pt c/o left arm weakness, Neurology consulted and no deficits or pathology noted. 6. Multiple medical issues: As her postoperative issues and complications were stabilized and improving, she was restarted on her home meds for epilepsy, diabetes, and lupus. No active issues. She was discharged home on postoperative day #13 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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| 412
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11368344-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fever and abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> transfusion of 2 units fresh frozen plasma ultrasound-guided drainage of intra-abdominal fluid collection <HISTORY OF PRESENT ILLNESS> ___ s/p abdominal MMY ___ with a complicated post-op course (anemia, s/p transfusion, ileus vs SBO, wound infection, s/p wound vac and LUE DVT, now on anticoagulation) now presents to the ED with abdominal pain, fever at home to 102.3. Patient was seen in the office ___ at which time she was doing well and had no abdominal pain. There were no localizing signs of infection on examination and she was afebrile at that time. Notably, she had asked at that visit whether she may resume sexual intercourse. She reports having vaginal intercourse on ___ without any dyspareunia. On ___ the patient was seen by ___ who measured her temperature to be 102.3. Her PCP advised that she be seen in the ED. She waited until ___ because she overall felt well. On ___ she had an episode of emesis x 1. Her abdominal pain worsened and she decided to come in to the ED. In the ED she received Levofloxacin, Flagyl, Vancomycin and Zofran. She received IVF. Upon evaluation by GYN in the ED, she reports abdominal pain. She has no nausea. She does not have an appetite. She reports lower abdominal pain, which is present in a band like distribution and with some radiation to the left back. It is worse in the left lower quadrant that right lower quadrant. The pain is not worsened with movement and has no positional component. It was initially ___ on arrival, but is now improved and she is able to sleep through it. The decision was made to admit the patient for continued monitoring and possible OR vs ___ drainage ___ medical management. <PAST MEDICAL HISTORY> Past OBGYNx: ___ - ___ TABx1 - ___ SABx1 - ___ SAB - hx of Gonorrhea in ___ and Chlamydia in high school - Fibroids as above. S/p ___ mult abd MMY (32 fibroids), now on Lupron - No h/o abnormal pap smears - no contraception at this time - sexually active w/ 1 partner - husband PMH: ___, type 2 diabetes mellitus, systemic lupus erythematosus, epilepsy, h/o PE ___, MRSA+, focal hepatic nodular hyperplasia, LUE DVT - ___, now on Lovenox and being bridged to Coumadin. History of post-op ileus vs SBO on her admission. PSH: 1. Hysteroscopy ___ at ___ 2. D+C ___. Abdominal myomectomy ___ requiring ICU admission but no blood transfusion. 4. Hysteroscopic polypectomy ___ (Prior surgeries at ___ 5. Abd MMY as above ___, s/p wound vac for infxn <SOCIAL HISTORY> ___ <FAMILY HISTORY> DM, SLE, Seizures <PHYSICAL EXAM> On arrival to the ED: 98.4 112 133/94 20 98% RA Upon GYN evaluation ___ 04: 50): 100.1 98 130/66 16 98%RA Sleeping on the gurney comfortably, once awake conversing freely, moving without difficulty. well groomed CTAB RRR No CVAT Abd: Soft, NT/ND in the upper abdomen / umbilicus. + moderately TTP LLQ > RLQ without rebound or guarding. Pelvic: SSE deferred as was done by ED resident. GC/CT cultures collected. No discharge or bleeding noted. On palpation of the vaginal wall I am not able to reach the patient's cervix due to length of the vaginal vault as well as the discomfort that she experienced mostly along the anterior vaginal wall, which is at least partially ___ full bladder. Rectal: deferred ___: NT/NE <PERTINENT RESULTS> ___ 19.8 > 9.5 / 28.3 < 537 N: 80.2 L: 13.8 M: 5.1 E: 0.2 Bas: 0.7 ___ ___: 16.9 PTT: 31.1 INR: 1.5 ___ 06: 05AM BLOOD WBC-24.0* RBC-3.35* Hgb-8.4* Hct-26.0* MCV-78* MCH-25.1* MCHC-32.4 RDW-16.0* Plt ___ ___ 06: 05AM BLOOD Neuts-83.0* Lymphs-9.1* Monos-7.4 Eos-0.1 Baso-0.4 ___ 06: 40AM BLOOD WBC-15.1* RBC-3.43* Hgb-8.3* Hct-26.5* MCV-78* MCH-24.3* MCHC-31.3 RDW-16.1* Plt ___ ___ 06: 40AM BLOOD Neuts-76.8* Lymphs-15.9* Monos-5.4 Eos-1.6 Baso-0.4 ___ 06: 40AM BLOOD ___ PTT-45.4* ___ ___ 06: 05AM BLOOD ESR-130* ___ 08: 40AM BLOOD ___ Cultures: ___ and ___ ___: no growth ___ and ___ Bcx: no growth ___ GC/CT: negative ___ Fluid collection: Gram stain showed PMNs but no organisms, NGTD; all other cx's neg. Imaging: ___ CT: No bowel obstruction; enlarged heterogenous uterus c/w postop. Several ___ organized fluid collections, largest between uterus/bladder spanning 5.7cm, largest one is 3.0 x 3.0cm; hematomas vs infxn; no free air. ___ PUS: 3.0 x 0.7 cm fluid collection between uterus and bladder. Enlarged heterogeneous uterus. No window for drainage. ___ rpt PUS: : 5.6 x 2.2 x 3.1 cm slightly complex fluid collection between the anterior lower portion of the uterus and the bladder, extending to the left of the midline, similar to ___. If drainage needed, portion of it may be accessible by transvaginal drainage from a left sided approach ___ EKG: Sinus rhythm. Early precordial QRS transition. Modest mid-precordial lead T wave changes are non-specific. Since the previous tracing of ___ inferior and precordial lead T wave changes are less prominent. ___ ultrasound guided transvaginal fluid drainage: Technically successful ultrasound-guided transvaginal aspiration of a 4 cm fluid collection between the uterus and bladder, yielding 9 cc of clear yellow fluid. Samples were sent for microbiology. The collection was drained to completion. <MEDICATIONS ON ADMISSION> CLINDAMYCIN PHOSPHATE - CLOBETASOL - DESONIDE - ENOXAPARIN - 90mg SQ BID FENTANYL patch 50mcg q 72h FOLIC ACID - 1 mg GABAPENTIN - 300mg BID HYDROXYCHLOROQUINE - 200 mg BID LEUPROLIDE OXCARBAZEPINE [TRILEPTAL] - 600 mg BID SILVER SULFADIAZINE - TRAMADOL - 50 mg BID WARFARIN - DOCUSATE SODIUM FERROUS SULFATE FEXOFENADINE MACROBID (treated for UTI by PCP, although ___ neg ___ per discussion with PCP's office earlier this week) <DISCHARGE MEDICATIONS> 1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 4. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp: *20 Tablet, Delayed Release (E.C.)(s)* Refills: *1* 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 6 days. Disp: *18 Tablet(s)* Refills: *0* 7. linezolid ___ mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp: *12 Tablet(s)* Refills: *0* 8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp: *12 Tablet(s)* Refills: *0* 9. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp: *14 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> intra-abdominal fluid collection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please keep the followup appointments you have with Dr. ___ ___ Dr. ___. Please refer to the Danger Signs below for when to call your physician or go to the Emergency Room. Please take your medications as prescribed. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, no heavy lifting of objects >10lbs for 6 weeks following your initial surgery on ___. * You may eat a regular diet. Wound care: * Continue your wound care instructions given by your visiting nurse. Anticoagulation: * You will follow up your anticoagulation with your primary physician ___. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted for fevers to 102.6 and abdominal pain following an abdominal multiple myomectomy on ___ that was complicated by wound infection requiring wound vac placement, medically managed ileus vs partial SBO requiring PICC + TPN, LUE DVT leading to coumadin and lovenox therapy. Her admission was complicated by monitoring for signs of infection, a concern for intr-abdominal abscess, n/v and constipation, and persistent tachycardia with a one-time episode of chest tightness. She also continued to receive care regarding her anticoagulation, wound healing, and other medical problems. 1. Infection: On admission she was started on broad-spectrum antibiotic coverage with levofloxacin and flagyl, and she was monitored closely for clinical change. Vancomycin was added on hospital day #2 due to persistent elevated WBC and fevers to 102.3. Her fevers improved by hospital day #4 and her WBC trended downwards; no bands were ever seen. On hospital day #5 she transitioned to oral metronidazole, levofloxaxin and linezolid; she was discharged on hospital day #5 with a planned 7-day course of antibiotics starting from the day after ___ drainage (see below). 2. Fluid collection and abdominal pain: Imaging showed concern for an abscess and on hospital day #3 she underwent ultrasound guided drainage of 9cc clear yellow fluid from a fluid collection between the bladder and uterus. Gram stain of the fluid showed 2+ PMNs, but no organisms, cultures showed no growth by the time of discharge. Her abominal pain continuously improved and did not require pain medications beyond hospital day #2. 3. N/V and constipation: During this hospitalization, she developed nausea, vomiting, and constipation, but her abdomen remained soft and her emesis was closely associated with PO intake. She received an aggressive bowel regimen resulting in adequate bowel movements, and her nausea improved. Her abdominal exam also continued to improve with resolution of her constipation. 4. Tachycardia and chest tightness: She was persistently tachycardic upon arrival to 110s but improved by hospital day #2, remaining the high-90s to low-100s without symptoms. She developed non-radiating, reproducible chest tightness on hospital day #3; an EKG showed sinus rhythm 95 bpm with nonspecific T wave changes and the pain resolved without intervention. 5. Anticoagulation for known LUE DVT: After discussion with Hematology, her Coumadin was initially stopped upon admission, and her Lovenox was held 24h prior to planned ___ drainage. She received 2 units FFP prior to ___ drainage, and her anticoagulation was restarted following the procedure without incident. Her Lovenox was stopped for a therapeutic INR, and she was discharged on Coumadin 5mg daily. Plans were made for her PCP to follow her anticoagulation regimen closely. 6. Wound dressing s/p vac: Her wound was changed daily with wet-to-dry dressings and remained clean dry and pink throughout her admission. She was discharged with home nursing for daily dressing changes. 7. Epilepsy, T2DM diet-controlled at home, and SLE: Regarding her multiple medical problems, her home medications for epilepsy and SLE were continued, and she was placed on insulin sliding scale for type II DM with excellent finger sticks no higher than ___.
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11372157-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> nausea, vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G3P0 with poor OB hx and ___ transferred from ___ ___ ED to ___ ED for hyperemesis gravidarum and T1DM. Patient reports that she has been unable to tolerate solids and minimal fluids since 4 weeks. She reports she has continued her basal insulin at the her regular doses but has not been regularly checking her fingersticks or taking her short acting insulin given her poor po tolerance. She reports when she does take her insulin, her fingersticks are regularly in the 200s. She is unable to estimate how many times a day she has vomiting but states that it is every time she attempts to eat or drink. She has tried Compazine only which she states just delays the vomiting with all po. She reports this is her third presentation to the ___ ED for this. She reports she was 130 pounds at the beginning of pregnancy and is now down to 95 pounds. Reports feeling fatigued and weak but denies palpitations, chest pain, SOB. She reports taking her regular 14 U NPH this pm before she went to the ED. On arrival to the ED, her HR was in the 140s which responded appropriately to fluids. Her ___ was 146. Bicarb was wnl. UA showed 10 ketones. She received Zofran, reglan and was po challenged with water and crackers. Of note, pt spent early pregnancy in ___, Denies any febrile illness or mosquito bites in ___. <PAST MEDICAL HISTORY> PNC: ___ ___ by LMP c/w 12 week ultrasound Labs [ ] will obtain from primary OB in am Genetics: ERA pending ___ Issues OBHx: G1 22wk SVD ___ urosepsis/PTL, stillbirth G2 30wk SVD c/b chorioamnionitis, neonatal demise at 1 week G3 current GynHx: denies PMH: T1DM x ___ years PSH: laparoscopic cholecystectomy ___ <SOCIAL HISTORY> SHx: denies T/E/D <PHYSICAL EXAM> Admission Exam: Exam: Pain Temp HR BP RR Pox Glucose 0 97.2 115 113/80 16 99% RA 146 113 mg/dl 0 98.3 90 ___ 98% RA 85 0 88 114/75 16 98% RA 185 A&O, comfortable, thin appearing RRR CTAB abd soft, gravid, nontender Ext no calf tenderness Discharge exam AVSS Pulm: normal respiratory effort Abd: soft, NT, ND Ext: wwp <PERTINENT RESULTS> ___ 06: 00AM BLOOD WBC-10.1* RBC-3.64* Hgb-11.3 Hct-32.5* MCV-89 MCH-31.0 MCHC-34.8 RDW-12.8 RDWSD-41.7 Plt ___ ___ 07: 40AM BLOOD WBC-9.2 RBC-3.75* Hgb-11.4 Hct-33.4* MCV-89 MCH-30.4 MCHC-34.1 RDW-12.6 RDWSD-41.1 Plt ___ ___ 06: 39AM BLOOD WBC-9.9 RBC-3.74* Hgb-11.4 Hct-32.6* MCV-87 MCH-30.5 MCHC-35.0 RDW-12.4 RDWSD-39.8 Plt ___ ___ 06: 30AM BLOOD WBC-9.9 RBC-3.58* Hgb-11.1* Hct-31.6* MCV-88 MCH-31.0 MCHC-35.1 RDW-12.4 RDWSD-40.5 Plt ___ ___ 07: 56AM BLOOD WBC-10.7* RBC-4.01 Hgb-12.4 Hct-35.8 MCV-89 MCH-30.9 MCHC-34.6 RDW-12.5 RDWSD-40.8 Plt ___ ___ 07: 33AM BLOOD WBC-9.8 RBC-3.94 Hgb-12.1 Hct-35.2 MCV-89 MCH-30.7 MCHC-34.4 RDW-12.4 RDWSD-40.7 Plt ___ ___ 06: 38AM BLOOD WBC-8.8 RBC-4.00 Hgb-12.2 Hct-35.8 MCV-90 MCH-30.5 MCHC-34.1 RDW-12.5 RDWSD-41.4 Plt ___ ___ 07: 00AM BLOOD WBC-8.7 RBC-3.74* Hgb-11.5 Hct-33.2* MCV-89 MCH-30.7 MCHC-34.6 RDW-12.6 RDWSD-40.9 Plt ___ ___ 07: 10AM BLOOD WBC-9.8 RBC-4.00 Hgb-12.3 Hct-35.5 MCV-89 MCH-30.8 MCHC-34.6 RDW-12.7 RDWSD-41.3 Plt ___ ___ 09: 45PM BLOOD Neuts-72.9* ___ Monos-5.6 Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.79* AbsLymp-2.41 AbsMono-0.67 AbsEos-0.06 AbsBaso-0.04 ___ 06: 00AM BLOOD Glucose-169* UreaN-6 Creat-0.4 Na-127* K-4.4 Cl-92* HCO3-24 AnGap-15 ___ 07: 40AM BLOOD Glucose-184* UreaN-6 Creat-0.4 Na-129* K-4.7 Cl-95* HCO3-26 AnGap-13 ___ 06: 39AM BLOOD Glucose-52* UreaN-5* Creat-0.4 Na-129* K-3.9 Cl-96 HCO3-24 AnGap-13 ___ 06: 30AM BLOOD Glucose-97 UreaN-5* Creat-0.4 Na-127* K-3.9 Cl-93* HCO3-25 AnGap-13 ___ 07: 56AM BLOOD Glucose-304* UreaN-6 Creat-0.4 Na-125* K-4.7 Cl-89* HCO3-24 AnGap-17 ___ 07: 33AM BLOOD Glucose-257* UreaN-6 Creat-0.4 Na-127* K-4.5 Cl-93* HCO3-25 AnGap-14 ___ 06: 38AM BLOOD Glucose-73 UreaN-5* Creat-0.4 Na-127* K-4.5 Cl-93* HCO3-25 AnGap-14 ___ 07: 00AM BLOOD Glucose-215* UreaN-4* Creat-0.4 Na-127* K-4.4 Cl-92* HCO3-26 AnGap-13 ___ 07: 00AM BLOOD Glucose-215* UreaN-4* Creat-0.4 Na-127* K-4.4 Cl-92* HCO3-26 AnGap-13 ___ 07: 10AM BLOOD Glucose-93 UreaN-6 Creat-0.4 Na-126* K-4.2 Cl-91* HCO3-27 AnGap-12 ___ 06: 20AM BLOOD Glucose-59* UreaN-5* Creat-0.4 Na-129* K-4.3 Cl-94* HCO3-24 AnGap-15 ___ 06: 23AM BLOOD Glucose-71 UreaN-3* Creat-0.3* Na-129* K-4.3 Cl-96 HCO3-24 AnGap-13 ___ 01: 41AM BLOOD Glucose-138* UreaN-3* Creat-0.4 Na-128* K-3.5 Cl-93* HCO3-25 AnGap-14 ___ 09: 15PM BLOOD Glucose-99 UreaN-3* Creat-0.4 Na-128* K-3.8 Cl-96 HCO3-25 AnGap-11 ___ 06: 02AM BLOOD Glucose-165* UreaN-<3* Creat-0.3* Na-126* K-3.8 Cl-94* HCO3-23 AnGap-13 ___ 06: 00AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.7 ___ 07: 40AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.7 ___ 06: 39AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.5* ___ 07: 56AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.6 ___ 07: 33AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7 ___ 06: 38AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9 ___ 07: 00AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.7 ___ 06: 38AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9 ___ 07: 00AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.7 ___ 07: 15PM BLOOD %HbA1c-8.0* eAG-183* ___ 06: 02AM BLOOD Osmolal-258* ___ 07: 15PM BLOOD TSH-0.36 <MEDICATIONS ON ADMISSION> Compazine, NPH 22U qam, 12U qhs, HISS with ___ ___ meals All: lactose intolerance <DISCHARGE MEDICATIONS> 1. Levemir 7 Units Breakfast Levemir 6 Units Bedtime ** Insulin Carb Counting Scale ** 2. Ondansetron ___ mg PO Q8H: PRN nausea RX *ondansetron [___ ODT] 8 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 3. Pyridoxine 50 mg PO DAILY RX *pyridoxine 50 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 4. Metoclopramide 10 mg PO Q6H: PRN nausea RX *metoclopramide HCl 10 mg 1 tab by mouth every 6 hours Disp #*60 Tablet Refills: *0 5. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> T1DM hyperemesis gravidum <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with hyperemesis. You were given intravenous fluids and anti-emetics and your nausea and vomiting improved. Your blood sugar levels were co-managed with ___ Diabetes. It is now safe for you to be discharged home.
