note_id
string | input
string | target
string | input_tokens
int64 | target_tokens
int64 |
|---|---|---|---|---|
10255928-DS-13
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Motrin / Diclofenac / aspirin <ATTENDING> ___ <CHIEF COMPLAINT> hypovolemic shock <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean hysterectomy, done at OSH <HISTORY OF PRESENT ILLNESS> ___ y/o ___ s/p c-section this morning c/b post-operative bleeding requiring hysterectomy and massive transfusion protocol, transferred to the ___ ICU with hypotensive shock, intubated on phenylephrine. . In brief, per OSH notes, she underwent scheduled, uncomplicated c-section this morning at 7: 30am. 3 hrs post-operative she developed vaginal bleeding unresponsive to pitocen, methergene and misoprostol. She was taken for exploratory laporotomy where she was found to have a boggy/ atonic uterus and > 1L blood in abdoman with no apparent source identified. Emergency supracervical hysterectomy was performed with total EBL of 2300 mL. Intraoperatively, she was started on phenylephrine and was transferred to the ICU where she remained pressor dependent and intubated. She was also started on an empiric course of gentamycin and clinda. . As per her labs, her baseline Hct was 38 prior to c-section and dropped to 24.5 prior to laporotomy. Intraoperatively, she received 4UpRBC, 2U FFP, 1 U cryo and 1U plts with repeat blood work showing Hct 30.6, plts 93, PTT > 120, fibrinogen < 70. Hct nadired at 10.9 at ___ although there was no apparrent source of ongoing blood loss. Due to concern for ongoing requirement for surgical intervention and access to blood products, transferred to ___. In total, she recieved 13UpRBC, 6U FFP, 1 plt, 1 cryoglobulin with blood work prior to transfer showing Hct 32, plts 79, PTT 34.5, fibrinogen 209. . On arrival to the ICU, patient remained intubated but responding appropriately to commands. She grimaced on abdominal palpation and FAST exam at bedside showed some organized clot with moderate amount of free fluid near splenic gutters. . Review of systems: unable to obtain ___ mental status <PAST MEDICAL HISTORY> OB History: This pregnancy complicated only by AMA for which pt received twice weekly monitoring. Velamentous cord insertion noted at delivery. GBS +. ___: RLTCS 7#8oz male infant 2 prior LTCS ___. Family reports both uncomplicated. SAb x 1 GYN Hx: Records unavailable, family reports no issues PMH: frequent coughs and colds; hyperthyroidism PSH: LTCS x 2 -> 3; now s/p ex-lap and hysterectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Admission <PHYSICAL EXAM> VS: T: 95.3 BP: 129/96 P: 111 R: 17 O2: 100% (FiO2 100% PEEP 5) General: intubated, opens eyes to verbal stimuli and follows simple commands HEENT: Sclera anicteric, enotracheal tube in place Neck: supple, L cordis in place Lungs: Clear to auscultation anteriorly CV: tachycardic, regular S1 S2 no r/m/g Abdomen: soft, distended, midline incision c/d/i with dressing in place. appears uncomfortable to palpation Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Exam: Gen: No acute distress, comfortable CV: Regular rate and rhythm, no murmurs Pulm: Clear to auscultation bilaterally, breathing comfortably on her own Abd: Soft, appropriately tender, moderately distended but stable, no rebound or guarding Normal lochia Vertical midline incision C/D/I with staples Ext: 1+ lower extremity pitting edema to knees, nontender calves bilaterally <PERTINENT RESULTS> Admission Labs: ___ 01: 32AM BLOOD WBC-7.2 RBC-3.88* Hgb-12.7 Hct-34.5* MCV-89 MCH-32.8* MCHC-36.8* RDW-14.8 Plt Ct-61* ___ 01: 32AM BLOOD Neuts-79.2* Lymphs-12.3* Monos-8.0 Eos-0.1 Baso-0.3 ___ 01: 32AM BLOOD ___ PTT-35.3* ___ ___ 04: 02AM BLOOD ___ 04: 02AM BLOOD ___ 01: 32AM BLOOD Ret Aut-1.5 ___ 01: 32AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-140 K-4.3 Cl-107 HCO3-23 AnGap-14 ___ 01: 32AM BLOOD ALT-15 AST-32 LD(LDH)-240 CK(CPK)-714* AlkPhos-37 Amylase-86 TotBili-4.9* DirBili-1.0* IndBili-3.9 ___ 01: 32AM BLOOD CK-MB-19* MB Indx-2.7 cTropnT-0.10* ___ 04: 02AM BLOOD CK-MB-22* MB Indx-2.6 cTropnT-0.16* ___ 01: 32AM BLOOD Albumin-2.3* Calcium-6.5* Phos-5.4* Mg-1.9 UricAcd-4.9 ___ 04: 22AM BLOOD Type-ART pO2-228* pCO2-34* pH-7.47* calTCO2-25 Base XS-2 ___ 01: 52AM BLOOD Lactate-3.7* ___ 04: 22AM BLOOD Lactate-2.6* ___ 04: 22AM BLOOD freeCa-0.93* Portable abd XRAY, ___: Likely ileus but cannot rule out early small-bowel obstruction. Portable CXR, ___: 1. Endotracheal tube terminating no less than 5 cm from the carina. Left IJ terminating in left brachiocephalic vein. No pneumothorax. 2. Bilateral hilar fullness, probably representing adenopathy. Recommend conventional radiographs when the patient is able to tolerate. 3. Mild bilateral lower interstitial edema with minimal left pleural effusion. <MEDICATIONS ON ADMISSION> on transfer: clindamycin benadryl prn itching dopamine gtt fentanyl prn lorazepam reglan misoprostol norepinephrine protonix propofol <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. 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> Post-partum hemorrhage, acute blood loss anemia, hemorrhagic shock <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Nothing in vagina x 6 weeks No tub bathing x 6 wks Please call your primary ob provider (Dr. ___ to arrange follow-up with him and staple removal - ___ (10 days after surgery)
|
___ y/o ___ s/p c-section this morning c/b post-operative bleeding requiring hysterectomy and massive transfusion protocol, transferred to the ___ ICU with hypotensive shock, originally intubated on phenylephrine, with rapid clinical improvement. . FICU Course: Patient was transferred to the ICU while intubated. Her hematocrit was monitored closely and remained stable. She was extubated the morning after admission and Pressors were discontinued as the patients condition improved. Patient subsequently called out the the postpartum OB/GYN service in stable condition. She was on clindamycin and gentamicin when called out. . Floor Course: Ms. ___ was transferred to the post-partum floor on ___, post-partum/post-op (PPD/POD) 2. Once transferred to the floor she did well. She finished her 24 hours of gentamicin and clindamycin on PPD2. She was able to be successfully weaned off oxygen by PPD 4. She was able to tolerate a regular diet, control her pain with oral pain medications, ambulate and void spontaneously by PPD/POD 5. She was discharged home in good condition on PPD 5 in good condition.