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Ms. ___ is ___ G3P0 who was admitted to the antepartum service at 12w 6d with T1DM and hyperemesis gravidarum on ___. In terms of her T1DM, she had no etiology of DKA and had normal TSH and A1c 8.0%. ___ was consulted who helped in managing patient's ___. Her admission regimen was NPH 22 units qam, 12 units qhs. Patient had labile ___ and by time of discharge she was on levemir 7 units qAM and levemir 6 units QPM. She was on Humalog carb counting 1:10 (breakfast), 1:10 (lunch) 1:8 (dinner). Her ___ were within goal at time of discharge. Her hyperemesis improved PO reglan, Zofran, Benadryl,Ativan and vitamin B6. Nutrition was consulted and recommended glucerna. Of note, patient was noted to have hyponatremia and renal was consulted who thought her hyponatremia was likely due to hyperglycemia and SIADH triggered by N/V. Her sodium remained stable in the high 120's. She was discharged home on ___ with outpatient f/u scheduled.
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11372157-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> hyperemesis, T1DM <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G3P0 @ 23w 0d with poor OB hx and ___ transferred from ___ to ___ for hyperemesis gravidarum and T1DM. Patient had a recent ICU admission at ___ from ___ for DKA. Her labs were as follows: 11.14 > 8.9 / 26.4 < 293 88% neut 129 | 101 | 13 --------------< 437 5.1 | 10 | 0.5 Anion gap 29, UA with ketones and 1000 glucose Patient reports that she has been doing well since her discharge last week. She was able to tolerate an omelete for breakfast and lunch. She has only had one episode of emesis today while in the ambulance. Of note, she had a PICC line placed on ___ for TPN. She currently denies any nausea. Patient reports she was 130 pounds at the beginning of pregnancy. Reports feeling fatigued and weak but denies palpitations, chest pain, SOB. Denies F/C, vaginal bleeding, urinary sx, leaking of fluid. Has +FM. She presented to the hospital so that she can transfer her care to ___. <PAST MEDICAL HISTORY> PNC: ___ ___ by LMP c/w 12 week ultrasound Labs: O+/Ab-,RPRnr,RI,HIV-,HbsAg- Screening: LR ERA FFS: normal anatomy Issues: *)T1DM on levemir 8units QAM/ 6units QPM. Most recent A1c 8.0% on ___ *)h/o of fetal demise, on IM progesterone OBHx: G1 22wk SVD ___ urosepsis/PTL, stillbirth G2 30wk SVD c/b chorioamnionitis, neonatal demise at 1 week G3 current GynHx: denies PMH: T1DM x ___ years PSH: laparoscopic cholecystectomy ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) T 97.9, HR 118 BP 108/68, RR 18, ___ 122 @ ___, 200 @ 2140 Gen: A&O, comfortable, thin appearing CV: RRR Pulm: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness FHR 140-150's (on discharge) VS: 97.4, HR 99, BP 133/94, O2 100% ___ 215 GEN: A&O x 3, NAD ABD: soft, nontender EXT: no edema, no calf tenderness <PERTINENT RESULTS> ___ WBC-7.6 RBC-2.82 Hgb-8.4 Hct-25.1 MCV-89 Plt-242 ___ WBC-7.3 RBC-3.08 Hgb-9.2 Hct-27.6 MCV-90 Plt-215 ___ WBC-8.1 RBC-2.84 Hgb-8.5 Hct-26.3 MCV-93 Plt-231 ___ WBC-9.1 RBC-2.61 Hgb-8.4 Hct-26.0 MCV-100 Plt-243 ___ WBC-8.7 RBC-2.90 Hgb-8.8 Hct-27.0 MCV-93 Plt-230 ___ WBC-9.2 RBC-2.81 Hgb-8.6 Hct-26.5 MCV-94 Plt-197 ___ WBC-9.1 RBC-2.83 Hgb-8.7 Hct-26.9 MCV-95 Plt-207 ___ WBC-8.6 RBC-2.64 Hgb-8.1 Hct-25.0 MCV-95 Plt-194 ___ WBC-8.0 RBC-2.64 Hgb-8.1 Hct-25.0 MCV-95 Plt-229 ___ WBC-9.7 RBC-2.02 Hgb-6.1 Hct-19.0 MCV-93 Plt-333 ___ WBC-8.7 RBC-3.19 Hgb-9.2 Hct-28.2 MCV-88 Plt-211 ___ WBC-11.0 RBC-2.87 Hgb-8.8 Hct-24.8 MCV-86 Plt-117 ___ WBC-10.9 RBC-2.87 Hgb-8.4 Hct-25.6 MCV-89 Plt-172 ___ WBC-11.0 RBC-3.30 Hgb-9.8 Hct-29.7 MCV-90 Plt-561 ___ ___ PTT-26.9 ___ ___ ___ PTT-27.9 ___ ___ Ret Aut-2.2 Abs Ret-0.05 ___ Ret Aut-1.7 Abs Ret-0.05 ___ Ret Aut-2.9 Abs Ret-0.07 ___ Glu-155 BUN-8 Cre-0.2 Na-125 K-4.3 Cl-91 HCO3-25 Gap-13 ___ Glu-77 BUN-8 Cre-0.2 Na-129 K-3.8 Cl-96 HCO3-27 Gap-10 ___ Glu-110 BUN-8 Cre-0.2 Na-129 K-4.1 Cl-96 HCO3-24 Gap-13 ___ Glu-78 BUN-8 Cre-0.2 Na-133 K-3.9 Cl-100 HCO3-26 Gap-11 ___ Glu-92 BUN-7 Cre-0.3 Na-128 K-4.0 Cl-94 HCO3-25 Gap-13 ___ Glu-72 BUN-10 Cre-0.2 Na-131 K-3.9 Cl-99 HCO3-27 Gap-9 ___ Glu-73 BUN-11 Cre-0.2 Na-131 K-4.0 Cl-99 HCO3-25 Gap-11 ___ Glu-538 BUN-12 Cre-0.3 Na-129 K-5.5 Cl-102 HCO3-24 Gap-9 ___ Glu-156 BUN-10 Cre-0.2 Na-128 K-4.2 Cl-96 HCO3-25 Gap-11 ___ Glu-132 BUN-12 Cre-0.3 Na-131 K-4.1 Cl-98 HCO3-24 Gap-13 ___ Glu-102 BUN-11 Cre-0.3 Na-131 K-3.9 Cl-98 HCO3-26 Gap-11 ___ Glu-84 BUN-11 Cre-0.3 Na-129 K-4.0 Cl-97 HCO3-26 Gap-10 ___ Glu-86 BUN-11 Cre-0.3 Na-129 K-4.2 Cl-99 HCO3-23 Gap-11 ___ Glu-80 BUN-12 Cre-0.3 Na-131 K-4.2 Cl-99 HCO3-24 Gap-12 ___ Glu-92 BUN-13 Cre-0.3 Na-133 K-4.0 Cl-100 HCO3-24 Gap-13 ___ Glu-78 BUN-11 Cre-0.3 Na-129 K-3.9 Cl-99 HCO3-24 Gap-10 ___ Glu-86 BUN-10 Cre-0.3 Na-128 K-4.1 Cl-98 HCO3-24 Gap-10 ___ Glu-83 BUN-11 Cre-0.3 Na-130 K-4.1 Cl-97 HCO3-25 Gap-12 ___ Glu-104 BUN-10 Cre-0.4 Na-131 K-4.0 Cl-98 HCO3-24 Gap-13 ___ Glu-122 BUN-8 Cre-0.3 Na-133 K-3.5 Cl-101 HCO3-23 Gap-13 ___ Glu-247 BUN-8 Cre-0.3 Na-128 K-3.8 Cl-96 HCO3-27 Gap-9 ___ Glu-71 BUN-11 Cre-0.3 Na-132 K-3.9 Cl-97 HCO3-28 Gap-11 ___ Glu-145 BUN-14 Cre-0.3 Na-132 K-4.4 Cl-97 HCO3-26 Gap-13 ___ Glu-83 BUN-15 Cre-0.3 Na-136 K-4.3 Cl-101 HCO3-25 Gap-14 ___ Glu-362 BUN-16 Cre-0.5 Na-126 K-5.5 Cl-89 HCO3-21 Gap-22 ___ Glu-301 BUN-16 Cre-0.4 Na-129 K-4.8 Cl-94 HCO3-23 Gap-17 ___ Glu-165 BUN-11 Cre-0.4 Na-133 K-4.5 Cl-99 HCO3-25 Gap-14 ___ ALT-20 AST-22 Amylase-45 Lipase-13 ___ ALT-18 AST-15 ___ ALT-17 AST-18 ___ ALT-19 AST-20 ___ ALT-24 AST-28 CK(CPK)-68 ___ ALT-17 AST-19 AlkPhos-172 TotBili-0.2 ___ ALT-15 AST-19 AlkPhos-167 TotBili-0.3 ___ ALT-16 AST-36 ___ ALT-18 AST-26 ___ ALT-87 AST-75 LD(LDH)-331 TotBili-0.2 ___ ALT-114 AST-89 ___ ALT-112 AST-92 AlkPhos-622 TotBili-0.3 ___ ALT-113 AST-77 AlkPhos-627 TotBili-0.2 GGT-723 ___ ALT-102 AST-51 AlkPhos-598 TotBili-0.2 ___ Calcium-7.8 Phos-2.7 Mg-1.6 ___ Calcium-7.6 Phos-3.0 Mg-1.6 ___ Calcium-7.8 Phos-2.7 Mg-1.7 ___ Calcium-7.8 Phos-3.7 Mg-1.8 ___ Calcium-7.6 Phos-3.0 Mg-1.7 ___ Calcium-7.8 Phos-3.3 Mg-1.7 ___ Calcium-7.6 Phos-3.3 Mg-1.6 ___ Calcium-7.6 Phos-3.8 Mg-1.7 ___ Calcium-7.8 Phos-3.7 Mg-1.7 ___ Calcium-7.7 Phos-3.6 Mg-1.6 ___ Calcium-8.0 Phos-3.7 Mg-1.6 ___ Calcium-7.9 Phos-3.8 Mg-1.6 ___ Calcium-8.0 Phos-3.7 Mg-1.7 ___ Calcium-8.0 Phos-3.1 Mg-1.9 ___ Calcium-8.2 Phos-4.3 Mg-1.8 ___ Calcium-8.3 Phos-4.1 Mg-1.6 ___ Calcium-8.7 Phos-3.9 Mg-1.6 ___ calTIBC-384 Ferritn-9.8 TRF-295 Iron-46 ___ VitB12-373 Folate-7.2 ___ calTIBC-321 Ferritn-74 TRF-247 ___ %HbA1c-6.6 eAG-143 ___ %HbA1c-5.0 eAG-97 ___ Triglyc-123 ___ Triglyc-114 ___ Triglyc-124 ___ Triglyc-116 ___ Triglyc-60 ___ Triglyc-123 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP. URINE CULTURE (Final ___: NO GROWTH Test Result ---- ------ HELICOBACTER PYLORI AG, EIA, SEE NOTE STOOL HELICOBACTER PYLORI AG, EIA, STOOL MICRO NUMBER: ___ TEST STATUS: FINAL SPECIMEN SOURCE: STOOL SPECIMEN QUALITY: ADEQUATE RESULT: Detected <MEDICATIONS ON ADMISSION> PNV, levemir 8units QAM/ 6units QPM, IM progesterone <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *2 2. Amoxicillin 1000 mg PO Q12H RX *amoxicillin 500 mg 2 capsule(s) by mouth twice a day Disp #*56 Capsule Refills: *0 RX *amoxicillin 250 mg 4 tablet(s) by mouth twice a day Disp #*104 Tablet Refills: *0 3. Clarithromycin 500 mg PO Q12H RX *clarithromycin [Biaxin] 500 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills: *0 4. Cyclobenzaprine 10 mg PO TID: PRN back pain RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills: *1 5. Dermoplast Spray 1 SPRY TP Q6H: PRN perineal pain 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H: PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 8. Ibuprofen 400 mg PO Q6H RX *ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *2 9. Omeprazole 20 mg PO Q12H RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*28 Capsule Refills: *0 10. Levemir 4 Units Breakfast Levemir 3 Units Bedtime ** Humalog Insulin Carb Counting Scale ** <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Hyperemesis gravidarum Type I Diabetes Gastroparesis Back pain Urinary retention likely from neurogenic bladder H. Pylori ___ vaginal delivery Intrapartum hemorrhage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with nausea and vomiting during pregnancy. We managed your nutrition and your diabetes while you were here over several months. Please continue checking your sugars and taking insulin as prescribed by your endocrinologist. You also tested positive for H. Pylori and we began treatment on ___. You should continue treatment for 1 more week. Your prescriptions have enough medication for 2 weeks, but please stop taking these after 7 days. (Clarithromycin, Amoxicillin, omeprazole) You had a forceps assisted vaginal delivery with a vaginal laceration that required repair in the operating room and blood transfusions due to high blood loss. Due to urinary retention, you had a foley catheter placed. This should remain in place until your follow-up appointment with Dr. ___. Your liver tests were a little bit abnormal while you were here. These tests will be repeated at your postpartum visit. Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Your insulin regimen at the time of discharge is: Insulin SC Carb Counting Scale Meal Bolus Rates (Insulin Humalog : Carbohydrate Ratio) Breakfast = 1 Unit : 20 gm Lunch = 1 Unit : 20 gm Dinner = 1 Unit : 18 gm Snacks = 1 Unit : 20 gm Correction Bolus Correct To Blood Glucose of 170 mg/dL Correction Factor (Day) = 1 Unit Insulin Humalog for every 80 mg/dL above 170 Levemir 4 units in am and 3 units at bedtime
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___ G3P0 with ___ transferred from ___ at 23w0d for hyperemesis gravidarum and poor glycemic control. . ANTEPARTUM COURSES *) T1DM: On admission, she had no evidence of DKA. ___ was consulted and followed her closely. She was continued on Levemir and received Humalog in her TPN. She received a small dose of subcutaneous Humalog if she attempted to eat, however, she usually vomited with almost all po intake. Her insulin regimen was titrated by ___ for optimization of her blood sugars. Her HgbA1C on ___ was 5.0%. Eye exam on ___ was notable for mild non proliferative retinopathy in her right eye without macular edema. She was re-evaluated by ophthalmology on ___, and her retinopathy was stable. At the time of delivery, her insulin regimen was Levemir 13 units in AM and ___, and 27 units of regular insulin in her TPN. *) hyperemesis: Ms ___ presented to ___ with a PICC line in place. Nutrition was consulted and followed her closely. They made recommendations for her TPN to optimize her nutritional status. GI was also consulted. There was concern for possible gastroparesis and a trial of Reglan (around the clock) and Erythomycin was trialed, however, with no improvement in her symptoms. Ms ___ had a + H Plori in a stool specimen. Treatment was deferred given her inability to tolerate any po's, and this can be further addressed postpartum. Celiac testing was normal. *) Back pain: On hospital day ~___, Ms. ___ began to develop lower back pain. Chem 10, CBC, and CK were all within normal limits. She had previously been ambulatory in the hallway, but her pain became so strong that it adversely affected her mobility. She was seen by physical therapy and chronic pain service. Physical therapy recommended daily strengthening exercises with exercise bands, which did help relieve her pain. Chronic pain service encouraged daily movement to chair and out of bed whenever possible. Spine MRI (___) showed no evidence of any acute process. Her pain was treated with dilaudid and ativan. Prior to delivery, she was incontinent of both urine and stool since she was unable to get to bathroom/commode in time. *) Psych: Ms. ___ was seen by our psychiatry team to evaluate whether there were interventions that could optimize her mood/comfort. They did not see a need for any intervention at the time of consult but advised us to be aware that Ms. ___ is at high risk of developing post partum depression. *) hyponatremia: She had a persistently low sodium, ranging 127-130. Renal was consulted and felt that her presentation was most consistent with SIADH which was triggered by her hyperemesis. They recommended fluid restriction which was trialed, but with no improvement in her sodium level. Given her poor po intake and continued TPN use, nutrition continued to follow her lytes closely. *) anemia: Her hematocrit was mostly in the ___ range and she received multiple doses of IV iron as well as 2 units of PRBCs on ___. Iron studies were normal. It was felt that her anemia was likely due to chronic disease. *) tachycardia: During her admission, Ms. ___ was tachycardia with a heartrate intermittently up to 120-130s. This was thought to be likely secondary to anemia, and less likely attributed to pulmonary embolism, as she had no tachypnea or hypoxia, negative lower extremity ultrasounds (no DVT), and her heart rate improved after blood transfusion. She was monitored on telemetry during episodes of tachycardia, and tele was discontinued once her heart rate stabilized. *) poor Ob history: Ms ___ had 2 prior losses at 22 and 30 weeks. While she was here, she was continued on IM progesterone weekly. At approximately 30 weeks gestation, she started having occasional contractions. Her exam was 1cm dilated and 70% effaced at that time. Her contractions resolved. The IM Progesterone was discontinued at 36 weeks gestation. INTRAPARTUM COURSE After careful consideration and a discussion with ___ regarding the risks/benefits of a preterm induction, the decision was made to proceed with induction at 36 weeks. She had a favorable cervix at that time (3-4cm dilated) and she underwent an induction with Pitocin. Ms ___ had a ___ vaginal delivery for a fetal bradycardia and maternal exhaustion on ___. She delivered a liveborn male (___) weighing 2690 grams with Apgars of 8 and 9. *) T1DM: Ms ___ was continued on the TPN during her induction. She was started on an insulin drip and ___ followed her closely. *) PPH: There was a postpartum hemorrhage with a total EBL of 1800cc. Ms ___ had a 2nd degree laceration as well as bilateral sulcal tears requiring an extensive repair in the operating room. She received 2 units of packed RBCs during the repair, and required an additional 2 units of RBCs, 1 unit FFP, and 1 unit of cryoprecipitate. She was closely monitored on labor and delivery and her bleeding remained stable. *) elevated blood pressures: Ms ___ had intermittently elevated blood pressures in labor. She had normal preeclampsia labs with the exception of a mildly elevated urine protein/creatinine ratio (0.4). She did not require an anti-hypertensive medication or Magnesium given she had no severe features. POSTPARTUM COURSE *) T1DM/hyperemesis: ___ was able to tolerate po's by PPD#2, therefore, she was transitioned back to a sc insulin regimen. Her TPN was weaned off on ___. Her fingersticks were quite difficult to control despite her consistent meal choices. ___ felt that her inconsistent breastfeeding/pumping and likely gastroparesis (delayed absorption) were contributing factors. Her fingersticks were mostly on the high side prior to discharge, but she had no overnight hypoglycemia. Her PICC line was removed. At the time of discharge, she was taking Levemir 4 units in AM and 3 units in ___, as well as Humalog with meals (carb counting). She will follow up with her primary endocrinologist on ___. *) PPH/vaginal repair: Following her delivery, her epidural was left in place for pain control. Her bleeding was stable and she did not require any further products. On PPD#2, her epidural was removed and she was transitioned to po pain medication. *) back pain/immobilization: Physical therapy continued to work with her to improve ambulation. She was able to ambulate with a walker with significant improvement. She will continue to receive home ___. Her pain was controlled with Motrin and Tylenol prior to discharge. She required only minimal narcotics. *) H Pylori: Since she was tolerating po's postpartum, the decision was made to intiate treatment. She started a 14 day course of Amoxicillin, Clarithromycin, and omeprazole which she will complete as an outpatient. *) urinary retention: ___ was noted to have urinary retention which persisted until 2 weeks postpartum. She was seen by urogynecology on ___ and failed a voiding trial. It was felt that she had pelvic floor neuropathy and management options were discussed. She was discharged home with a catheter in place and will return in 3 weeks for another voiding trial and possible CIC teaching. Please see consult note in OMR for details. *) birth control: Ms ___ opted for ___ and this was placed on ___. Ms ___ was discharged to home on ___ in stable condition. ___ and home ___ was arranged. She will also have close outpatient follow up with MFM, endocrine (at ___, and urogynecology.
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| 1,701
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11372257-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cesarean scar pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Tranvaginal US Guided Injection of Methotrexate <HISTORY OF PRESENT ILLNESS> ___ yo G4P2 with history of cesarean pregnancy transferred to ED from ___ for management of recurrent ectopic pregnancy. Patient has known she's been pregnant since last ___ with home pregnancy test. Pregnancy confirmed that same day at ___, where she also had a TVUS, but was not told results, was told to follow-up as an outpatient. Patient developed vaginal bleeding today for the first time. Presented to ___ where she was found to have a cesarean ectopic pregnancy and transferred to ___ for further management. On arrival, denies abdominal and vaginal pain. Received IV Tylenol for headache, now resolved. VB was light, now resolved. This was a planned and desired pregnancy. She is confused as to why this is happening again and wants to know how she can avoid it in next pregnancy. <PAST MEDICAL HISTORY> OB: G4P2 - pC/S, ___ yo, full term, 3 KG (elective in ___ - rC/S, ___ yo, full term, 4kg, (elective repeat in ___ - Cesarean ectopic 8 months ago, treated in ___, denies medical management, reports subsequently negative HCG tests (these reports/documentation is not available) GYN: - LMP: ___, monthly regular periods - Sexually active: yes, one partner - STIs: unable to ask, in open room in ED, no privacy, partner present PMH: ___ PSH: - Rhinoplasty - Breast augmentation - C/S x2 - ? D&C for treatment of cesarean ectopic - Surgical repair of first Pfanninstiel incision <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of colon and GYN cancer. Twin brother with pancreatic cancer. <PHYSICAL EXAM> ADMISSION Vitals: 98.2 80 16 99/64 100%RA O2 General: NAD, comfortable, sleeping until awoken Resp: breathing comfortably Abd: soft, non-distended, non-tender, no rebound or guarding Ext: non-tender, no edema Pelvic: normal external genitalia, no blood in vault, small white discharge, cervix nulliparous, closed, no CMT, no adnexal tenderness, 7 wk uterus, anteverted, mobile, mildly tender with manipulation DISCHARGE <PERTINENT RESULTS> ====== LABS ====== ___ 09: 31PM BLOOD WBC-7.5 RBC-3.43* Hgb-10.8* Hct-32.2* MCV-94 MCH-31.5 MCHC-33.5 RDW-12.5 RDWSD-43.1 Plt ___ ___ 09: 31PM BLOOD Neuts-55.0 ___ Monos-8.6 Eos-4.0 Baso-0.4 Im ___ AbsNeut-4.14 AbsLymp-2.39 AbsMono-0.65 AbsEos-0.30 AbsBaso-0.03 ___ 09: 31PM BLOOD ___ PTT-20.5* ___ ___ 09: 31PM BLOOD Glucose-92 UreaN-8 Creat-0.5 Na-139 K-4.3 Cl-107 HCO3-19* AnGap-13 ___ 09: 31PM BLOOD ALT-23 AST-24 AlkPhos-65 TotBili-0.5 ___ 09: 31PM BLOOD Albumin-4.0 ___ 09: 31PM BLOOD HCG-6130 ___ 11: 44PM BLOOD Lactate-0.7 ___ 11: 17AM URINE Color-Straw Appear-Clear Sp ___ ___ 11: 17AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR* ___ 11: 17AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-3 TransE-<1 ====== MICRO ====== Urine culture: no growth Blood cultures: pending / no growth to date ======= IMAGING ======= PELVIC ULTRASOUND (___): FINDINGS: Located within the cesarean section scar is a single gestational sac containing a yolk sac, but no embryonic pole. Mean sac diameter measures 7 mm which corresponds to a gestational age of 5 weeks and 2 days. Endometrium is normal. There is a 3.3 x 2.9 x 2.9 cm anechoic, thin-walled simple cyst in the left ovary. The right and left ovaries are otherwise normal in appearance. There is no free fluid. IMPRESSION: Ectopic pregnancy in the Caesarean section scar. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> None <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cesarean section ectopic <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 seen in the emergency room and evaluated in the hospital for concerns of a cesarean ectopic pregnancy. You have been clinically stable over night with no vaginal bleeding and no abdominal pain. We briefly reviewed the management decisions for managing this pregnancy, and we have jointly decided to have you meet with Dr. ___, a specialist, early next week to discuss the next best steps. We will contact you for further details about this appointment. Please do not hesitate to call us with any concerns at ___.
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Ms. ___ is a ___ year old G4P2 with history of cesarean pregnancy 8 months prior who was transferred to ___ from ___ for management of cesarean scar pregnancy at approximately 6 weeks gestational age (by sure LMP ___. On presentation, she was hemodynamically stable without vaginal bleeding or other evidence of cesarian scare rupture or spontaneous abortion. Hematocrit was stable. A transvaginal ultrasound demonstrated a gestational sac in the lower anterior quadrant of the uterus consistent with a cesarean scare ectopic pregnancy. She was monitored on the Antepartum service overnight and remained stable throughout her stay. The patient was counseled regarding her options for termination and continuation of the pregnancy, as well as of the risks of uterine rupture, hemorrhage, and abnormal placentation. The patient was undecided, and given her clinical stability; outpatient follow-up was scheduled to further counseling and set a treatment plan.
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11372257-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> known cesarean scare ectopic pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound-guided intrasac methotrexate injection <HISTORY OF PRESENT ILLNESS> Patient is referred to me by Dr ___ concern for cesarean scar pregnancy. We reviewed her S from today and from over the weekend with radiology. She reports she feels well, no VB or pain. The remainder of the 10 point ROS is neg. <PAST MEDICAL HISTORY> OB: G4P2 - pC/S, ___ yo, full term, 3 KG (elective in ___ - rC/S, ___ yo, full term, 4kg, (elective repeat in ___ - Cesarean ectopic 8 months ago, treated in ___, denies medical management, reports subsequently negative HCG tests (these reports/documentation is not available) - Current cesarean scare ectopic pregnancy GYN: - LMP: ___, monthly regular periods - Sexually active: yes, one partner - STIs: unable to ask, in open room in ED, no privacy, partner present PMH: ___ PSH: - Rhinoplasty - Breast augmentation - C/S x2 - ? D&C for treatment of cesarean ectopic - Surgical repair of first Pfanninstiel incision <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of colon and GYN cancer. Twin brother with pancreatic cancer. <PHYSICAL EXAM> Temp: 98.7 (Tm 98.9), BP: 96/57 (92-100/55-61), HR: 77 (61-77), RR: 16, O2 sat: 97%, O2 delivery: ra Gen: NAD Resp: No evidence of respiratory distress Abd: soft, non-tender Ext: no edema, non-tender <PERTINENT RESULTS> ___ 06: 56AM BLOOD WBC-7.1 RBC-3.63* Hgb-11.4 Hct-33.2* MCV-92 MCH-31.4 MCHC-34.3 RDW-12.3 RDWSD-41.2 Plt ___ ___ 08: 58AM BLOOD ___ PTT-24.8* ___ ___ 06: 56AM BLOOD Creat-0.6 ___ 06: 56AM BLOOD ALT-21 AST-16 ___ 08: 58AM BLOOD ___ ___ 06: 56AM BLOOD ___ <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> None <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cesarean scar ectopic <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, ___ were admitted for management of a cesarean section scar ectopic pregnancy. ___ underwent a procedure to inject methotrexate into the pregnancy tissue. An additional intramuscular injection of methotrexate was recommended and ___ declined. ___ will follow up in 2 days for a scheduled D&C. Please follow these instructions *** NOTHING TO EAT OR DRINK STARTING MIDNIGHT BEFORE YOUR PROCEDURE ___ - Stop taking folate and prenatal vitamins - Do not take Ibuprofen, motrin, an other NSAIDs - No sex or vaginal penetration - No vigourous activity Call with - severe abdominal pain - Bleeding - Lightheadedness, fainting - Other concerns
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Ms. ___ is a ___ year old G4P2 who was admitted to the Antepartum service with recurrent cesarean ectopic pregnancy for intrasac methotrexate injection. She was admitted for the planned Interventional Radiology guided procedure to inject methotrexate into the gestational sac. Please see prior discharge summary for details related to her initial diagnosis and evaluation. Her procedure was uncomplicated, and she recovered appropriately. She declined systemic methotrexate. She was discharged in stable condition with a plan for dilation and curettage four days later.