| 1,768
| 256
|
10255928-DS-14
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Motrin / Diclofenac / aspirin / Amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> Generalized weakness, aches <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old Gravida 5 Para 3 status-post repeat low transverse C-section at ___ on ___ complicated by ___ requiring exploratory laparotomy with Supracervical Hysterectomy who presents with approximately 3 week history of generalized fatigue, whole body aches and weakness. Patient also reports a subjective fever at home with chills. Patient initially presented to ___ ___ on ___ and was diagnosed with a urinary tract infection and prescribed Macrobid. She was contacted a day later with result 1 bottle of blood culture with evidence of Strep Viridans. She was then prescribed Levaquin which she reports being told to start after her Macrobid. She was scheduled to start this medication today, but has not yet taken a dose of her medication. She represented to the outside hospital on ___ for repeat Blood cultures which have shown no growth to date. Her review of systems is significant for generalized weakness and achiness. She is tolerating a regular diet and denies any nausea/vomiting, constipation, diarrhea or vaginal bleeding. She does report some mild chest discomfort in her mid chest and lower abdominal pain. <PAST MEDICAL HISTORY> OB History: ___: Repeat low transverse C section (LTCS) 7#8oz male infant complicated by post partum hemorrhage requiring supracervical hysterectomy 2 prior LTCS ___ Spontaneous abortion x 2 GYN History: Denies prior history of sexually transmitted infection Past medical history: A thorough review of prior H&P reveals Hyperthyroidism Past surgical history: Low transverse c-section x 3 Exploratory Laparotomy with Supra-cervical hysterectomy <SOCIAL HISTORY> No tobacco/ethanol/drugs <PHYSICAL EXAM> Admission Physical Exam per Dr. ___: No acute distress, appears overall well CV: Regular rate and rhythm Pulm: Clear to auscultation bilaterally Back: No costo vertebral angle tenderness Abd: well healing vertical midline incision, +bowel sounds, soft, mild tenderness to palpation to right and left of incision (R>L), no guarding and no rebound SVE: No tenderness with internal examination, cervix could not be appreciated <PERTINENT RESULTS> IMAGING: ___ CT Abd/pelvis w/ contrast: FINDINGS: CHEST: The pulmonary arterial tree is well opacified and no filling defect to suggest pulmonary embolism is seen. The aorta is normal in caliber and configuration without evidence of acute aortic syndrome. The heart and great vessels appear grossly normal with incidental note of common origin of the brachiocephalic and left common carotid arteries. No pericardial effusion is seen. The lung parenchyma appears grossly clear with a 2-mm pulmonary nodule noted in the right middle lobe (2: 30). No evidence of endobronchial lesion is seen. No pathologically enlarged lymph nodes are identified. ABDOMEN: A hypodensity measuring 3 mm in the right hepatic lobe (3b: 99) is too small to characterize. The spleen, pancreas, gallbladder, adrenal glands, and kidneys appear grossly unremarkable. Loops of small and large bowel are normal in size and caliber. No intra-abdominal free air, free fluid, or lymphadenopathy is seen. Incidental note is made of a circumaortic left renal vein. PELVIS: The right ovarian vein is expanded with filling defect compatible with thrombus. The patient is reported to have a supracervical hysterectomy. However, there appears to be soft tissue in the region of the expected uterus. Fluid in the region of the expected endometrial canal appears to have a triangular configuration on the axial images, a configuration which would typically be seen with uterus. There is surrounding soft tissue stranding and small amounts of free fluid, of unclear significance given recent laparotomy. A cyst in the right adnexal region measuring 3.1 x 2.2 cm (3B: 141) could be paraovarian or exophytic from the right ovary. Fat stranding surrounds the pelvic loops of large bowel and appendix; however, is likely secondary to the recent laparotomy. There is scattered diverticulosis. Soft tissue changes from midline abdominal incision are noted. No free air or lymphadenopathy is identified. No concerning osseous lesion is seen. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Right ovarian vein thrombus. 3. Despite the given history of supracervical hysterectomy, tissue is seen in the region of the expected uterus with fluid in a configuration typically seen with a uterine cavity. Correlation with operative report recommended. If it is confirmed that the uterus has been removed, this tissue and fluid collection cannot be clearly explained by CT and further evaluation with MRI may be performed. 4. 2-mm pulmonary nodule. In a low-risk patient, no further specific followup is needed. In a high-risk patient, followup CT at 12 months is currently advised. MRI Abd/Pelvis: There has been a supracervical hysterectomy. The remnant cervix is noted in situ measuring 6.4 cm craniocaudal x 2.7 cm in AP diameter. A nabothian cyst is noted in the lower cervix measuring 9 mm (series 5, image 20). Post-surgical change / susceptibility artifact is noted at the resection margin at the superior aspect of the cervix (series 10, image 48). The right ovary measures 2.5 x 3.8 cm. Within this, there is a 2.7 x 2.2 cm cystic lesion identified which is hyperintense relative to ovarian parenchyma on T1-weighted imaging (series 10, image 52) and hyperintense relative to ovarian parenchyma on T2-weighted imaging (series 5, image 17). It does not demonstrate internal enhancement (series 1303, image 50) and findings are compatible with a hemorrhagic / proteinaceous cyst. The left ovary is unremarkable with dominant physiological follicles noted in relation to it and measures 1.6 x 2.1 cm (series 5, image 12). No pelvic adenopathy or free fluid is noted in the pelvis. No evidence for fluid collection or abscess. The visualized bladder, rectum, and sigmoid colon are unremarkable. There is evidence for right ovarian vein thrombosis (series 1302, image 16) unchanged from prior CT examination ___. Bone marrow signal is normal. No osseous lesions are identified. IMPRESSION: 1. The patient is status post supracervical hysterectomy with remnant cervix noted in situ. Post-surgical changes noted at the superior margin of the cervix at the resection margin with no evidence for intra-abdominal abscess or drainable collection identified. 2. 2.7 x 2.2 cm hemorrhagic / proteinaceous cyst noted in relation to the right ovary. 3. Right ovarian vein thrombosis, unchanged from prior CT examination from ___. ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No vegetations or clinically-significant valvular disease seen. Normal global and regional biventricular systolic function MICROBIOLOGY: Review of Outside hospital records ___ Urine Culture: > 100,000 and > 3 organisms ___ Blood Culture: 1: Strep Viridans, 2: No Growth ___ Blood Culture : No Growth ___ Blood culture: no growth ___ Blood culture: no growth LABS: ___ 02: 40PM BLOOD WBC-4.6# RBC-4.25# Hgb-12.9 Hct-38.5 MCV-91 MCH-30.4 MCHC-33.5 RDW-12.4 Plt ___ ___ 09: 45AM BLOOD WBC-4.2 RBC-4.30 Hgb-13.9 Hct-40.3 MCV-94 MCH-32.4* MCHC-34.6 RDW-13.1 Plt ___ ___ 05: 21AM BLOOD WBC-3.7* RBC-4.20 Hgb-13.1 Hct-39.2 MCV-93 MCH-31.1 MCHC-33.4 RDW-13.2 Plt ___ ___ 02: 40PM BLOOD Neuts-55.6 ___ Monos-5.6 Eos-5.1* Baso-0.4 ___ 05: 21AM BLOOD Neuts-47.8* ___ Monos-8.0 Eos-7.4* Baso-0.7 ___ 02: 40PM BLOOD Glucose-94 UreaN-14 Creat-1.0 Na-138 K-4.2 Cl-104 HCO3-26 AnGap-12 ___ 02: 40PM BLOOD TSH-1.3 <MEDICATIONS ON ADMISSION> Percocet prn <DISCHARGE MEDICATIONS> 1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours) for 11 days. Disp: *22 syringe* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right ovarian vein thrombus S/P C/section complicated by DIC requiring supracervical hysterectomy. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, you were admitted to the ___ Gynecology service for observation. You infectious disease work up was negative. You were diagnosed with a right ovarian vein thrombus for which you were started on Lovenox (anticoagulation medicine). You will be taking Lovenox for 2 weeks.