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11372885-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> "Vaginal bleeding on and off since ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Laparascopic Hysterectomy <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ G2P2 who has vaginal bleeding on and off since ___. Patient is s/p 2u PBRBC's transfusion ___. She was seen in GYN triage on ___ and HCT was found to be 28.8. She was reassured, told to increase her birth control to twice daily dosing for 7 days and restart at the normal daily dosing. She was also told to increase her iron pills to three times a day dosing. She presents today because she has had vaginal bleeding with passage of clots since 1700 the night before presentation. She has also had severe cramps associated with this vaginal bleeding. Of note, she has bled through one pack of 18 tampons including pads. She had opened another pack of 18 tampons prior to presentation. Also, she complains of dizziness when standing. She denies chest pain or SOB. Around ___ this AM, she fell off the toilet onto the bathroom floor. She did lose consciousness for a few seconds but remained on the bathroom floor for about 30 minutes because she felt too dizzy to stand up. Her husband found her in that position. She is scheduled for hysterectomy on ___. Ros: denies shortness of breath or chest pain. <PAST MEDICAL HISTORY> PMH: - Hodkin's lymphoma s/p radiation & chemotherapy, remission for over ___ - Hypothyroidism PSH: Hysteroscopic myomectomy, adenoidectomy and eye surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Grandmother with uterine fibroids <PHYSICAL EXAM> VS: T 98.3 HR 104 BP 114/69 RR 20 O2Sat 100 Orthostatics: Lying 108/64, sitting ___, standing ___ 139 Phyical exam: General: Pale appearing and teary. In no acute distress Heart Regular rate and rhythm Lungs Clear to auscultation bilaterally Abdomen: Soft/Non-distended/ mild tenderness to palpation in bilateral lower quadrants. No rebound, no guarding. Sterile speculum exam: Pooling of blood in posterior vaginal vault. Evidence of blood clot coming out of the cervical os. Bimanual Examination: Firm and fibroid uterus. No Cervical motion tenderness. No adnexal masses or adnexal tenderness <PERTINENT RESULTS> ___ 11: 00PM WBC-9.1 RBC-2.97* HGB-9.6* HCT-26.9* MCV-90 MCH-32.2* MCHC-35.6* RDW-17.7* ___ 11: 00PM PLT COUNT-219 ___ 08: 24PM ___ PTT-26.9 ___ ___ 08: 24PM ___ 07: 50PM WBC-9.7 RBC-2.61* HGB-8.4* HCT-24.2* MCV-93 MCH-32.0 MCHC-34.5 RDW-17.2* ___ 07: 50PM PLT COUNT-260 ___ 01: 17PM WBC-11.0 RBC-2.60* HGB-8.4* HCT-24.6* MCV-95 MCH-32.4* MCHC-34.2 RDW-17.1* ___ 01: 17PM PLT COUNT-338 ___ 01: 17PM ___ PTT-24.9 ___ ___ 01: 17PM ___ <MEDICATIONS ON ADMISSION> - Reclipsen PO daily - Levoxyl 75mcg Po daily - Ferous sulfate 325mg PO TID <DISCHARGE MEDICATIONS> 1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* 5. 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> Uterine Fibroids <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 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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Ms ___ was admitted into the gynecology service for symptomatic anemia from bleeding associated with her uterine fibroids. She was found to have a hematocrit of 24.6 on presentation and was typed and crossed for transfusion of 2units of red blood cells. While receiving the first unit of her red blood cells, she had an episode of brisk bleeding from her vagina of approximately 300ml of blood. She was triggered for this bleeding and also because she had persistent tachycardia. She was then placed on telemetry, transfused the remaining 1.5units of blood at a faster rate and a STAT complete blood count was ordered, which revealed a hematocit of 24.2. Her post-transfusion hematocrit was found to be 26.9. At this point, it was decided that she would likely undergo a total laparascopic hysterectomy possibly open hysterectomy the next day. On hospital day 2, Ms ___ hematocrit was found to be 25.3 in the morning and she received another 1 unit of red blood cells before being taken in the operating room. She had a total laparascopic hysterectomy without any complications and her EBL was 25ml. Her blood counts were found to be 31.2 in the evening after her procedure and 27.1 on post-operative day 1. She did well after her surgery and was discharged on hospital day 3 and post-operative day 1 with adequate pain control, tolerating a regular diet and medications by mouth, voiding and ambulating without difficulty.
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11375346-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> labial abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> incision and drainage of labial abscess, placement of Word catheter <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G5P4 presents with left labial pain and concern for labial abscess. The patient presented to ___ this morning and was seen by Dr. ___. She reports noticing a bump on her left upper labia this past ___, which gradually became larger and more painful. It is warm to the touch and very tender. She has not noticed any drainage from the area or abnormal vaginal discharge. She denies fevers or chills. She denies urinary symptoms, has had normal BMs. She reports shaving in that area every so often, she most recently shaved after she noticed the bump had already appeared. <PAST MEDICAL HISTORY> OBHx: G5P4 - LTCS x2 - SVD x2 - SAB x1 GYN Hx: - s/p bilateral tubal ligation - hx of ASCUS Pap in ___, normal Pap testing since then - denies hx of STI PMHx: - morbid obesity - cerebral venous thrombosis - seizure disorder s/p stroke - HTN - T2DM, uncontrolled - OSA - anemia PSHx: - BTL - LTCS x2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> ___ <PHYSICAL EXAM> Discharge Physical Exam Gen NAD CV RRR P CTAB Abd soft, obese, nontender GU mons erythema receded from marked border, left labia with improved erythema, no residual fluctuance, continued minimal serous drainage from incision, +TTP but improved from prior Ext WWP <PERTINENT RESULTS> ___ 02: 22PM WBC-8.5 RBC-4.08 HGB-10.5* HCT-33.3* MCV-82 MCH-25.7* MCHC-31.5* RDW-16.7* RDWSD-49.8* ___ 02: 22PM NEUTS-66.9 ___ MONOS-5.9 EOS-2.5 BASOS-0.6 IM ___ AbsNeut-5.70 AbsLymp-2.03 AbsMono-0.50 AbsEos-0.21 AbsBaso-0.05 ___ 02: 22PM PLT COUNT-295 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 2. MetFORMIN XR (Glucophage XR) ___ mg PO QPM 3. lisinopril-hydrochlorothiazide ___ mg oral DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills: *0 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. MetFORMIN (Glucophage) ___ mg PO QHS 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*5 Tablet Refills: *0 6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills: *0 7. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *0 8. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 9. lisinopril-hydrochlorothiazide ___ mg oral DAILY 10. MetFORMIN XR (Glucophage XR) ___ mg PO QPM 11. Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> labial abscess, mons cellulitis <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. You have a word catheter in place to help prevent the re-accumulation of fluid in the labia. This will be removed at your visit in the office with Dr. ___ ___ week. 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 follow up appointment. * You may eat a regular diet. * You may walk up and down stairs. Abscess Care: * You may shower and allow soapy water to run over incision/catheter; no scrubbing of incision. No tub baths for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing incision and drainage of a left labial abscess, with Word catheter placement. Please see the admission H&P for full details. Her post-procedure course was uncomplicated. Immediately post-procedure, her pain was controlled with IV dilaudid. Her diet was advanced without difficulty and she was transitioned to PO oxycodone and Tylenol for pain control. She was started on IV Unasyn. Infectious Diseases was consulted on HD 3 and made recommendations to broaden her coverage with the addition of Vancomycin and to obtain a CT scan to further assess for undrained collections. CT pelvis demonstrated an evacuated abscess cavity with catheter in place and surrounding tissue edema, with no evidence of another collection/abscess. She was maintained on IV antibiotics until hospital day 8, at which point she was transitioned to PO Augmentin. She remained afebrile throughout her admission, with an appropriately down trending WBC. The Medicine service was consulted during this admission for optimization of her blood pressure medications and glucose control. General Surgery was also consulted to evaluate the abscess for possible debridement. She remained stable and did not warrant surgical debridement. By post-procedure day 9, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. The word catheter was left in place with plan for removal in the office next week. She was then discharged home in stable condition with outpatient follow-up scheduled on PO antibiotics.
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11378063-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> proteinuria <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery of twin A STAT cesarean delivery of twin B for terminal bradycardia following suspected placental abruption <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 35wd with di-di twins from IVF donor egg sent in for evaluation of 300 protein on UA in the office yesterday. She was seen in the offive yesterday and had normal blood pressures in 120/70s. Denies HA. Reports intermittent floaters x1 week no other vision change, no vision changes at this time. Reports occasional RUQ pain that comes and goes and appears to be related to fetal movment. No recent increase in ___ swelling. No VB, LOF. +FM. Pt feeling contractions as a tightening no associated with the upper abdominal sharp pains that she feels with fetal movement. <PAST MEDICAL HISTORY> ___ ___ IVF Pg Labs O+/Abs-/RI/RPRNR/HBsAg-/HIV-/GBS unknown Genetics nl ERA x2 FFS normal x2 GLT elevated, normal GTT EFW ___ A36% B 47% (full report unavailable at the time of this note) ___ A 1027g 48%, B 1180g 64% Issues: bilateral R>L upper quadrant sharp intermittent pain for the past several weeks OBHx: G1 GynHx: reports remote history of abnormal pap in college with negative colpo and repeat paps wnl PMH: depression/anxiety/bulemia, currently in treatment PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Upon admission: VS 140/92 repeat 133/96 A&O, comfortable RRR CTAB abd soft, gravid, nontender Ext trace edema SVE deferred Toco q6min FHT A 120/mod var/+accels/ one short variable to 100 with good return to baseline B 120/mod/+accels/ one short variable to 110 with good return to baseline Upon discharge: ***************** <PERTINENT RESULTS> ___ WBC-11.1 RBC-4.23 Hgb-12.3 Hct-35.9 MCV-85 Plt-182 ___ WBC-9.4 RBC-3.97 Hgb-12.1 Hct-34.3 MCV-86 Plt-116 ___ WBC-9.6 RBC-4.14 Hgb-12.2 Hct-36.2 MCV-88 Plt-125 ___ WBC-14.8 RBC-4.05 Hgb-11.6 Hct-35.3 MCV-87 Plt-124 ___ WBC-10.1 RBC-3.22 Hgb-9.3 Hct-28.8 MCV-89 Plt-209 ___ Creat-0.6 ALT-19 UricAcd-6.4 ___ Creat-0.7 ALT-18 AST-23 UricAcd-6.7 ___ Creat-0.7 ALT-21 AST-27 UricAcd-6.5 ___ Creat-0.7 ALT-26 AST-33 ___ Creat-0.7 ALT-27 AST-35 UricAcd-6.7 ___ Creat-0.7 ALT-38 AST-47 Mg-5.7 UricAcd-7.3 ___ Creat-0.6 ALT-25 AST-34 UricAcd-6.1 ___ BLOOD pO2-21 pCO2-79 pH-6.99 calTCO2-21 Base XS--16 Comment-CORD VEIN ___ BLOOD pO2-18 pCO2-89 pH-6.95 calTCO2-21 Base XS--17 Comment-CORD ___ ___ URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE RBC-0 WBC-38 Bacteri-MANY Yeast-NONE Epi-1 ___ URINE ___ Cre-80 TProt-223 Pr/Cr-2.8 ___ URINE pH-7 Hrs-24 Vol-2700 Cre-48 TProt-95 Pr/Cr-2.0 ___ URINE 24Creat-1296 24Prot-2565 URINE CULTURE (Final ___: NO GROWTH R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> PNV <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm twin delivery, 35w6d, one vaginal, one by c/s preeclampsia <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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On ___, Ms. ___ ___ with IVF di-di twins at 35 weeks 0 days, was admitted to the ___ service for pre-eclampsia evaluation after she was discovered to have proteinuria at a routine pre-natal visit. On admission, she had elevated blood pressures, non-severe range, and was otherwise asymptomatic. She was also found to have a UTI, which complicated her diagnosis, given her proteinuria. She was therefore admitted for observation for gestational hypertension and 24 hour urine collection following treatment of her UTI. On admission and throughout her hospitalization, she had reassuring fetal testing. She was also seen by the NICU and the faculty ___ services in consultation. During her hospitalization, her 24 hour urine returned with 2565 mg protein, and she developed signs and symptoms of severe pre-eclampsia, including persistent headache as well as severe range blood pressures and thrombocytopenia. She was started on a magnesium drip for seizure prophylaxis, and she received IV labetalol 20mg for blood pressures >160/100s. Given the development of severe pre-eclampsia, she was transferred to L&D for induction, given that she was noted to be vertex/vertex. On ___, the patient underwent an SVD of twin A followed by a STAT low transverse cesarean delivery of twin B for a terminal bradycardia noted in the setting of presumed placental abruption. Please see the dictated op note for details. She was treated with Magnesium sulfate for 24 hours postpartum. Her pain was controlled with a Dilaudid PCA until POD#1, then she was transitioned to po pain medication. On ___, her blood pressures were persistently elevated and she was started on Nifedipine CR 30mg with good result. She otherwise had an uncomplicated postpartum course and was discharged home on POD#4.
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11380412-DS-9
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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> Dilation and Curettage <HISTORY OF PRESENT ILLNESS> Pt arrives at ___ with ctx. Pt reports spotting started around 4am; ctx started at ___. Seen in triage this morning, ___, sent walking. Ctx have increased in intensity, feeling lower back pain. No LOF, active fetal movement. Denies headache, blurred vision, epigastric pain, sudden weight gain. <PAST MEDICAL HISTORY> PMH: Concussion and Mumps. PSH: NO SIGNIF SURGICAL HX Social hx: denies toxic habits <ALLERGIES> No Known Drug Allergies. Medications: PNV Current Outpatient Prescriptions: amoxicillin 500 mg Oral capsule, Take 1 capsule twice daily Prenatal Multivit-Ca-Min-Fe-FA (PRENATAL VITAMIN) Oral tablet, OTC with folic acid Past OB Hx: Obstetric History G1 P0 T0 P0 A0 E0 M0 L0 Comment: Reviewed ___ ___: q ___ pap: Never doneHPV Test: Not indicated : HPV Vaccine: unknownGyn Dx: NonePelvic Surg: NoneOB Risks: None Current pregnancy: G1, P0, Term0, Preterm0, Abt0, Sab0, Tab0, Ect0, Live0, ___ ___, by Last Menstrual Period BLOODGRP B ___ RH RH(D) POSITIVE ___ ABSCREEN ___ BELOW ___ RUBELLASEROL 446.0 ___ HBSAG Negative ___ SYPHSCRINTER Non-Reactive ___ GBS POS TWG: 29lbs Estimated body mass index is 24.14 kg/(m^2) as calculated from the following: Height as of ___: 5' 4.75" (1.645 m). Weight as of ___: 144 lb (65.318 kg). <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On day of discharge: afebrile, vital signs stable Gen: NAD Pulm: normal work of breathing Abd: soft, nondistended, incision c/d/i <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth BID prn Disp #*30 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth Q 6 hours prn Disp #*45 Tablet Refills: *0 4. Ferrous Sulfate 325 mg PO BID anemia start iron at home for 4 weeks, continue prenatal vitamins only if breastfeeding RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 (One) tablet(s) by mouth twice a day Disp #*90 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Term preganncy, delivered Spontaneous vaginal delivery, liveborn male Endometritis, PP hemorrhage, retained POCs, D and C <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___ RN discharge packet Refer to "Warning Signs" below Pelvic Rest
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Ms. ___ was admitted to the postpartum service on ___ after undergoing spontaneous vaginal delivery. Her postpartum course was complicated by a postpartum hemorrhage with retained products of conception requiring dilation and curettage in the operating room. Please ___ the operative report for details. Her postpartum course was also complicated by chorioamnionitis for which she received an extended course of antibiotics due to persistent fever and development of endometritis on postpartum day 1. She was discharged home in stable condition on postpartum day 3 with outpatient followup.
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11381948-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> nausea, vomiting, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> MRI of abdomen normal <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 @ 18w5d with abdominal pain since yestereday. Describes the pain as sharp, epigastric but radiating "everywhere", worse on R. ___. Nothing makes it better or worse. Tried tums, zantac at home. This am, developed nausea/ vomiting/ anorexia. Had 3 BM's today, not loose, but more than usual. Denies fevers, chills. Denies LOF, VB, cramping/ ctx. <PAST MEDICAL HISTORY> PNC: O+, ab neg, RI, RPR NR, HBsAg neg, HBsAb pos ___ ___ by 6wk US FFS normal OBhx: LTCS ___ arrest of descent GYNhx: h/o PID ___ reg menses nl paps dx with uterine septum on FFS PMH: denies PSH: cesarian delivery <PHYSICAL EXAM> On arrival Exam: 97.3, HR 84, BP 101/60, RR 20 NAD, appears sleepy Abdomen soft, ND, +TTP epigastrum/ R abdomen, no uterine tenderness, voluntary guarding, no rebound BME: mobile uterus, uterus NT, no CMT, cervix closed/long/soft <PERTINENT RESULTS> ___ 07: 25AM BLOOD WBC-6.9 RBC-3.31* Hgb-10.0* Hct-28.8* MCV-87 MCH-30.2 MCHC-34.8 RDW-13.3 Plt ___ ___ 03: 58PM BLOOD WBC-13.3*# RBC-3.86* Hgb-11.7* Hct-33.1* MCV-86 MCH-30.2 MCHC-35.3* RDW-13.4 Plt ___ ___ 03: 58PM BLOOD WBC-13.3*# RBC-3.86* Hgb-11.7* Hct-33.1* MCV-86 MCH-30.2 MCHC-35.3* RDW-13.4 Plt ___ ___ 07: 25AM BLOOD Neuts-67.1 ___ Monos-5.4 Eos-1.2 Baso-0.1 ___ 03: 58PM BLOOD Neuts-87.3* Lymphs-8.4* Monos-3.4 Eos-0.9 Baso-0.1 ___ 07: 25AM BLOOD Glucose-82 UreaN-3* Creat-0.4 Na-136 K-3.7 Cl-107 HCO3-23 AnGap-10 ___ 03: 58PM BLOOD Glucose-72 UreaN-3* Creat-0.4 Na-136 K-4.4 Cl-102 HCO3-23 AnGap-15 ___ 03: 58PM BLOOD ALT-16 AST-28 AlkPhos-66 Amylase-46 TotBili-0.3 ___ 07: 25AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.6 ___ 03: 58PM BLOOD Calcium-9.4 Phos-4.3 Mg-1.8 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: ___ MLs PO Q6H (every 6 hours) as needed for Constipation. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Gastroenteritis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Eat bland diet, small meals. Call if vomiting, diarrhea, fever, weakness.
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The patient is a ___ yo G2P1 with nausea, vomiting, abdominal pain admitted to the antepartum service at 18+ weeks secondary to an ultrasound initially concerning for appendicitis however MRI was negative for appendicitis. The patient's symptoms were attributed to likely gastroenteritis. Her MRI was negative for appendicitis, cholecystitis, and torsion. She had no uterine tenderness to suggest chorioamnionitis. The patient did have a history of pelvic inflammatory disease in the past, however she had no CMT or tenderness with pelvic exam. She was kept in house for serial exams were all stable. She was able to tolerate POs. The patient's pain was treated with percocet. She was discharged to home on ___ in stable condition. TAUS was reassuring for fetal well being.
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11382145-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fevers <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1P1 PP day ___ s/p SVD on ___ who presents with abdominal pain and fever. Symptoms began yesterday evening when she spiked a fever of 104.4 at home with an oral thermometer, which improved after taking Tylenol and Ibuprofen. Today she continued to feel unwell and began to feel general fatigue and became very warm and sweaty. She again had another fever before being instructed to come into triage for evaluation. Since her delivery, her vaginal bleeding has decreased with intermittent abdominal pain improved with Tylenol and Ibuprofen. <PAST MEDICAL HISTORY> PMH: denies PSH: denies OBHx: G1P1 - G1 SVD, FT GYNHx: - LSIL on recent pap smear in ___ colpo; for repeat cotesting ___ - Denies hx of STIs <SOCIAL HISTORY> SH: denies T/D/E <PHYSICAL EXAM> Vitals: T 101.9 (axilla), 100.9 (oral) Gen: A&O, NAD, diaphoretic, warm to touch CV: RRR Breast: severely engorged breasts bilaterally, no erythema Resp: CTAB MSK: no CVA tenderness bilaterally Abd: +BS, soft, minimal middle lower abdominal pain, no rebound or guarding Ext: calves nontender bilaterally, no edema SPE: normal external genitalia, blood in vault requiring 2 scopettes to clean, parous cervix, no abnormal discharge in vault SVE: no adnexal tenderness or fullness bilaterally, no CMT, minimal fundal tenderness <PERTINENT RESULTS> UA: (straight catherization) >182 WBC, 20 RBC, few bacteria, +nitrites Lytes: 137 | 103| 14 -------------<126 3.0 | 20 | 0.6 Blood cultures: pending CBC: 13>12.1/36.3<251, 0 bands, 89 neuts <DISCHARGE INSTRUCTIONS> continue cephalexin 500mg 4 times a day (every 6 hours) for at least 5 days
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___ yo G1P1 PP day ___ s/p SVD on ___ who presents with fever. The patient was febrile in triage to high of 101.9 and appears diaphoretic and unwell, though clinically stable. Her UA had + nitrites and also had >182 WBCs. Overally, clinically, it was concerning for a complicated UTI. The patient was started on IV ceftriaxone, and was transitioned to Keflex for outpatient treatment. Her urine culture was sent for antibiotic sensitivities. The patient was finally discharged on ___ in stable condition for outpatient follow-up. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H Mild Pain 2. Cephalexin 500 mg PO Q6H Duration: 5 Days RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp #*20 Capsule Refills:*0 3. Ibuprofen 600 mg PO Q6H Moderate Pain Discharge Disposition: Home Discharge Diagnosis: postpartum fever, likely pyelonephritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11383038-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> uterine vaginal prolapse stress urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robot assisted supracervical hysterectomy, bilateral salpingo-oophorectomy, sacrocervicocolpopexy, tension free vaginal tape sling, cystoscopy, excision umbilical skin lesion <HISTORY OF PRESENT ILLNESS> ___ who presents with urinary incontinence as well as bulge and tissue protrusion in the vagina. She has had the urinary incontinence for a long time. She leaks with coughing and sneezing for example. In the last year, she felt something coming down out of the vagina. Her PCP diagnosed her with prolapse. She voids about every two hours in the daytime and wakes up twice at night to urinate. She does have urgency and sometimes urge incontinence. She does also describe fecal urgency. She does not feel like she is always emptying her bladder. She denies recurrent bladder infections, kidney stones, hematuria or dysuria. She has rare constipation. She is sexually active. She does experience vaginal dryness. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Neuropathy, hypercholesterolemia, basal cell carcinoma right ankle, esophagitis, vitamin D deficiency, osteoporosis, hypertension, warts, carpal tunnel syndrome, reflux. Past Surgical History: Tonsillectomy in ___, D and C, cholecystectomy in ___, tubal ligation in ___, laparoscopic lysis of adhesions, Mohs surgery for basal cell carcinoma of the face, breast biopsy, wisdom tooth extraction. Past GYN History: Last Pap smear ___. No history of abnormal Paps. Past OB History: Gravida 4, para 3, three vaginal deliveries. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Uncle heart attack; father, hypertension; uncle, colon cancer; aunt, breast cancer. <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> ___ 08: 20AM BLOOD WBC-7.2 RBC-5.07 Hgb-15.5 Hct-47.1* MCV-93 MCH-30.6 MCHC-32.9 RDW-12.7 RDWSD-43.4 Plt ___ ___ 08: 20AM BLOOD Plt ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Hydrochlorothiazide 25 mg PO DAILY <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 #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Please take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe ___ cause sedation. Do not take with alcohol or while driving RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 5. Hydrochlorothiazide 25 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine vaginal prolapse, stress urinary incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 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 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 robot assisted supracervical hysterectomy, bilateral salpingo-oophorectomy, sacrocervicocolpopexy, tension free vaginal tape sling, cystoscopy, excision umbilical skin lesion. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV morphine and toradol. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 300 mL with 0 mL residual. Her diet was advanced without difficulty and she was transitioned to oral pain medications. For her history of hypertension, she was continued on her home dose of hydrochlorothiazide. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11384293-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Flagyl / nitrofurantoin / naproxen / trospium / Aleve <ATTENDING> ___ <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Abdominal Hysterectomy, Left Salpingo-oophorectomy, right salpingectomy for pelvic mass <HISTORY OF PRESENT ILLNESS> ___ woman who has had lower pelvic discomfort and urinary leakage for sometime. She recently had an evaluation with ___. At that visit, she was identified as having trigonitis. ___ underwent a pelvic ultrasound, which revealed a large complex mass. The ultrasound performed at ___ Ultrasound Consultants on the ___ revealed a 14 x 10 x 13 cm complex cystic left adnexal mass with several vascularized septations, one of which contained a 4-cm solid-appearing region. The patient is here for discussion of treatment options. She denies any symptoms suggestive of metastatic disease. In specific, she denies any chest pain, shortness of breath, upper abdominal discomfort or pain. Ms. ___ has a history significant for diverticular disease. She underwent a sigmoid colectomy with colostomy reversal by Dr. ___ in ___. She had bilateral mastectomy for breast cancer on one side and DCIS on the other and she has undergone a right oophorectomy in the past. <PAST MEDICAL HISTORY> PMH: L pelvic fx, breast ca, osteoporosis, diverticulitis PSH: Dermoid ovarian cyst ___ B/L Mastectomy with L axillary dissection Sigmoidectomy w/ ___ ___ ___ takedown ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father passed from a PE at age ___, h/o TB requiring lung resection. Mother h/o CVA. <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> ___ 08: 37PM GLUCOSE-187* UREA N-11 CREAT-0.7 SODIUM-141 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16 ___ 08: 37PM estGFR-Using this ___ 08: 37PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.7 ___ 08: 37PM WBC-22.8*# RBC-4.26 HGB-12.4 HCT-38.9 MCV-91 MCH-29.1 MCHC-31.9* RDW-13.0 RDWSD-43.3 ___ 08: 37PM PLT COUNT-241 ___ 07: 18PM GLUCOSE-134* NA+-140 K+-4.1 CL--105 TCO2-25 ___ 07: 18PM HGB-12.2 calcHCT-37 <MEDICATIONS ON ADMISSION> omeprazole Reclast multivitamins fexofenadine 180mg fluticasone prn <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *3 2. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain Do not drive while taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #*50 Tablet Refills: *0 3. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4000g in one day RX *acetaminophen 500 mg ___ tablet(s) by mouth q6hrs Disp #*30 Tablet Refills: *3 4. Bisacodyl 10 mg PO/PR DAILY: PRN contstipation RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*30 Suppository Refills: *3 5. Ferrous Sulfate 325 mg PO DAILY take with stool softeners RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*60 Tablet Refills: *3 6. Senna 8.6 mg PO BID: PRN constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*30 Tablet Refills: *3 7. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills: *3 8. Ciprofloxacin HCl 500 mg PO Q12H UTI Duration: 7 Days Complete entire antibiotic course, even if not feeling symptoms RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> final diagnosis pending pathology <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. You were also diagnosed with a urinary tract infection while in the hospital. Please take the full antibiotic course. We will follow-up with you on results of the urine culture and if you need to switch antibiotics for adequate treatment. 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. * 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 an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy with cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with a dilaudid PCA. Her diet was advanced slowly without difficulty and she was transitioned to oral pain meds. On post-operative day #2 her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She had developed some tachycardia that spontaneously resolved. No further evaluation was made with imaging. We do recommend, however, that she follow-up with her primary care for further evaluation of her blood pressures, which were persistently in the mild range while in house. Also while in house, pathology called to amend their frozen section analysis. Based on a brief review of pathology, they do believe that her pelvic mass was not ovarian clear cell carcinoma but rather struma ovarii. Final pathology is still pending, so no treatment decisions were made while in house. By post-operative day 6, she was tolerating a regular diet, voiding spontaneously, ambulating independently, having bowel movements and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11385318-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ ___ G1P1 who presented as a transfer from ___ for evaluation of a bleeding cervical mass. She had light spotting for the past week, nad prior to admission she had heavy vaginal bleeding for about an hour with a few small blood clots. She then presented to ___ where she was found to have a posterior cervical mass concerning for malignancy. She was hemodynamically stable with HCT 34.7. Her bleeding was stable, and so she was transferred to ___ for gyn onc evluation and possible radiation treatment. Currently, she denied any abdominal pain/cramping, dizziness, SOB/CP, or palpitations. She denied any unintentional weight loss, nausea, back pain, change in bowel or bladder habits, or vaginal discharge. She never had any postmenopausal bleeding in the past until last week. <PAST MEDICAL HISTORY> Obstetric History: G1P1 - SVD x 1, uncomplicated pregnancy and delivery Gynecologic History: - Menopause ___ years ago. Denies ___ postmenopausal bleeding - Menses previously monthly, regular. Denies history of menorrhagia or dysmenorrhea. - Denies ___ abnormal Pap test. Her last was "a few years ago" by her primary care physician - ___ STIs or pelvic infections. Not sexually active. <PAST MEDICAL HISTORY> Denies - no history of HTN, heart disease, lung disease, bleeding or clottoing problems Past Surgical History: - has metal in her arm from repair of a childhood fracture <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> - Denies family history of ovarian, uterine, cervical, breast, or colon cancer. No family history of heart disease or stroke. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm pulm: clear to ausculatation bilaterally abd: soft, nontender, nondistended, incision clean/dry/intact GU: minimal bleeding on pad ___: nontender, nonedematous <PERTINENT RESULTS> ___ 12: 45PM BLOOD ___ ___ Plt ___ ___ 06: 00AM BLOOD ___ ___ Plt ___ ___ 06: 00PM BLOOD ___ ___ Plt ___ ___ 06: 00PM BLOOD ___ ___ ___ 06: 00AM BLOOD ___ ___ ___ 06: 00PM BLOOD ___ ___ ___ 06: 00AM BLOOD ___ <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cervical 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 Gynecology Oncology service after undergoing a cervical biopsy, CT and MRI. The team feels you are safe to be discharged. If you have heavy vaginal bleeding, dizziness, or lightheadedness, it is important that you call your doctor.