|
Ms. ___ was admitted to the GYN service for further evaluation of generalized weakness and suspected bacteremia. Repeat blood cultures were drawn and she was prophylactic ally placed on clindamycin (due to pencillin allergy) for Strep viridans growth on a blood culture (1 of 2 bottles) drawn at an outside hospital. Infectious Disease was consulted for further recommendations, who recommended an echocardiogram to rule out vegetations, which was negative. She was also briefly transitioned to vancomycin to better cover Strep Viridans, although upon final review of this patient's clinical status with Infectious Disease, it was determined that the Strep Viridans was likely a contaminant given that the patient was afebrile throughout stay, had a normal white count, and had multiple repeat blood cultures that were negative. Antibiotics were discontinued and she remained afebrile for >48 hours off antibiotics. With regard to her weakness, a TSH and hematocrit were checked and were both within normal limits. Her symptoms improved significantly after receiving IV hydration. Ms. ___ was noted to have an incidental finding of right ovarian vein thrombus on imaging. Hematology was consulted regarding this. Although septic thrombophlebitis was unlikely given afebrile in-house and normal white count,Ms. ___ was started on anticoagulation therapy given her generalized symptoms and subjective fevers at home. She was discharged on lovenox BID and will continue this for 2 weeks per hematology recommendations, with a follow up CT to reevaluate. Ms. ___ was discharged home in stable condition on hospital day 3, afebrile and in stable condition.
| 2,378
| 349
|
10258142-DS-5
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lidocaine <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> removal of cervical ectopic pregnancy cervical Foley balloon removal of cervical Foley balloon <HISTORY OF PRESENT ILLNESS> ___ yo G3P1 at 7w3d by Clomid/IUI dating presenting with vaginal bleeding and possible cervical ectopic pregnancy on outside imaging today. She has had intermittent vaginal bleeding, with outside ultrasound on ___ showing a live SIUP, size equal to dates, with a sub-chorionic hematoma. She had a follow-up ultrasound within the past week that also showed a live SIUP, but with resolution of the hematoma. However, today she called to report heavy vaginal bleeding with some clots and "tissue," and had an ultrasound that was concerning for a cervical ectopic pregnancy with 2 gestational sacs seen - 1 intra-uterine and 1 in the cervix. She was referred to the ED for further evaluation. At present she reports mild cramping/soreness but is overall comfortable, with decreased bleeding from earlier in the day. Per the ED resident, on pelvic exam the cervix is open with clot/?POC seen within the os, and a small amount of blood in the vaginal vault. <PAST MEDICAL HISTORY> OBHx: G3P1 - SVD x 1 - SAB x 1 GynHx: denies h/o abnormal Paps, STIs MedHx: denies SurgHx: D&E x 1 <SOCIAL HISTORY> Denies T/E/D. <PHYSICAL EXAM> Vital signs: T: 98 BP: 103/70 HR: 72 RR: 18 O2 sat: 100%RA I/O: UOP 500cc since arrival on floor at 20: 40 General: In bed, NAD Cardiac: RRR Pulm: CTA Abdomen: soft, minimally tender, no masses GU: Peripad with spotting, no active bleeding Ext: no edema, no erythema <PERTINENT RESULTS> ___ 01: 40PM BLOOD WBC-13.0*# RBC-4.36 Hgb-13.9 Hct-39.1 MCV-90 MCH-32.0 MCHC-35.7* RDW-12.6 Plt ___ ___ 06: 47PM BLOOD Hct-31.3* ___ 11: 20AM BLOOD WBC-8.4 RBC-3.43* Hgb-11.2* Hct-31.9* MCV-93 MCH-32.6* MCHC-35.0 RDW-12.3 Plt ___ ___ 07: 35AM BLOOD WBC-6.5 RBC-3.33* Hgb-10.8* Hct-31.6* MCV-95 MCH-32.3* MCHC-34.0 RDW-12.2 Plt ___ . Early OB U/S < 14 weeks; TV OB U/S (___): IMPRESSION: 1. Single living intrauterine gestation with size equals dates. 2. Gestational sac within the cervix is unchanged in size and position. Non-living embryonic pole size measures 1 week less than dates with no cardiac activity. Again, this could represent a spontaneous abortion in progress versus a cervical ectopic. Close clinical correlation with beta hCG and/or ultrasound followup is recommended. 3. Fibroid uterus. . <MEDICATIONS ON ADMISSION> Pre-natal vitamins <DISCHARGE MEDICATIONS> 1. Prenatal Oral 2. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cervical ectopic pregnancy and live intra-uterine pregnancy Vaginal bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure to take care of you while you were in the hospital. You were admitted because you told us about vaginal bleeding. On your third day of hospitalization, we took you to the operating room and removed the products of ectopic pregnancy from the cervix. Your intra-uterine pregnancy was confirmed to be live pre- and post-procedure using ultrasound imaging. To stop the steady, slow bleeding we saw after the procedure, we placed a balloon catheter in your cervix with two stitches to hold the balloon in place. After two days, we removed both the catheter and the stitches. You recovered well from the procedure, with pain well-controlled on no medications. . General instructions: * A small amount of vaginal spotting over the next few days is normal. * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ was admitted for observation given her heterotopic cervical pregnancy and vaginal bleeding. Her bleeding slowed and on hospital day #3, she underwent an uncomplicated removal of the cervical ectopic pregnancy with placement of an intra-cervical Foley balloon and Prolene stitch as cerclage given the steady, slow bleeding post-procedure; see operative report for details. She had an uncomplicated recovery with removal of the Foley/cerclage and discharge home on hospital day #5, post-operative day #2 in stable condition, with live IUP seen on u/s following Foley balloon removal the day of discharge.
| 1,188
| 126
|
10260365-DS-17
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Percocet <ATTENDING> ___. <CHIEF COMPLAINT> heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Supracervical hysterectomy Right salpingo-oophorectomy Partial left salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ obese gravida 3, para 3 ___ female who has new diagnosis of fibroid uterus, which was detected by ultrasound in ___ however, recently she was seen at ___ ___ Emergency ___ for heavy and irregular vaginal bleeding. On that visit, it was noted that she had normal vital signs. Her hematocrit was 40. Since then has had attempt at Novasure which failed, due to uterine size ___ ___. Recent EM biopsy showed menstrual endometrium wo cellular abnormalities PUS: uterus 15x9cm, largest fibroid 7x7cm <PAST MEDICAL HISTORY> Pertinent Gyn History: Other: none Menses Regular and Heavy Bleeding: see HPI Contraception: LTL ___: denies STDs: no past history Last pap: Negative PMH: hx for clot in shoulder, no anticoagulation at present, morbid obesity Past Surgical History: None <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Cancer Brother throat - heart disorder Father Family history of problems with anesthesia, blood clotting disorders, pulmonary embolis or bleeding disorders denied. <PHYSICAL EXAM> Estimated Body mass index is 46.43 kg/(m^2) as calculated from the following: Height as of this encounter: 5' 5"(1.651 m). Weight as of this encounter: 279 lb(126.554 kg). Constitutional: well developed, morbid obesity female Skin: no lesions Lymphatic: no cervical, supraclavicular, or inguinal adenopathy Eyes: sclerae anicteric, EOMI, PERRLA and anicteric ENT: external ear normal, oropharynx normal and Mallampati class: 1 Thyroid: non-tender, not enlarged, no palpable mass Chest: clear to auscultation and resonant to percussion Heart: regular rate, rhythm and no murmur, rub, gallop Breasts: no masses, no nipple discharge, no skin or nipple changes Abdomen: no masses, no palpable hepatosplenomegaly, soft, non-tender Extremities: normal, no cyanosis, no clubbing, no edema Neurological: alert and oriented, normal to confrontation and cranial nerves II-XII intact Pelvic: External Genitalia: no lesions or inflammation and normal escutcheon Vagina: no lesions Pelvic Supports: normal, no cystocele, rectocele, enterocele, or prolapse Cervix: no lesions, no cervical motion tenderness and multiparous appearance Uterus: irregular contour, difficult to outline and 12 week sized Adnexa: no palpable mass, no tenderness Anus and Perineum: no hemorrhoids Rectum: not indicated <MEDICATIONS ON ADMISSION> acetaminophen-codeine 300-30mg every ___ hours as needed for pain ibuprofen 400mg, 1 tablet every 6 hours as needed for pain <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills: *1 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain 3. Ibuprofen 600 mg PO Q8H: PRN PAIN RX *ibuprofen 600 mg 1 (One) tablet(s) by mouth ONE EVERY 6 HOURS Disp #*60 Tablet Refills: *0 RX *ibuprofen 600 mg 1 tablet(s) by mouth EVERY 6 HOURS AS NEEDED Disp #*60 Tablet 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> Ms. ___, You were admitted to the gynecology service after undergoing the procedure listed below. We observed you in the hospital and felt you were safe to go 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), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing a supracervical hysterectomy, right salpingo-oophorectomy and partial left salpingo-oophorectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Given her history of an unprovoked upper extremity deep venous thrombosis, she was given subcutaneous heparin three times a day for prophylaxis. Her diet was advanced without difficulty and she was transitioned to oral pain medication. 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.
| 1,227
| 201
|
10260854-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodine-Iodine Containing / Taxol / Doxil <ATTENDING> ___ <CHIEF COMPLAINT> Perineal discharge in setting of advanced ovarian cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> CT abdomen and pelvis (at outside hospital) Incision and drainage of left mons abscess <HISTORY OF PRESENT ILLNESS> ___ yo with poorly differentiated metastatic ovarian cancer s/p TAH/ BSO/ cytoreductive therapy in ___ on chemotherapy who presented to outside hospital complaining of blood in urine and incontinence. States she woke up in a pool of pink tinged fluid that looked like urine. Kept leaking even after she felt like she had emptied her bladder. Went to ___), had CT scan which showed a large pelvic mass and right hydronephrosis. A foley catheter was placed and the decision was made to transfer to ___ for further work up. Denies h/o incontinence before. C/o significant rectal pressure/urge to have bowel movements over last few days, very uncomfortable to have bowel movement and is going frequently. No air or feces in urine or vagina. No nausea/ vomiting however c/o significant anorexia. No URI symptoms. No CP, SOB. No lightheadedness. No abdominal pain/ back pain. Denies leg pain, weakness, numbness. Oncology history: Initially admitted with wt loss, anorexia, fevers, and leukocytosis and was found to have a complex adnexal mass. CT scan revealed multiple bilateral pulmonary nodules c/w metastatic disease. CA 125/ CEA were elevated. She had mult studies ___, endoscopy, mammography, CT guided lung biopsy) that could not reveal definitive source of malignancy and therefore the patient underwent exlap with resection of pelvic mass, TAH/BSO, and cytoreductive surgery on ___. Pathology revealed very poorly differentiated carcinoma thought ovarian in nature. She is currently undergoing chemotherapy with carboplatin and Taxotere (after desensitization) at ___ ___ q3 weeks. A recent CT scan in ___ showed 2 pelvic masses that were not present previously. <PAST MEDICAL HISTORY> PMH: 1. Benign Hypertension 2. Alcholism in past, currently sober 3. Tobacco use, 15 pack-year history. PSH: 1. D&C 2. Tonsillectomy 3. Wisdom teeth excision <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denies any family history of gyn malignancy. She reports that her mother died of non-Hodgkin's' lymphoma and her father died of lung cancer. Her brother died of CAD at age ___ y/o. <PHYSICAL EXAM> T 98.6, HR 66, BP 120/70, RR 18, 96%RA Foley 200cc/ 2.5 hours since arrival NAD RRR Decreased breath sounds throughout however R>L, o/w clear Abdomen soft, NT, ND. Well healed vertical incision. L groin with 2cm x 1.5cm fluctuant mass, erythematous, tender, no surrounding erythema. Foley with clear yellow urine Significant amount of discharge noted on clothing despite foley placement SSE: Pooling of clear-yellow-pink fluid in vault. Cuff appears intact. no obvious fistula/ sinus tract. BME: Large pelvic mass appreciated, firm, minimally mobile, no palpable dehiscence of cuff. Rectal: pelvic mass appreciated on rectal exam, no palpable communication between rectum and vagina. normal rectal tone. ext NT/NE <PERTINENT RESULTS> ___ 07: 15PM WBC-35.8*# RBC-3.18* HGB-10.2* HCT-30.5* MCV-96 MCH-32.2* MCHC-33.6 RDW-16.9* ___ 07: 15PM NEUTS-87.2* LYMPHS-8.6* MONOS-3.0 EOS-0.9 BASOS-0.2 ___ 07: 15PM PLT COUNT-308# ___ 07: 15PM GLUCOSE-119* UREA N-7 CREAT-0.5 SODIUM-141 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18 ___ 07: 15PM CALCIUM-9.5 PHOSPHATE-4.2 MAGNESIUM-1.9 ___ 07: 48AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 07: 48AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR ___ 07: 48AM URINE RBC-12* WBC-8* Bacteri-FEW Yeast-NONE Epi-<1 ___ 07: 48AM URINE CastHy-3* ___ 07: 48AM URINE Uric AX-FEW ___ 07: 48AM URINE Mucous-MOD <MEDICATIONS ON ADMISSION> lorazepam PRN anxiety, potassium supplements <DISCHARGE MEDICATIONS> 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety, insomnia. 2. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 3. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Advanced ovarian cancer Abscess of left groin <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: - Severe pain - 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 may resume your regular diet and home medications.
|
Ms. ___ was admitted to the gyn onc service for further care. A foley was placed with return of clear yellow urine. She continued to have perineal drainage, which was felt to be vaginal in origin secondary to tumor progression. The CT was reviewed with a ___ attending radiologist. The known pelvic masses (6cm in diameter) were seen, as well as moderate to severe right hydronephrosis from tumor compression and two pulmonary nodules (she has known pulmonary nodules, CT limited by non-contrast). Her creatinine is within normal limits and she has no flank pain. Urology has arranged to see the patient as an outpatient this ___. On admission, she had a left mons abscess, which after explaining the procedure and obtaining writen consent, was incised and drained at the bedside and packed. . She was discharged on HD #2 in stable condition. She has follow-up with gyn oncology, as well as urology, this week. She will have ___ for twice daily packing changes. She is discharged on 10 days on cipro BID.