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Ms. ___ was admitted to the gynecology oncology service for observation after heavy vaginal bleeding in the setting of a newly diagnosed cervical mass. She was found to be hemodynamically stable on admission. A biopsy was taken of the mass and bleeding was well controlled with ___'s solution. Please see admission H&P for further details. She had a CT torso/abdomen/pelvis and an MRI of the pelvis for further characterization of her mass. She was monitored over her admission for bleeding with pad counts. She remained hemodynamically stable and pad counts were appropriate and was felt to be safe to be discharged with further outpatient management on HD#2.
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11393446-DS-20
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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> None <HISTORY OF PRESENT ILLNESS> ___ ___ who presents from radiology where she was being seen for size less than dates and was incidentally found to have a short cervix, 1.2cm with funnelling. She has been in her usual state of health and denies F/C, VB, LOF, abdominal pain/cramping, unusual vaginal d/c or odor. She reports AFM. She is without complaints currently. <PAST MEDICAL HISTORY> PNC: ___: ___ by ___ trimester U/S labs: B+/Ab-/RPRNR/RI/HBSAG-/GC and CT neg monitoring: declined QUAD issues: - teen pregnancy - h/o DV OBHX - TAB x1, ___ trimester GYNHX: - denies abnl pap smears, cervical procedures, STIs, fibroids PMH: nil PSH: - right sided neck surgery ___ - TAB <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> temp 97.0, HR 82, RR 20, BP 109/60 NAD RRR CTAB ABD soft NTND gravid ext NT B/L SSE: mild amount of normal appearing vaginal discharge, cervix appears closed SVE: FT, long, posterior TAUS: breech, adequate fluid FHT: 150s AGA TOCO: no ctx over 2 hours of monitoring U/A +leuk, o/w neg TAUS: adequate fluid, +fetal movement, breech <PERTINENT RESULTS> ___ 10: 24AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD ___ 10: 24AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01: 53PM PLT COUNT-202 ___ 01: 53PM NEUTS-76.5* ___ MONOS-3.8 EOS-0.7 BASOS-0.1 ___ 01: 53PM WBC-10.5# RBC-3.60* HGB-11.3* HCT-32.8* MCV-91 MCH-31.3 MCHC-34.4 RDW-13.1 RADIOLOGY Final Report TV OB US ___ 7: 51 AM OB F/U WITH MEASUREMENT; TV OB US Reason: f/u recommended for growth, s UNDERLYING MEDICAL CONDITION: ___ year old woman for follow up growth please do after ___ REASON FOR THIS EXAMINATION: f/u recommended for growth, s EXAMINATION: Obstetrical ultrasound, followup. INDICATION: Small for dates. There is an intrauterine pregnancy present with a single fetus in breech presentation. The placenta is anterior and is clear of the cervix with no evidence of placenta previa. There is a normal amount of amniotic fluid present. Transabdominal ultrasound suggested that the cervix was shortened and therefore endovaginal ultrasound was performed which showed funneling of the cervix. Only approximately 12 mm of nondilated cervix remains. The upper 2.5 cm of the cervix is dilated to maximum of approximately 5 mm. Examination of fetal anatomy was unremarkable. The following fetal parameters were measured: BPD: 24 weeks 5 days. HC: 24 weeks 1 day. AC: 23 weeks 0 days. FL: 24 weeks 2 days. AVERAGE ULTRASOUND AGE: 24 weeks 1 day. CLINICAL GESTATIONAL AGE: 25 weeks 3 days. EFW: 622 grams, ___ percentile. IMPRESSION: 1. Appropriate growth since earlier sonogram. Estimated fetal weight approximately ___ percentile. 2. Funneling of the cervix with only 12 mm of nondilated cervix remaining. Findings were discussed with Dr. ___. Patient was taken to labor floor by stretcher. <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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Progesterone Micronized 100 mg Capsule Sig: Two (2) Capsule PO qday () as needed for high risk for preterm delivery: Please take as instructed per vaginum. Disp: *30 Capsule(s)* Refills: *3* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Short cervix <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please maintain bedrest, except with bathroom privileges. Please go to ATU as scheduled and see Dr. ___ as scheduled (see below). Please call if you have abominal pain, contractions, leak of fluid, vaginal bleed or you do not feel your baby move.
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Ms. ___ was admitted given shortened cervix noted incidentally on an ultrasound where she was being followed for size less than dates. While in house, she was given betamethazone to enhance fetal lung maturity. The patient was seen by neonatologists and questions answereed. Pt was placed on bedrest with bathroom privileges. She was monitored by regularly scheduled NST and ultrasound imaging at the antenatal testing unit. Given her early gestation, maternal fetal medicine team was consulted. Recommendation to begin progesterone 200mg PV was made and started. Pt had GLT done while inhouse and was wnl at 98. The patient had cervical length measurements done approximately q weekly. CL was noted to remain stable over the last two weeks at appx 2.2 cm. Given absence of contractions and stable cervical length, pt was discharged home on HD 26.
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11393446-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> none <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P0010 at 28+5wks with ___ ___. She presents from the ATU where she was being seen for follow up of short cervix which was an incidental finding. Today, there is no measurable cervial length and SVE indicated 1cm dilated (per Dr. ___ which is a change. She denies F/C, VB, LOF, abdominal pain/cramping. She reports AFM. She is without complaints currently. Pt was hospitalized on ___ and d/c on ___. She is betamethasone complete and uses prometrium 100 mg BID PV for PTD prophylaxis. <PAST MEDICAL HISTORY> PRENATAL COURSE: (1) ___: ___ by ___ trimester U/S (2) Labs: B+/Ab-/RPRNR/RI/HBSAG-/GC and CT neg (3) Social issues: - teen pregnancy - h/o DV PAST OBSTETRIC HISTORY - TAB x1, ___ trimester PAST GYNECOLOGIC HISTORY - denies abnl pap smears, cervical procedures, STIs, fibroids PAST MEDICAL HISTORY nil PAST SURGICAL HISTORY - right sided neck surgery ___ - TAB <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: T 98.8, HR 96, RR 18, BP 110/69 GENERAL: NAD HEART: RRR LUNGS: CTAB ABDOMEN: soft NT, ND gravid EXTREMITIES: NT B/L SVE: deferred FHT: 150s AGA TOCO: rare contractions TAUS: (ATU) BPP ___, AFI 11.7cm, and vtx <PERTINENT RESULTS> ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ URINE CULTURE neg <MEDICATIONS ON ADMISSION> prometrium 200mg pv daily prenatal vitamins <DISCHARGE MEDICATIONS> 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Cap(s) 2. Progesterone Micronized 100 mg Capsule Sig: Two (2) Capsule PO daily () as needed for short CL.` Disp: *60 Capsule(s)* Refills: *3* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy cervical insufficiency <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine bed rest, no heavy lifting
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___ G2P0010 admitted at 28+5 weeks with short cervix; cervical dilation. . Ms ___ was sent to labor and delivery from the ATU. She only had a rare contraction on the monitor and she had no signs or symptoms of infection. Fetal testing was reassuring in the ATU. After monitoring on labor and delivery, she was transferred to the antepartum floor. She was already betamethasone complete and had a NICU consult during her previous admission. She was continued on vaginal prometrium and was on strict bedrest. . She remained quite stable with no contractions and when re-evaluated at 30+2 weeks gestation, her cervix remained 1cm/60%. She was discharged home on bedrest and will have close outpatient follow up. Fetal testing was reassuring during this admission. Ultrasound done on ___ showed an EFW 994g(21%). On ___, she had a BPP ___, AFI 15.7, and vertex.
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11393944-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Phenergan <ATTENDING> ___ <CHIEF COMPLAINT> chronic pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnostic laparoscopy Total vaginal hysterectomy <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <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. * If TLH/TVH: Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No 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 diagnostic laparoscopy total vaginal hysterectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Given her history of chronic opioid use, her pain was controlled with dilaudid PCA. Upon discussion with chronic pain service, recommended continuing all home medications with IV dilaudid as needed for breakthrough pain. She was also kept on IV tylenol and toradol. 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 oxycontin, oxycodone, flexeril, gabapentin, 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 met with case management and social work to discuss eligibility for rehabilitation and meal support at home. For her history of hypertension, she was continued on metoprolol with holding parameters. She was also continued on clonazepam for her history of anxiety as well as omeprazole for her history of GERD. By POD#2, she was discharged home in stable condition with outpatient follow up scheduled. Discharge Medications: 1. Docusate Sodium 100 mg PO TID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 2. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills:*0 3. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*3 4. ClonazePAM 1 mg PO TID PRN anxiety 5. CloNIDine 0.2 mg PO QHS 6. Cyclobenzaprine 5 mg PO TID:PRN muscle spasms 7. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 8. Gabapentin 900 mg PO TID 9. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills:*3 10. Lidocaine 5% Patch 1 PTCH TD QAM PRN pain 11. Memantine 15 mg PO QHS 12. Metoprolol Succinate XL 50 mg PO QHS 13. Omeprazole 20 mg PO TID 14. Ondansetron 4 mg PO Q8H:PRN nausea 15. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 16. Tizanidine 4 mg PO QHS:PRN muscle spasm 17. Topiramate (Topamax) 100 mg PO QHS 18. Zolpidem Tartrate 5 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Chronic pelvic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11394056-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> peanut / hazelnuts / sesame seed / birch / latex <ATTENDING> ___. <CHIEF COMPLAINT> "pelvic organ prolapse". <MAJOR SURGICAL OR INVASIVE PROCEDURE> Transvaginal hysterectomy, Bilateral salpingectomy, uterosacral vault suspension, posterior repair, cystoscopy <HISTORY OF PRESENT ILLNESS> HPI: Mrs. ___ is a ___ yo Gravida 2 Para 2 who returns today regarding uterine prolapse. Her symptoms have been present for approximately 8 months. She is currently using a pessary Mrs. ___ also reports vaginal pressure and palpable prolapse. Prior to pessary use she would need to splint to void. Her treatment has included: Pelvic floor exercises Pessary She reports occasional stress incontinence events. She reports urinary urgency and frequency but denies dysuria. She reports bladder emptying with normal uninterrupted flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. She denies constipation. She denies needing to splint to have BM's. She denies fecal incontinence and states she has a normal bowel movement almost daily. She is sexually active. She denies dyspareunia or vaginal dryness. She is otherwise without any other significant complaints. Recent UDS: + SUI @ capacity MUCP 72, 63 cm H20 <PAST MEDICAL HISTORY> PAST OB HISTORY G 2 P 2 Vaginal: 2 C-Section: 0 PAST GYN HISTORY She is postmenopausal since ___ She denies post-menopausal bleeding. Her last PAP smear was reportedly normal PAST MEDICAL HISTORY: Diabetes High blood pressure PAST SURGICAL HISTORY None <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On day of discharge: 24 HR Data (last updated ___ @ 535) Temp: 98.4 (Tm 98.4), BP: 96/61 (96-117/61-69), HR: 88 (88-94), RR: 18, O2 sat: 99% (94-99), O2 delivery: RA Fluid Balance (last updated ___ @ 427) Last 8 hours Total cumulative -391ml IN: Total 509ml, IV Amt Infused 509ml OUT: Total 900ml, Urine Amt 860ml, ___ pad 40ml Last 24 hours Total cumulative -448ml IN: Total 1027ml, PO Amt 220ml, IV Amt Infused 807ml OUT: Total 1475ml, Urine Amt 1435ml, ___ pad 40ml ___ 2053 FSBG: 173 ___ 0311 FSBG: 150 ___ 0535 FSBG: 128 <PHYSICAL EXAM> General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, nontender to palpation without rebound or guarding GU: pad with minimal spotting, foley draining clear orange urine Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> NA <MEDICATIONS ON ADMISSION> cholecalciferol (vitamin D3) 50 mcg (2,000 unit) capsule capsule(s) by mouth (Prescribed by Other Provider; one po ___ hydrochlorothiazide 25 mg tablet tablet(s) by mouth (one po ___ metformin 500 mg tablet tablet(s) by mouth (Prescribed by Other Provider; one po ___ simvastatin 20 mg tablet tablet(s) by mouth (Prescribed by Other Provider; one po qhs) <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hrs RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth two (2) times a day Disp #*60 Capsule Refills: *0 3. TraMADol 25 mg PO Q6H: PRN pain ___ cause sedation. Do not drink or drive while taking RX *tramadol 50 mg half tablet(s) by mouth every six (6) hours Disp #*5 Tablet Refills: *0 4. Hydrochlorothiazide 25 mg PO DAILY And home meds <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Stage 2 uterine prolapse, stage 2 anterior wall prolapse, stage 2 posterior wall prolapse, stress urinary incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 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 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Leave the steri-strips in place. They will fall off on their own. If they have not fallen off by 7 days post-op, you may remove them. * 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 a Total Vaginal Hysterectomy, High uterosacral vaginal vault suspension, Bilateral Salpingectomy, posterior repair, mid urethral sling, cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV morphine/Tylenol/toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, she underwent a backfill trial of void with 300cc and voided 350cc with a PVR of 0cc. Her diet was advanced without difficulty, and she was transitioned to PO tramadol, Tylenol. 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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11394202-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Plaquenil / Iodine-Iodine Containing / Shellfish Derived / Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain s/p cesarean section <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Pt is ___ y.o. g4p1 ___ s/p primary ltcs for arrest of descent. Presents with 2 week h/o diffuse abdominal pain, worse over the past 2 days. Was seen in GYN triage ___ with presumed small bowel ileus. Now with increased upper abdominal pain, diffuse and constant with periodic "spasms" of sharper pain. Now with more nausea and decreased appetite. Loose green stools. Pt reports more pain with movement, after eating, after moving bowels. Reports sweats and chills, but hasn't taken temperature at home. Has been using Tylenol and Motrin for pain over past 2 days. No dysuria; no increased vaginal bleeding. Breastfeeding and pumping. <PAST MEDICAL HISTORY> POB/GYN Hx: C/s after ___ stage arrest on ___ after 3.5 hr push. -ovarian cystectomy ___: Sjogrens's syndrome (ocular/derm symptoms previously--in remission during pregnancy), Raynauds -left ankle surgery -arm surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> PE: WDWN, in some discomfort, especially with movement T 97.7 HR 103 bp 125/72 RR 12 O2sat 100% Abdomen- non-distended, diffusely tender- greater bilateral upper quadrants, +BS Fundus- firm, +moderate tenderness <PERTINENT RESULTS> ___ 02: 11PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02: 11PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG ___ 02: 11PM URINE RBC-1 WBC-27* BACTERIA-MOD YEAST-NONE EPI-7 ___ 02: 11PM URINE WBCCLUMP-RARE MUCOUS-RARE ___ 01: 10PM GLUCOSE-95 UREA N-14 CREAT-0.5 SODIUM-137 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 ___ 01: 10PM estGFR-Using this ___ 01: 10PM ALT(SGPT)-14 AST(SGOT)-13 ALK PHOS-86 AMYLASE-70 TOT BILI-0.2 ___ 01: 10PM LIPASE-56 ___ 01: 10PM ALBUMIN-3.6 CALCIUM-9.9 PHOSPHATE-4.2 MAGNESIUM-2.0 ___ 01: 10PM WBC-10.8 RBC-3.81* HGB-12.0 HCT-35.7* MCV-94 MCH-31.7 MCHC-33.8 RDW-12.9 ___ 01: 10PM NEUTS-66 BANDS-0 ___ MONOS-12* EOS-2 BASOS-0 ___ MYELOS-0 ___ 01: 10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL ___ 01: 10PM PLT SMR-VERY HIGH PLT COUNT-685* ___ CT: IMPRESSION: 1. Diffusely abnormal appearance to the omentum with stranding and nodularity. Intra-abdominal and pelvic ascites as detailed above. The imaging findings may be seen with underlying peritoneal infection or inflammation (including the possibility of meconium peritonitis). Similar findings can be seen with carcinomatosis but this is less likely given the normal appearance of the ovaries intraoperatively and no mass identified. Would recommend repeat imaging with MRI after antibiotic therapy to ensure resolution. A diagnostic aspiration could be attempted under ultrasound guidance of the largest left-sided ascitic pocket if it will aid in clinical management. 2. Post-gravid uterus with small uterine fibroid. 3. No findings of bowel obstruction with top normal size to the small bowel, likely reflecting a component of underlying mild ileus. ___ MRI/MRV: IMPRESSION: No venous thrombosis or collateral formation in the IVC or pelvic veins. Fluid with hyperenhancing surrounding peritoneum in the cul-de-sac which is not definitely infected but could be. It is amenable to transvaginal aspiration. Smaller hematoma anterior to the body of the uterus. Expected appearance of uterus after cesarian section. Normal ovaries. Interval resolution of the inflammatory process in the omentum and mesentery. <MEDICATIONS ON ADMISSION> Meds: Tylenol/Motrin PRN (vicodin d/c'd ___ <DISCHARGE MEDICATIONS> 1. Vicodin ___ mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> post op complications s/p c/section <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Pelvic rest for 1 month. Ambulate as tolerated. No heavy lifting > 25 lbs.