| 1,412
| 226
|
10260854-DS-11
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodine-Iodine Containing / Taxol / Doxil <ATTENDING> ___ <CHIEF COMPLAINT> Advanced ovarian cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Colonoscopy Blood transfusion <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G3P2 with stage IV metastatic ovarian cancer who underwent exploratory laparotomy, appendectomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right ureterolysis, tumor debulking/cytoreductive surgery in ___ who has been having progressive disease in her pelvis and retroperitoneum refractory to platinmum chemotherapy. She has three known pelvic masses, the largest 8cm in size, that appears to be impinging on her sigmoid colon. The patient herself reports she has been having difficulty having bowel movements for about one week with intermittent straining and inability to completely empty her bowels. Over the past two days she has been able to completely empty her bowels after using ex-lax and currently does not feel these symptoms. She is here for admission for a sigmoidoscopy by GI tomorrow with possible stent placement for obstruction. She also reports a fever at home of 101.6 today. She states she has been having intermittent fevers for months now, but mostly low grade. Denies any cough, SOB, CP, sick contacts or dysuria. <PAST MEDICAL HISTORY> PMH: 1. Benign Hypertension 2. Alcholism in past, currently sober 3. Tobacco use, 15 pack-year history. PSH: 1. D&C 2. Tonsillectomy 3. Wisdom teeth excision <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denies any family history of gyn malignancy. She reports that her mother died of non-Hodgkin's' lymphoma and her father died of lung cancer. Her brother died of CAD at age ___ y/o. <PHYSICAL EXAM> On admission: VS- 98.6 93/54 89 18 100%RA appears comfortable overall, in NAD RRR Lungs CTA B abdomen soft nontender, nondistended, vertical midline incision well-healed no CVA tenderness pelvic/rectal exam deferred <PERTINENT RESULTS> ___ 01: 30PM BLOOD WBC-62.0*# RBC-2.89* Hgb-8.6* Hct-28.2* MCV-98 MCH-29.9 MCHC-30.6* RDW-16.5* Plt ___ ___ 09: 41PM BLOOD WBC-56.8* RBC-2.32* Hgb-7.2* Hct-22.4* MCV-97 MCH-30.8 MCHC-31.9 RDW-17.0* Plt ___ ___ 09: 41PM BLOOD Neuts-83* Bands-8* Lymphs-3* Monos-1* Eos-4 Baso-1 ___ Myelos-0 ___ 05: 19AM BLOOD WBC-56.4* RBC-2.85* Hgb-8.5* Hct-26.2* MCV-92 MCH-29.9 MCHC-32.5 RDW-19.2* Plt ___ ___ 05: 19AM BLOOD Neuts-79* Bands-8* Lymphs-5* Monos-3 Eos-5* Baso-0 ___ Myelos-0 ___ 05: 19AM BLOOD ___ PTT-28.4 ___ ___ 05: 19AM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-139 K-3.4 Cl-104 HCO3-29 AnGap-9 ___ 01: 30PM BLOOD ALT-4 AST-8 AlkPhos-172* TotBili-0.3 ___ 09: 41PM BLOOD Calcium-8.4 Phos-4.2 Mg-1.7 ___ 01: 30PM BLOOD TotProt-7.2 Albumin-3.1* Globuln-4.1* Calcium-8.9 Phos-3.8 Mg-1.9 ___ 01: 30PM BLOOD ___ ___ 09: 41PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09: 41PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR ___ 09: 41PM URINE RBC-1 WBC-6* Bacteri-NONE Yeast-NONE Epi-<1 ___ 9: 41 pm URINE MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___: Blood culture: pending at the time of this report <MEDICATIONS ON ADMISSION> oxycodone, lorazepam, tylenol, potassium <DISCHARGE MEDICATIONS> 1. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *100 Tablet(s)* Refills: *0* 2. Ultram 50 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO bid prn as needed for anxiety. 7. Outpatient Lab Work CBC with differential, Chem-7 to be done ___ Then please fax results to Dr ___ at ___ <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Advanced ovarian 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 while taking narcotic pain medications -Please follow up with Dr. ___ as scheduled. You may also consider following up with Dr. ___ as you decide.
|
Ms. ___ was taken for colonic stent placement on HD2. Please see OMR note. Briefly no stent was placed as there was no stricture or obstruction found. She was felt to have colonic dysmotility. As an inpatient she had flatus and bowel movements. She tolerated a regular diet. She received 2 units of PRBCS for anemia. She was discharged in stable condition on HD 3. At the time of this report blood cultures are pending but no growth to date. Her exam was not suggestive of infection. She is known to have had a leukemoid reaction along with tumor fevers prior to her initial debulking in ___.
| 1,544
| 142
|
10260854-DS-8
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodine-Iodine Containing <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy appendectomy total abdominal hysterectomy bilateral salpingo-oophorectomy tumor debulking/cytoreductive surgery <HISTORY OF PRESENT ILLNESS> ___ year-old G3P2 who presented to ___ for surgical management of a large pelvic mass. Patient initially presented to ___ on ___ on transfer from outside hospital for fever (101.6), leukocytosis (WBC > 50), and a abdominal/pelvic CT revelated a large pelvic mass (12.5 cm). At the time, she endorsed a three month history of increasing early satiety, weight loss (at least 25 lbs) with anorexia, and soaking night sweats, increased fatigue, and a three-week history of non-bloody diarrhea. Her workup at ___ included a pelvic CT suggesting bilateral complex adnexal masses with pulmonary mets but without ascites or peritoneal disease, elevated CA125 with normal AFP and near normal CEA, and a negative EGD. A subsequent ___ guided biopsy on ___, complicated by a pneumothorax requiring chest tube placement, returned a largely necrotic mass suggestive of poorly differented malginancy with tumor markers suggesting carcinoma, but without definitive diagnosis. Patient now presents to ___ for surgical removal of pelvic mass, with tissue biopsy for definitive diagnosis to guide further oncological management. <PAST MEDICAL HISTORY> 1. Benign Hypertension 2. Alcholism, now x 9 months alcohol free 3. Tobacco use, 15 pack-year history. Past surgical history: PSH: 1. D&C 2. Tonsillectomy 3. Wisdom teeth excision <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denies any family history of gyn malignancy. She reports that her mother died of ___ lymphoma and her father died of lung cancer. Her brother died of CAD at age ___ <PERTINENT RESULTS> ___ 09: 40AM WBC-80.6* RBC-3.54* HGB-8.9* HCT-28.6* MCV-81* MCH-25.1* MCHC-31.0 RDW-16.3* ___ 09: 40AM UREA N-8 CREAT-0.6 SODIUM-140 POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-29 ANION GAP-16 <DISCHARGE INSTRUCTIONS> No driving while on narcotics. Nothing in the vagina for 6 weeks. No heavy lifting or strenuous exercise for 6 weeks.
|
The pt was admitted on ___ for an uncomplicated total abdominal hysterectomy, bilateral slpingo-ophorectomy, appendectomy, and resection of pelvic mass. Intraoperative frozen section pathology suggestive of papillary cancer. Please see operative note for full details. Postoperatively, an epidural catheter, complicated by wet tap, was placed postoperatively with excellent control of pain. Epidural ___ was removed post-operative day 2 with transition to PO meds with good control of pain. Urine output was adequate throughout hospital course. Foley was discontinued on post-operative day 2. Patient was maintained on pneumo-boots and subcutaneous heparin throughout hospital course. Patient's diet was advanced to sips on post-op day 1, to clears and then solids on post-op day 2, and was well-tolerated without nausea or vomiting. A nutrition consult was placed given her history of anorexia and weight loss. Patient was briefly hypotensive to systolic ___ after epidural placement in the PACU, but responded appropriately to a single bolus of phenylephrine with return of her systolic blood pressure to greater than 90. A supratherapeutic INR was attributed to poor nutrition status. Subcutaneous vitamin K was given on postoperative day 2 to improve INR for epidural catheter removal. The pt was discharged home in stable condition. 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. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*2* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*60 Tablet(s)* Refills:*2* 4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Tylenol-Codeine #3 300-30 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: do not take more than 4000 mg of acetaminophen a day. Disp:*50 Tablet(s)* Refills:*0* 6. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 7. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: cancer Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Followup Instructions: ___
| 607
| 622
|
10264949-DS-16
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex / IVP dye <ATTENDING> ___. <CHIEF COMPLAINT> Endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Attempted laparoscopic converted to exploratory laparotomy, total abdominal hysterectomy, right salpingo- oophorectomy, left salpingectomy, bilateral pelvic and periaortic lymph node dissection, infracolic omentectomy, and peritoneal biopsies. <HISTORY OF PRESENT ILLNESS> The patient is a ___ G3 P3, who presented in ___ to her primary care complaining of pelvic pressure and urinary frequency. She was evaluated for a urinary tract infection and was treated; however, her symptoms persisted and she was referred to Gynecology. In ___, she saw Dr. ___ performed a pelvic ultrasound. The pelvic ultrasound was notable for a thickened endometrium and she ultimately underwent an endometrial biopsy revealing a high-grade adenocarcinoma with both serous and grade 3 endometrioid adenocarcinoma. She was referred here for further evaluation. The patient has been extremely anxious since her diagnosis. She has never had any postmenopausal bleeding. She denies any significant changes in her bowel or bladder habits, though does still note occasional pains in the lower abdomen as well as some burning with urination. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Notable for "borderline" diabetes as well as obesity and anxiety. PAST SURGICAL HISTORY: Notable for three laparotomies, one in ___ for an ovarian cyst, one in ___ for kidney stone and one in ___ for an ovarian cyst. She was told that one of her surgeries that she no longer had a left ovary. OBSTETRICAL HISTORY: She is a G3 P3. She underwent three spontaneous vaginal deliveries without complications. GYN HISTORY: She was postmenopausal at the age of ___. She has a distant history of abnormal Pap smears. However, the last one in ___ was normal. She has never been on hormone replacement therapy. She has known uterine fibroids; however, denies any other significant gynecologic infections or issues. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Notable for a sister and maternal and paternal aunts with breast cancer. She denies any history of ovarian or uterine cancers. Her father was diagnosed with colon cancer in his ___ and also with sarcoma. She also has a family history significant for diabetes, high blood pressure and ulcerative colitis. <PHYSICAL EXAM> On the day of discharge: Afebrile, vital signs within normal limits Gen: no acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender to palpation, mildly distended, no rebound/guarding, incision appears clean/dry/intact Ext: non-tender, symmetric <PERTINENT RESULTS> ___ EKG Sinus rhythm. Premature ventricular complex. Non-specific ST segment flattening. Compared to the previous tracing of ___ the ventricular rate is slower and ventricular ectopy is now appreciated. ------- ___ 07: 35PM BLOOD WBC-22.3*# RBC-4.25 Hgb-13.1 Hct-39.1 MCV-92 MCH-30.8 MCHC-33.4 RDW-12.5 Plt ___ ___ 07: 30AM BLOOD WBC-16.1* RBC-3.70* Hgb-11.0* Hct-33.6* MCV-91 MCH-29.8 MCHC-32.8 RDW-12.6 Plt ___ ___ 07: 05AM BLOOD WBC-11.4* RBC-3.20* Hgb-10.1* Hct-29.6* MCV-93 MCH-31.6 MCHC-34.2 RDW-12.7 Plt ___ ___ 07: 20AM BLOOD WBC-9.9 RBC-3.77* Hgb-11.3* Hct-34.6* MCV-92 MCH-29.9 MCHC-32.6 RDW-12.5 Plt ___ ___ 07: 25AM BLOOD WBC-10.2 RBC-3.76* Hgb-11.8* Hct-34.2* MCV-91 MCH-31.3 MCHC-34.5 RDW-12.7 Plt ___ ___ 07: 30AM BLOOD WBC-10.1 RBC-3.81* Hgb-11.8* Hct-35.0* MCV-92 MCH-30.9 MCHC-33.6 RDW-13.1 Plt ___ ___ 07: 35PM BLOOD Glucose-196* UreaN-16 Creat-0.7 Na-139 K-4.1 Cl-105 HCO3-23 AnGap-15 ___ 07: 30AM BLOOD Glucose-127* UreaN-14 Creat-0.7 Na-138 K-4.2 Cl-104 HCO3-26 AnGap-12 ___ 07: 05AM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-141 K-3.6 Cl-106 HCO3-28 AnGap-11 ___ 07: 20AM BLOOD Glucose-103* UreaN-9 Creat-0.5 Na-141 K-3.5 Cl-105 HCO3-26 AnGap-14 ___ 07: 25AM BLOOD Glucose-112* UreaN-9 Creat-0.5 Na-142 K-3.5 Cl-106 HCO3-24 AnGap-16 ___ 07: 30AM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-140 K-3.8 Cl-105 HCO3-24 AnGap-15 ___ 07: 35PM BLOOD Calcium-8.4 Phos-4.2 Mg-1.9 ___ 07: 30AM BLOOD Calcium-8.3* Phos-2.4*# Mg-2.0 ___ 07: 05AM BLOOD Calcium-7.7* Phos-1.5* Mg-1.9 ___ 07: 20AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.9 ___ 07: 25AM BLOOD Calcium-8.4 Phos-1.9* Mg-2.1 ___ 07: 30AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.8 ------ SURGICAL PATHOLOGY REPORT - Revised Revised A p53 stain is positive (diffusely over-expressed) in the tumor. ***** Electronically Signed Out ***** Diagnosed by: ___, MD, PHD Signed Out: ___ 07: 20 CLIA # ___ PATHOLOGIC DIAGNOSIS: 1. Uterus, cervix, bilateral tubes and ovaries (1A-1P): Endometrial adenocarcinoma, see synoptic report. 2. Infra-colic omentum, omentectomy (2A-2E): Metastatic adenocarcinoma. 3. Left pelvic lymph nodes, resection (3A-3D): No malignancy identified. Two lymph nodes (___). 4. "Residual cervix" (4A): No malignancy identified. Portion of cervix. 5. Posterior cul-de-sac, biopsy (5A): Metastatic adenocarcinoma. 6. Right pelvic lymph nodes, resection (___): No malignancy identified. Three lymph nodes (___). 7. Right ___ lymph nodes, resection (7A-7B): No malignancy identified. Five lymph nodes (___). 8. Inter-iliac lymph nodes, resection (8A): No malignancy identified. Fibroadipose tissue and large nerve. Endometrium: Hysterectomy, with or without Other Organs or Tissues Synopsis Staging according to ___ Joint Committee on Cancer Staging Manual -- ___ Edition, ___ Macroscopic Specimen Type: Hysterectomy Right salpingo-oophorectomy Left salpingo-oophorectomy Omentectomy Tumor Size: Greatest dimension: 0.8 cm. Microscopic Histologic Type: Mixed carcinoma: Predominantly serous with a minor endometrioid component. Histologic Grade: Histologic grade, G3: Serous Washings/Cytology: Positive Cytology #: ___ Extent of Invasion Primary Tumor (pT): pT3a(IIIA): Tumor involves serosa, and/or adnexa (direct extension or metastasis) Myometrial Invasion: No invasion Cervix: negative Ovaries: Right: metastasis Left: negative Fallopian Tubes: Right: metastasis; implant Left: negative Serosa: implant Omentum: metastasis; implant (microscopic) Regional Lymph Nodes (pN): pNO: No regional lymph node metastasis Pelvic Lymph Nodes: Number of lymph nodes examined: 5. Number involved: 0 Para-aortic lymph nodes: Number of lymph nodes examined: 5. Number involved: 0 Distant metastasis: PMX: Cannot be assessed Lymphovascular invasion: Not identified CYTOLOGY REPORT - Final Specimen(s) Submitted: PERITONEAL WASHINGS Diagnosis PERITONEAL WASHINGS: POSITIVE FOR MALIGNANT CELLS. Consistent with papillary serous carcinoma. <MEDICATIONS ON ADMISSION> 1. Celexa 30 mg PO daily <DISCHARGE MEDICATIONS> 1. Citalopram 30 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H Take with food. Do not take >2400 mg ibuprofen in 24 hrs. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 3. Acetaminophen 1000 mg PO Q6H pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 4. OxycoDONE (Immediate Release) 10 mg PO Q4H: PRN pain RX *oxycodone 10 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 5. Simethicone 40-80 mg PO QID: PRN gas pains RX *simethicone 80 mg 1 tablet by mouth QID: PRN Disp #*60 Tablet Refills: *0 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth BID: PRN Disp #*60 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> High-grade endometrial cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 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. * Your staples will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ was admitted to the gynecology oncology service after undergoing attempted laparoscopic converted to exploratory laparotomy, total abdominal hysterectomy, right salpingo- oophorectomy, left salpingectomy, bilateral pelvic and periaortic lymph node dissection, infracolic omentectomy, and peritoneal biopsies. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural, which was managed by the acute pain service. She required a small amount of O2 therapy to maintain normal O2 saturations on post-operative day 0 and 1, but had no respiratory symptoms and was weaned off oxygen by post-operative day 2. On post-operative day 2, her epidural was removed and she was transitioned to oral pain medications (ibuprofen, tylenol, oxycodone) with IV dilaudid as needed for breakthrough pain. Her urine output was adequate and she was able to ambulate, so her foley catheter was removed on post-operative day 2 and she was able to void spontaneously. Her diet was slowly advanced over several days and she was was tolerating a regular diet by the time of discharge. For her borderline diabetes, her finger sticks were checked regularly and remained within normal limits. She did not require any insulin during her hospitalization. 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.