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Ms. ___ was admitted on PPD#15 with ongoing abdominal pain and tenderness that began ___ days after her cesarean section. CT showed a diffusely abnormal appearance to the omentum with stranding and nodularity as well as intra-abdominal and pelvic ascites. There was no evidence of bowel obstruction. Due to fundal tenderness the patient was started on intravenous antibiotics including ampicillin, gentamycin and clindamycin for presumed endomyometritis and completed a course of approx. 3 days. She was treated with Vicodin and Motrin for pain control. She was afebrile throughout her hospitalization. Both general surgery and rheumatology were consulted. General surgery did not feel the patient had a surgical issue. Rheumatology was consulted because the patient has a history of Sjogren's although she had been in remission during pregnancy and the post-partum period. Rheumatology did not believe her abdominal pain was attributable to a vasculitic process. The patient was also seen by social work for assistance in coping with readmission in the immediate postpartum period. MRI/MRV was performed ___ that showed no venous thrombosis or collateral formation in the IVC or pelvic veins and resolution of the inflammatory process affecting the omentum and mesentery. Over her hospital course the patient's symptoms slowly improved and she was discharged home in stable condition on hospital day #5 to follow-up with Dr. ___ primary ___ in 1 week.
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11394202-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Plaquenil / Iodine-Iodine Containing / Shellfish Derived / Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> single intrauterine pregnancy - post-dates <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary c-section <PAST MEDICAL HISTORY> OBHx: chemical preg x 3 GYNHx: LMP ___, denies abn pap/STI's PMH: Sjogren, Raynaud's, MVP and cardiac palpitations PSH: ovarian cysts <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Vitals: T 98.6 HR 94 RR 16 BP 125/85 SVE: long/closed/posterior <PERTINENT RESULTS> ___ 02: 25PM CREAT-0.6 ___ 02: 25PM estGFR-Using this ___ 02: 25PM ALT(SGPT)-12 ___ 02: 25PM WBC-10.4 RBC-4.74 HGB-15.7 HCT-43.8 MCV-93 MCH-33.1* MCHC-35.8* RDW-12.9 ___ 02: 25PM NEUTS-75.1* LYMPHS-17.6* MONOS-6.5 EOS-0.5 BASOS-0.3 ___ 02: 25PM PLT COUNT-170 ___ 09: 06PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09: 06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-TR <MEDICATIONS ON ADMISSION> caffeine, zyrtec, magnesium, calcium, PNV, fish oil <DISCHARGE MEDICATIONS> 1. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ 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* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> arrest of descent, postdates pregnancy Slow return of bowel function, ?ileus baby girl 7#7oz ___ ___ Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> No heavy lifting, tampons, intercourse for 6 weeks. See instruction sheet
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Ms. ___ underwent a cesarean delivery on ___ for arrest of descent after induction of labor for post-dates. For full details of the procedure please see Dr. ___ report. Ms. ___ post-operative course was complicated by a slow return to bowel function and diarrhea. Her diarrhea resolved spontaneously and she tested negative for c. difficile. Regarding her slow return to bowel function, Ms. ___ did not experience nausea or vomiting, and passed flatus throughout her postpartum course making suspicion for obstruction low. Ms. ___ diet was advanced slowly and she was discharged home on post-partum day number 5 in stable condition, ambulating, voiding, tolerating a regular diet with her pain well controlled on oral pain medication.
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11398222-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Vasotec / Nitroglycerin / Flovent Diskus <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection, omentectomy, port placement, blood transfusion <HISTORY OF PRESENT ILLNESS> The patient is a ___ G4 P1 postmenopausal female, who was undergoing a routine gynecologic evaluation where a pelvic mass was appreciated. She was sent for a pelvic ultrasound, which revealed a complex adnexal mass. Given its concerning features, she was advised to undergo an abdominal and pelvic CT scan as well as a CA-125 level. The CA-125 returned elevated at 1073 and the CT was notable for a 7.3 x 7.7 x 8.2 cm predominantly cystic mass arising from the region of the right ___. Along the right lateral wall mass was an enhancing soft tissue measuring 4.1 x 1.8 x 4.2 cm. The left ___ was also felt to be prominent for a postmenopausal female. There were mildly enlarged bilateral external iliac lymph nodes, the largest measuring 1.2 cm. There were several prominent enhancing perirectal lymph nodes as well measuring up to 5 mm. There was no free fluid and no obvious evidence of other peritoneal carcinomatosis in the upper abdomen. Given these findings, the patient was referred to the ___ ___ for further evaluation. The patient states that she is completely asymptomatic. She denies any pelvic pain, any postmenopausal bleeding or abnormal discharge. She has longstanding constipation as well as urinary frequency, though does not feel that these symptoms have changed significantly over time. She states she has a good appetite and denies any changes in her weight. Of note, the patient does have a history of undergoing a radical right mastectomy in ___ in ___. She states that she was told after her surgery that she never had cancer by a different doctor and therefore the pathology is unclear. Given this history, however, she does follow up regularly with the breast clinic and her most recent mammogram in ___ of this year was normal. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Notable for coronary artery disease. She had a non-ST elevation MI in ___ in which two stents were placed. She also has hypertension and diabetes. She has chronic lymphedema of the right upper extremity as well as lower extremity edema bilaterally. PAST SURGICAL HISTORY: 1. Radical mastectomy, ___. 2. Cardiac stent x 2, ___. 3. Tonsillectomy, ___ years old. PAST OB HISTORY: She is a G4 P1-0-3-1. She has had one spontaneous vaginal delivery in ___ and had three elective terminations. GYNECOLOGIC HISTORY: Her last menstrual period was at ___ years old. She is no longer sexually active. She denies ever taking any oral contraceptive pills or hormone replacement. She has had endometrial polyps removed once here in the ___ and several times in ___. She denies any postmenopausal bleeding or other significant gynecologic issues. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her mother was diagnosed with ovarian cancer at the age of ___. Her father had cardiac disease and passed away of a heart attack at ___. He also had diabetes. Maternal grandfather had lung cancer, but was a long-term smoker. Her sister has cardiac disease as well. <PHYSICAL EXAM> on discharge: afebrile, vital signs stable General: comfortable appearing, NAD, AxO CV: RRR Resp: CTAB, mild expiratory wheezes Abd: normoactive BS, soft, nondistended, appropriate tenderness to palpation, no rebound or guarding, incision c/d/i with steristrips GU: no bleeding Ext: 2+ symmetric edema, no calf tenderness <PERTINENT RESULTS> ___ 05: 46AM BLOOD WBC-4.8 RBC-3.70* Hgb-11.6* Hct-33.8* MCV-91 MCH-31.2 MCHC-34.1 RDW-13.4 Plt ___ ___ 04: 20AM BLOOD WBC-6.3 RBC-3.58* Hgb-11.3* Hct-33.8* MCV-95 MCH-31.5 MCHC-33.3 RDW-13.4 Plt ___ ___ 05: 21AM BLOOD WBC-7.9 RBC-3.41* Hgb-10.8* Hct-32.0* MCV-94 MCH-31.6 MCHC-33.6 RDW-13.4 Plt ___ ___ 05: 57AM BLOOD WBC-10.4 RBC-3.52* Hgb-11.1* Hct-33.1* MCV-94 MCH-31.6 MCHC-33.6 RDW-13.6 Plt ___ ___ 06: 33AM BLOOD WBC-13.0* RBC-3.03* Hgb-9.7* Hct-29.0* MCV-96 MCH-32.1* MCHC-33.6 RDW-13.1 Plt ___ ___ 05: 00AM BLOOD WBC-15.0* RBC-3.63* Hgb-11.5* Hct-33.7* MCV-93 MCH-31.8 MCHC-34.2 RDW-12.8 Plt ___ ___ 07: 13PM BLOOD WBC-11.5*# RBC-3.80* Hgb-11.9* Hct-35.5* MCV-93 MCH-31.3 MCHC-33.6 RDW-12.8 Plt ___ ___ 05: 46AM BLOOD Glucose-142* UreaN-8 Creat-0.6 Na-134 K-3.1* Cl-98 HCO3-28 AnGap-11 ___ 04: 20AM BLOOD Glucose-125* UreaN-9 Creat-0.6 Na-136 K-3.5 Cl-103 HCO3-23 AnGap-14 ___ 05: 21AM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-133 K-4.1 Cl-100 HCO3-23 AnGap-14 ___ 05: 57AM BLOOD Glucose-91 UreaN-10 Creat-0.7 Na-135 K-3.4 Cl-101 HCO3-25 AnGap-12 ___ 06: 33AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-128* K-3.6 Cl-97 HCO3-22 AnGap-13 ___ 05: 00AM BLOOD Glucose-227* UreaN-9 Creat-0.8 Na-130* K-3.7 Cl-94* HCO3-20* AnGap-20 ___ 12: 18AM BLOOD Glucose-223* UreaN-9 Creat-0.8 Na-126* K-3.5 Cl-92* HCO3-17* AnGap-21* ___ 07: 13PM BLOOD Glucose-150* UreaN-9 Creat-0.7 Na-128* K-2.8* Cl-94* HCO3-21* AnGap-16 ___ 05: 46AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.8 ___ 04: 20AM BLOOD Calcium-8.1* Phos-1.5* Mg-2.1 ___ 05: 21AM BLOOD Calcium-7.8* Phos-1.8* Mg-2.4 ___ 05: 57AM BLOOD Calcium-7.7* Phos-1.8* Mg-2.5 ___ 06: 33AM BLOOD Calcium-7.8* Phos-2.2* Mg-2.8* ___ 05: 00AM BLOOD Calcium-7.8* Phos-3.5 Mg-2.8* ___ 12: 18AM BLOOD Calcium-7.8* Phos-3.3 Mg-3.1* ___ 07: 13PM BLOOD Calcium-7.7* Phos-2.9 Mg-1.5* ___ 07: 13PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 12: 18AM BLOOD Osmolal-268* ___ 02: 07AM URINE Hours-RANDOM Creat-67 Na-26 K-92 Cl-LESS THAN ___ 02: 07AM URINE Osmolal-501 SURGICAL PATHOLOGY REPORT - Final PATHOLOGIC DIAGNOSIS: 1. ___ and fallopian tube, right (1A-N): Ovarian serous carcinoma, poorly differentiated (see synoptic report). 2. Uterus with left adnexa, hysterectomy (2A-T): Ovarian serous carcinoma, poorly differentiated (see synoptic report). 3. Lymph nodes, left pelvic (3A-D): Metastatic serous carcinoma involving two out of two lymph nodes ___, see synoptic report). 4. Lymph nodes, right obturator (4A-D): Metastatic serous carcinoma involving one out of five lymph nodes ___, see synoptic report). 5. Lymph nodes, right external iliac (5A-6): Metastatic serous carcinoma involving two out of six lymph nodes ___, see synoptic report). 6. Omentum (6A-F): a. No malignancy identified. b. Benign mature adipose tissue. ___ Synopsis Staging according to ___ Joint Committee on Cancer Staging Manual -- ___ Edition, ___ Macroscopic Specimen Type: Right salpingo-oophorectomyLeft salpingo-oophorectomyHysterectomyOmentectomyLymph node dissection Tumor Site: Right and left ovaries. Dominant Side (2x larger): Right Surface Involvement: Absent Tumor Size: Greatest dimension: 8.7 cm. Other Organs/Tissues Received: Uterus, bilateral adnexae, lymph nodes, omentum, cervix Microscopic Histologic Type: Serous, carcinoma Histologic Grade (WHO classification): G3: Poorly differentiated Washings/Cytology: Atypical Cytology #: ___ Fallopian Tube: Right: luminal tumor Left: luminal tumor (present at LVI) Uterus: Omentum: Negative Extent of Invasion Primary Tumor (pT) TNM (FIGO): pT3c (IIIC): Peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension and/or regional lymph node metastasis Regional Lymph Nodes (pN): pN1: Regional lymph node metastasis Lymph Nodes: Number of lymph nodes examined: 13. Number involved: 5. Distant Metastasis: PMX: Cannot be assessed Venous/lymphatic vessel invasion (V/L): Present Additional Pathologic Findings: - Entire tubal fimbria has been examined microscopically - Uterine leiomyoma (up to 2.6 cm) - Atrophic endometrium. <MEDICATIONS ON ADMISSION> albuterol, ipratroprium 0.03% BID, lipitor 10mg daily, hctz 25mg daily, losartan 100mg daily, fluticasone 2 spray, meclizine 25 prn, metformin 500mg daily, metoprolol 50 XL daily, pantoprazole 40mg daily, januvia 100mg daily, zolpidem 5mg daily, asa 81mg daily, calcium 300mg bid, vit d3 400daily, colace 100 bid, senna 8.6 daily, loratadine 10daily, alendronate 70 1x/wk, clobetasol 0.5% 2x/wk, furosemide 20mg PRN edema <DISCHARGE MEDICATIONS> 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 10 mg PO HS 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Docusate Sodium 100 mg PO BID Hold for loose stools. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 7. Albuterol Inhaler ___ PUFF IH Q4H: PRN wheezes 8. Hydrochlorothiazide 25 mg PO DAILY 9. MetFORMIN (Glucophage) 500 mg PO BID 10. Senna 1 TAB PO BID: PRN constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet Refills: *2 11. rolling walker Rolling walker for gait training, prognosis good, with lifetime need. Diagnosis ovarian cancer 12. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 13. Ibuprofen 400 mg PO Q8H: PRN pain take with food; only take if Tylenol does not work RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp #*50 Tablet Refills: *0 14. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION BID wheezing Duration: 2 Weeks RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation 2 puffs inhaled twice a day Disp #*1 Inhaler Refills: *1 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Likely ovarian cancer, final pathology pending <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 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 . 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 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 gynecology oncology service after undergoing an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph node dissection, and omentectomy. Please refer to Dr. ___ report for full details of the operation. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural managed by the Acute Pain Service. She had some nausea and dizziness, and her epidural settings were adjust with good relief of symptoms. Post-operative labs in the PACU were notable for hyponatremia to 128 (from her chronic baseline of 132). Cardiac enzymes were normal. Her hyponatremia was treated with fluid restriction and resolved by the end of her hospital course. She was continued on her home antihypertensives. Given her cardiac history, she was kept on telemetry which showed infrequency PVCs but no other events. She was kept on an insulin sliding scale for her diabetes. On post-operative day 2, a port was placed by interventional radiology given poor access and in anticipation of her need for chemotherapy. A complete blood count reveal anemia to 29, consistent with blood loss from her operation. She received a transfusiom of 1 unit of packed red blood cells without complication, and her HCT increased appropriately to 33. For pain control, she was transitioned from an epidural to a Dilaudid PCA, and her diet was advanced to clear liquid. On post-operative day 3, she was evaluated by physical therapy who recommended that she receive physical therapy at home after discharge. She experienced persistent nausea without emesis. Her abdominal exam was benign. Her diet was backed down to sips. On post-operative day 4, her urine output was adequate so her Foley catheter was removed and she voided spontaneously without problems. Her diet was then advanced on post-operative day 5 without complication, and she was transitioned to oral acetaminophen and ibuprofen with adequate pain control. She had some wheezes on exam, and was ordered for symbicort which she has used in the past. By post-operative day 6, she was tolerating a regular diet, voiding spontaneously, ambulating with a walker, and pain was controlled with oral medications. She was then discharged home in stable condition with home ___ and physical therapy.