| 2,698
| 337
|
10264949-DS-17
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex / IVP dye <ATTENDING> ___. <CHIEF COMPLAINT> Nausea and vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p exlap TAH, RSO, pelvic paraaortic lymph node dissection omentectomy for metastatic endometrial adenocarcinoma on ___ presenting for new abdominal pain, nausea vomiting since yesterday afternoon. Patient has known midline hernia, and was concerned for incarcerated hernia. Reports pain started acutely yesterday then developed nausea, vomiting. Reports has ___ episodes of emesis yesterday last evening. Last episode of emesis at 0300. Pain improved after morphine. Reports last bowel movement 1 day prior. Unsure last flatus. Denies blood in emesis. Denies dizzy/lightheadedness, fever, chills. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: - anxiety - Denies history of diabetes, hypertension, blood clots or clotting disorders PAST SURGICAL HISTORY: - ___- Ex lap TAH, RSO, omentectomy, pelvic and paraaortic lymphnode dissection for metastatic endometrial adenocarcinoma - Ex lap ___ for an ovarian cyst - Ex Lap ___ for kidney stone and one - Ex Lap ___ for an ovarian cyst OB/GYN: - G3P3 SVD x 3 - Postmenopausal age ___ - ex lap as above for endometrial adenocarcinoma ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Sister, maternal and paternal aunt with breast cancer. - Denies history of uterine ovarian cancer - Father with colon cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, nontender, nondistended ___: nontender, nonedematous <PERTINENT RESULTS> ___ 09: 30PM BLOOD WBC-14.8* RBC-4.29 Hgb-14.5 Hct-41.0 MCV-96 MCH-33.7* MCHC-35.3* RDW-14.2 Plt ___ ___ 12: 20PM BLOOD WBC-4.1 RBC-3.69* Hgb-12.3 Hct-34.9* MCV-95 MCH-33.3* MCHC-35.2* RDW-13.2 Plt ___ ___ 09: 30PM BLOOD Neuts-90.5* Lymphs-5.2* Monos-3.8 Eos-0.3 Baso-0.1 ___ 12: 20PM BLOOD Neuts-76.7* Lymphs-14.3* Monos-6.0 Eos-2.5 Baso-0.4 ___ 09: 30PM BLOOD Glucose-148* UreaN-22* Creat-0.8 Na-141 K-4.3 Cl-99 HCO3-25 AnGap-21* ___ 01: 15PM BLOOD Glucose-99 UreaN-19 Creat-0.6 Na-141 K-3.9 Cl-105 HCO3-27 AnGap-13 ___ 05: 59AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-141 K-3.9 Cl-104 HCO3-27 AnGap-14 ___ 06: 00AM BLOOD Glucose-107* UreaN-5* Creat-0.5 Na-140 K-3.7 Cl-105 HCO3-27 AnGap-12 ___ 12: 20PM BLOOD Glucose-99 UreaN-6 Creat-0.6 Na-140 K-4.0 Cl-103 HCO3-26 AnGap-15 ___ 09: 30PM BLOOD Albumin-4.9 Calcium-10.4* Phos-5.2*# Mg-1.7 ___ 01: 15PM BLOOD Calcium-8.9 Phos-3.8 Mg-1.7 ___ 05: 59AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7 ___ 06: 00AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.6 ___ 12: 20PM BLOOD Calcium-10.0 Phos-4.0 Mg-1.8 ___ 03: 27AM BLOOD Lactate-1.9 ___ 06: 35PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06: 35PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06: 35PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 Urine Culture negative <MEDICATIONS ON ADMISSION> - Celexa 30mg daily <DISCHARGE MEDICATIONS> 1. Zolpidem Tartrate 5 mg PO HS 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *2 3. Senna 8.6 mg PO BID: PRN constipation RX *sennosides [senna] 8.6 mg 1 by mouth once a day Disp #*40 Capsule Refills: *2 <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 received a nasogastric tube and bowel rest. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: - Take your medications as prescribed. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ was admitted to the gynecologic oncology service for management of a small bowel obstruction. . Her hospital course is detailed as follows. She had a nasogastric tube and was made NPO on admission. Her pain and nausea were controlled with IV dilaudid and zofran. On hospital day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She complained of dysuria on hospital day #1; urinalysis and urine culture were negative for infection and her symptoms resolved spontaneously after removal of the Foley catheter. . Her nasogastric tube was clamped on hospital day #2, and she had no nausea or residual output. On hospital day #3, her NG tube was removed and her diet was slowly advanced without difficulty on hospital days ___. She did not require pain medications after hospital day #3. . She was seen by social work during her admission. . By post-operative day #4, her nausea and vomiting had resolved, she was tolerating a regular diet, voiding spontaneously, and ambulating independently. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,416
| 239
|
10264949-DS-18
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex / IVP dye <ATTENDING> ___ <CHIEF COMPLAINT> nausea, vomiting, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p exlap TAH, RSO, pelvic paraaortic lymph node dissection omentectomy for metastatic endometrial adenocarcinoma on ___ presenting as a transfer from ___ where was found to have partial SBO after presenting with nausea, vomiting and abdominal pain since ___. . Patient was previously admitted from ___ with small bowel obstruction that was managed conservatively with NPO, NG tube, IV fluids. Her NGT was clamped on hospital day #2 and removed on hospital day #3. She was discharged on hospital day #4 after tolerating a regular diet. . She reports that she was doing well after discharge and tolerating a regular diet until ___ when she began having intermittent abdominal pain. She had one episode of vomiting on ___. Her pain continued throughout the weekend and she again began to vomit yesterday, vomiting nearly 20 times and was unable to tolerate PO. Last emesis was at 2300 last night. Her last BM was yesterday and was normal. She last passed flatus yesterday vs. ___ (she is unsure). Denies fever, chills, vaginal bleeding, vaginal discharge, dysuria. . She received IV narcotics & antiemetics in the ___ which significantly improved her pain and nausea. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: - anxiety - Denies history of diabetes, hypertension, blood clots or clotting disorders . PAST SURGICAL HISTORY: - ___- Ex lap TAH, RSO, omentectomy, pelvic and paraaortic lymphnode dissection for metastatic endometrial adenocarcinoma - Ex lap ___ for an ovarian cyst - Ex Lap ___ for kidney stone and one - Ex Lap ___ for an ovarian cyst . OB/GYN: - G3P3 SVD x 3 - Postmenopausal age ___ - ex lap as above for endometrial adenocarcinoma ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Sister, maternal and paternal aunt with breast cancer. - Denies history of uterine ovarian cancer - Father with colon cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, non tender, nondistended ___: nontender, nonedematous <PERTINENT RESULTS> ADMISSION LABS: ___ 05: 20AM BLOOD WBC-11.9*# RBC-3.78* Hgb-12.5 Hct-36.8 MCV-97 MCH-33.1* MCHC-34.0 RDW-13.2 Plt ___ ___ 05: 20AM BLOOD Neuts-86.8* Lymphs-9.4* Monos-3.4 Eos-0.3 Baso-0.2 ___ 05: 20AM BLOOD Glucose-132* UreaN-17 Creat-0.7 Na-139 K-4.2 Cl-101 HCO3-27 AnGap-15 ___ 05: 20AM BLOOD Calcium-9.3 Phos-4.7* Mg-1.7 ___ 05: 32AM BLOOD Lactate-2.3* ----- ___ 05: 49AM BLOOD CA125-138* ----- DISCHARGE LABS: ___ 05: 56AM BLOOD WBC-5.0# RBC-3.35* Hgb-11.4* Hct-32.3* MCV-96 MCH-34.0* MCHC-35.3* RDW-13.2 Plt ___ ___ 05: 56AM BLOOD Plt ___ ___ 05: 56AM BLOOD Glucose-79 UreaN-8 Creat-0.6 Na-142 K-3.8 Cl-104 HCO3-26 AnGap-16 ___ 05: 56AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.6 <MEDICATIONS ON ADMISSION> - Celexa 30mg daily <DISCHARGE MEDICATIONS> 1. Citalopram 30 mg PO DAILY 2. Bisacodyl 10 mg PR HS: PRN constipation RX *bisacodyl [Dulcolax (bisacodyl)] 10 mg 1 suppository(s) rectally daily Disp #*30 Suppository 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 for a recurrent small bowel obstruction. You were treated with bowel rest. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: - Take your medications as prescribed. - Follow the dietary instructions provided by Nutrition Services. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ was admitted to the gynecologic oncology service for management of a recurrent small bowel obstruction. . She was made NPO on admission and declined placement of a nasogastric tube. Her pain and nausea were controlled with IV dilaudid and zofran. She did not require pain medications or antiemetics once NPO. Her diet was slowly advanced without difficulty to a regular diet by hospital day 3. . She declined a social work visit during this admission. . By hospital day 3, her nausea and vomiting had resolved and she was tolerating a regular diet. She was discharged home in stable condition with outpatient follow-up scheduled.