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11398464-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Ovarian cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy Bilateral salpingoophorectomy Lymph node dissection Omental biopsy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ who underwent neoadjuvant chemotherapy after she presented in ___ with thromboembolic disease in the setting of a complex pelvic mass. This was biopsied for a high-grade adenocarcinoma consistent with ovarian cancer. After completing 3 cycles of chemotherapy, she was seen in follow- up. Imaging revealed resolution of her pulmonary emboli, and stabilization of her DVTs. Interval cytoreductive surgery was recommended. <PAST MEDICAL HISTORY> OB/GYN Hx: Menopause age ___. Distant h/o abnl pap s/p cryo. SVD x 3. PMH: b/l PEs/DVTs ___, admitted to ___ MICU where imaging demonstrated ascites and pelvic mass. U/S-guided bx ___ w/ high-grade adenoCA, likely ovarian origin. S/p 3 cycles of ___ chemo c/b neuropathy of feet and myelosuppression. PSH: None <SOCIAL HISTORY> ___ <FAMILY HISTORY> Sister with DVT and Factor V Leiden mutation. Mother with "breast lump" that was removed. Mother died of respiratory failure and father died of AD. <PHYSICAL EXAM> On discharge; VSS NAD RRR, port on L upper chest with site c/d/i CTAB Abdomen soft, minimally TTP, no r/g. Incision c/d/i with staples. Peripad minimal old blood ___ <PERTINENT RESULTS> ___ 02: 19PM BLOOD WBC-6.4# RBC-3.75* Hgb-12.0 Hct-34.3* MCV-91 MCH-32.0 MCHC-35.0 RDW-17.6* Plt ___ ___ 06: 28AM BLOOD WBC-7.8 RBC-3.68* Hgb-11.5* Hct-33.9* MCV-92 MCH-31.2 MCHC-33.8 RDW-17.8* Plt ___ ___ 06: 56AM BLOOD WBC-6.0 RBC-3.30* Hgb-10.4* Hct-30.0* MCV-91 MCH-31.5 MCHC-34.5 RDW-16.8* Plt ___ ___ 05: 24AM BLOOD WBC-5.9 RBC-3.12* Hgb-10.1* Hct-29.3* MCV-94 MCH-32.5* MCHC-34.6 RDW-16.7* Plt ___ ___ 04: 50AM BLOOD WBC-3.5* RBC-2.89* Hgb-9.5* Hct-27.1* MCV-94 MCH-32.9* MCHC-35.1* RDW-16.2* Plt ___ ___ 05: 57AM BLOOD WBC-5.3# RBC-3.10* Hgb-10.0* Hct-29.1* MCV-94 MCH-32.3* MCHC-34.4 RDW-16.1* Plt ___ ___ 08: 48AM BLOOD ___ PTT-25.9 ___ ___ 06: 28AM BLOOD ___ PTT-23.4 ___ ___ 02: 51PM BLOOD ___ PTT-37.9* ___ ___ 11: 55PM BLOOD ___ PTT-33.7 ___ ___ 06: 56AM BLOOD ___ PTT-45.0* ___ ___ 03: 08PM BLOOD ___ PTT-45.2* ___ ___ 05: 24AM BLOOD ___ PTT-65.7* ___ ___ 11: 25AM BLOOD ___ PTT-69.0* ___ ___ 11: 25PM BLOOD ___ PTT-78.5* ___ ___ 06: 00AM BLOOD ___ PTT-57.9* ___ ___ 11: 48AM BLOOD ___ PTT-62.5* ___ ___ 03: 00AM BLOOD ___ PTT-58.9* ___ ___ 04: 50AM BLOOD ___ PTT-58.8* ___ ___ 05: 57AM BLOOD ___ PTT-23.9 ___ ___ 06: 28AM BLOOD Glucose-119* UreaN-9 Creat-0.8 Na-138 K-4.1 Cl-102 HCO3-29 AnGap-11 ___ 06: 56AM BLOOD Glucose-94 UreaN-11 Creat-0.7 Na-140 K-3.7 Cl-102 HCO3-29 AnGap-13 ___ 11: 25AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-139 K-3.8 Cl-101 HCO3-27 AnGap-15 ___ 04: 50AM BLOOD Glucose-104* UreaN-5* Creat-0.7 Na-142 K-4.0 Cl-102 HCO3-31 ___ CXR for ___ placement: FINDINGS: The tip of the PICC line lies in the region of the cavoatrial junction and could be pulled back approximately 2 cm. No evidence of acute cardiopulmonary disease. <MEDICATIONS ON ADMISSION> Lovenox 60mg BID, Lorazepam 0.5 prn, Zofran 8 prn <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. 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* 3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp: *60 Tablet(s)* Refills: *2* 4. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous BID (2 times a day). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Nothing in your vagina for three months. - No heavy lifting for at least 6 weeks. - You may shower. No bath tubs for 3 weeks. - You may switch to Lovenox 80mg once daily on ___ until then take 60mg twice daily. - Please take stool softeners while taking narcotic pain medications because narcotics will make you constipated. Do not drive while taking narcotics. You may also take Milk of Magnesia for constipation. - Call Dr. ___ for an appointment next week to discuss restarting your chemotherapy - Please start taking a daily multivitamin - you can get one over the counter.
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Mrs. ___ was admitted and underwent an uncomplicated TAH/BSO with omentectomy and ___ lymph node dissection on ___. Please see operative report in ___ for further details. She did receive 2 units of PRBCs and 2 units of FFP in the OR. She had a TAP block for pain. She was transferred to the PACU in good condition, where she had an uneventful initial recovery. She was then transferred to the floor. A PICC line was placed on the floor in anticipation of frequent blood draws for heparin and poor peripheral access. Her diet was slowly advanced and she was transitioned to PO pain meds. Therapeutic heparin was started on ___ (POD #2), and titrated to a PTT goal of 55-70. This was well tolerated. Given her poor access, it was discussed that she would be a good candidate for a port placement. This was arranged and occurred on ___ without complications. Her heparin was held that morning and she was restarted on her therapeutic lovenox in the evening. She was discharged home in good condition on post-op day #7.
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11398755-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound guided dilation and curettage <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p uncomplicated 8 wk TAB at ___ on ___. She reports the case was uncomplicated. She reports minimal vaginal bleeding and only a small amount cramping suprapubic pain. She woke up this morning with fevers and chills with a tmax at home to 103 despite tylenol. She denies N/V, C/P, or foul smelling vaginal discharge. She denies any change in urinary or bowel habits and she denies feeling dizzy, having dysuria, SOB, or calf pain. This pregnancy was diagnosed in the setting of a recent luteal phase Implanon insertion (she had a neg ucg at the time of Implanon insertion). She is s/p Implanon removal. <PAST MEDICAL HISTORY> GYN HISTORY: - LMP first week of ___, IUP s=d by TVUS ___ - Recurrent BV infections - Chlamydia ___ both self and partner were treated - Feels safe with partner ___ who is the father of her children. denies DV. - Last Pap from ___, here, negative. History of abnormal Pap in the past, on ___, ASC - H. Seen last in ___ clinic on ___, where ECC was normal and colposcopy was satisfactory. She has not returned to follow up in ___ clinic, but is planning to as soon as possible and was delayed by the pregnancy diagnosis - HSV in ___. No outbreaks since. OB HISTORY: G7P2 - SVD x2, son aged ___ and daughter aged ___. Both pregnancies with cerclage. - SAB x1 at 16 weeks ___ incompetent cervix - TAB x4, one c/b retained POCs, fevers and endometritis requiring repeat D&C and IV antibiotics PAST MEDICAL HISTORY: anemia PAST SURGICAL HISTORY: ___ ___-cholecystectomy. <PHYSICAL EXAM> On admission: T 102, HR 120, BP 92/53, RR 18 02 100 % RA GENERAL: A&O, NAD CV: tachy regular RESP: CTAB Abd: soft, NT/ND. No R/G. +BS. PELVIC: uterus ___, retroverted. significant uterine TTP. No adnexal TTP. No CMT speculum: os multiparous, closed. No products visible at os Ext: NT On discharge: Afebrile, vital signs stable Gen: no acute distress CV: regular rate and rhythm Pulm: CTAB Abd: soft, nondistended, non tender, no rebound/guarding Extr: non tender/nonedematous <PERTINENT RESULTS> ___ 05: 36AM BLOOD WBC-3.4* RBC-2.89* Hgb-9.5* Hct-27.2* MCV-94 MCH-33.0* MCHC-35.1* RDW-12.2 Plt ___ ___ 12: 45PM BLOOD WBC-3.8* RBC-2.89* Hgb-9.6* Hct-27.3* MCV-95 MCH-33.3* MCHC-35.2* RDW-12.1 Plt ___ ___ 05: 10AM BLOOD WBC-3.4* RBC-2.76* Hgb-9.1* Hct-26.0* MCV-94 MCH-33.2* MCHC-35.1* RDW-12.0 Plt ___ ___ 07: 11PM BLOOD WBC-6.8 RBC-3.71* Hgb-11.9* Hct-34.6* MCV-93 MCH-32.0 MCHC-34.3 RDW-11.8 Plt ___ ___ 05: 43AM BLOOD ___ PTT-30.5 ___ ___ 05: 36AM BLOOD ___ PTT-30.2 ___ ___ 12: 45PM BLOOD ___ PTT-32.1 ___ ___ 05: 10AM BLOOD ___ PTT-30.9 ___ ___ 01: 03AM BLOOD ___ PTT-30.3 ___ ___ 07: 11PM BLOOD ___ PTT-32.8 ___ ___ 05: 10AM BLOOD Glucose-132* UreaN-5* Creat-0.5 Na-138 K-3.3 Cl-108 HCO3-24 AnGap-9 ___ 01: 03AM BLOOD Glucose-104* UreaN-6 Creat-0.4 Na-136 K-3.5 Cl-109* HCO3-20* AnGap-11 ___ 07: 11PM BLOOD Glucose-104* UreaN-8 Creat-0.6 Na-133 K-3.4 Cl-101 HCO3-22 AnGap-13 ___ 05: 43AM BLOOD ALT-142* AST-67* AlkPhos-39 ___ 05: 36AM BLOOD ALT-150* AST-100* TotBili-0.3 ___ 12: 45PM BLOOD ALT-73* AST-68* AlkPhos-30* TotBili-0.5 Hepatitis serology pending at discharge IMAGING: RUQ Ultrasound: The liver is normal in echotexture without focal lesion, intra- or extra-hepatic biliary ductal dilatation. The gallbladder is surgically absent. The common bile duct is not dilated measuring 3 mm. The pancreas is normal. The imaged aorta is normal in caliber. The imaged IVC is unremarkable. The main portal vein is patent with hepatopetal flow. No free fluid is seen. The kidneys are normal bilaterally without hydronephrosis, stone, or mass. The right kidney measures 11.6 cm. The left kidney measures 11.1 cm. The spleen measuers 13.4 cm in the sagittal axis. On images obtained with the abdominal probe, here is a apparent 12. x 2.___ircumscribed oval hypoechoc structure at the lowe pole of the spleen, however, this was not confirmed with more focused scanning with the linear probe. <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted for treatment of endometritis (infection of lining of uterus). You underwent a procedure to evacuate the uterus of remaining products of conception. You received IV antibiotics and will need to continue taking an oral antibiotic for the next 2 weeks. Your liver enzymes were slightly elevated, and an ultrasound showed no abnormalities of your liver. Your liver enzymes were decreasing at the time of your discharge, but you will need to follow-up with your primary care physician regarding this. 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 * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks * You may eat a regular diet
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Ms. ___ was admitted to the GYN service for treatment of post-TAB endometritis. Given evidence of retained products on ultrasound, she underwent an uncomplicated D&C. Please see operative report for further details regarding the procedure. She received 36 hours of IV gentamicin and clindamycin. She was afebrile after initiation of antibiotics and remained afebrile throughout her stay. Her WBC trended down appropriately. Her post operative Hematocrit was stable. She was discharged with 2 weeks of doxycycline. On admission, Ms. ___ was incidentally noted to have an elevated INR of 1.4 (maximum of 1.7 during this admission). LFTs were therefore checked and found to be mildly elevated. Hepatology was curbsided who recommended hepatitis series be checked (pending at discharge) and a right upper quadrant ultrasound was obtained which was negative. Ms. ___ had no right upper quadrant symptoms. The patient's LFTs were stable on discharge. She was advised to obtain follow up lab work and see her PCP regarding this. Discharge Medications: 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Take with meals . Disp:*40 Tablet(s)* Refills:*0* 2. doxycycline hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Endometritis, retained products of conception Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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