| 1,182
| 135
|
10265464-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> intrauterine fetal demise <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and evacuation under ultrasound guidance <HISTORY OF PRESENT ILLNESS> ___ G2P___ with intrauterine fetal demise at 25 weeks diagnosed on ultrasound. She was counseled on her options including induction of labor vs surgical management and she elects to proceed with D&E. <PAST MEDICAL HISTORY> depression and schizophrenia <SOCIAL HISTORY> ___ <FAMILY HISTORY> Uncle with DS. <PHYSICAL EXAM> On day of discharge: afebrile, VSS Gen: NAD Pulm: normal work of breathing Abd: soft, nondistended, appropriate TTP Ext: no edema <PERTINENT RESULTS> ___ 04: 31PM ACA IgG-1.6 ACA IgM-8.2 ___ 04: 31PM FETAL HGB-0 ___ 04: 31PM ___ ___ 04: 31PM ___ PTT-24.1* ___ ___ 04: 31PM WBC-16.4* RBC-4.06* HGB-14.2 HCT-39.5 MCV-97 MCH-35.0* MCHC-35.9* RDW-13.6 ___ 04: 31PM ___ ___ 04: 31PM TSH-1.6 ___ 04: 31PM URIC ACID-6.0* ___ 04: 31PM ALT(SGPT)-12 LD(LDH)-231 ___ 04: 31PM GLUCOSE-74 CREAT-0.6 ___ 04: 32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR ___ 04: 32PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H: PRN pain do not drive while taking this medication RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every 4 hours Disp #*15 Tablet Refills: *0 3. Methylergonovine Maleate 0.2 mg PO TID Duration: 3 Days RX *methylergonovine 0.2 mg 1 tablet(s) by mouth every 8 hours Disp #*8 Tablet Refills: *0 4. Lorazepam 0.5 mg PO Q4H: PRN anxiety RX *lorazepam 0.5 mg 1 tablet(s) by mouth every 4 hours Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> intrauterine fetal demise <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 in the hospital for a procedure called dilation and evacuation after suffering a pregnancy loss. You are now safe to go home. Please follow these instructions: - Please keep all followup appointments -
|
Ms. ___ was admitted after dilation and evacuation of an intrauterine fetal demise. Please see the operative report for full details. Her post-operative course was uncomplicated and she was ambulating, tolerating a regular diet and voiding and she was discharged home in stable condition on post-operative day 0.
| 848
| 63
|
10266621-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine <ATTENDING> ___ <CHIEF COMPLAINT> fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curettage, supracervical hysterectomy, bilateral salpingectomies, lysis of adhesions and cystoscopy for symptomatic fibroid uterus and endometriosis <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 0 with a long history of a known fibroid uterus. The patient initiated care with me on ___. Prior to that initial visit, she had seen Dr. ___, a gynecologist here at ___. The patient presents to discuss definitive therapy for her fibroid uterus. Most recently, she had urinary retention because of the compression of her fibroid uterus on her bladder. This was resolved by her having an indwelling catheter for 48 hours. On ___, she was seen by nurse practitioner ___, who removed that catheter. Patient now without uribary symptoms. The patient presents today for an endometrial biopsy. On ___, an ultrasound showed an enlarged fibroid uterus measuring 13.8 x 8.1 x 10.3 cm, which has increased in size from her ___, ultrasound when it was 10.5 x 8.9 x 10.3 cm. There were multiple masses consistent with fibroids. The largest fibroid located in the lower uterine segment which measured 7.8 x 6.2 x 7.9 cm, which has increased in size. The endometrium was distorted by fibroids and could not be adequately assessed. The right ovary was normal. A small left hydrosalpinx was demonstrated. A cyst containing internal low-level echos consistent with a known endometrioma was demonstrated on the left. This measured 2.3 x 1.9 x 0.9 cm. There was no free fluid. These findings were discussed with the patient. <PAST MEDICAL HISTORY> OB/GYN HISTORY: She has regular menses, has never been pregnant. Denies any history of abnormal Pap smears or sexually transmitted infections. PAST MEDICAL HISTORY: Noncontributory. OPERATIVE HISTORY: In ___, repair of ruptured ovarian cyst and a prophylactic appendectomy; in ___, a left knee ACL repair; ___, removal of cavernous hemangioma in her left triceps. She has never had a bad reaction to anesthesia. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother, hypertension. Dad, history of cardiovascular disease status post quadruple bypass valve replacement. Paternal uncle, heart disease. Maternal aunt, multiple cancers. Paternal aunt, diagnosed with ovarian cancer at age ___. <PHYSICAL EXAM> OFFICE PHYSICAL EXAMINATION: GENERAL: This is a well-developed, well-nourished woman, in no apparent distress. VITAL SIGNS: Blood pressure 104/67, weight 115 and BMI 21. ABDOMEN: Soft, nondistended and nontender. There was a palpable mass approximately three fingerbreadths below the umbilicus, nontender, consistent with a known fibroid uterus. There was no inguinal lymphadenopathy. PELVIC: Normal female external genitalia with normal Bartholin, urethral and Skene's glands. The vaginal vault had a normal-appearing discharge. There were no lesions. Cervix, nulliparous, without cervical motion tenderness. Uterus approximately 14-16 cm in maximal vertical dimension. There was a large posterior fibroid, uterus not very mobile on exam. Due to the large pelvic abdominal mass, assessment of her adnexa was incomplete. There were no obvious masses and she was nontender lateral to the uterus. 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 with staples 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. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing dilation and curettage, supracervical hysterectomy, bilateral salpingectomies, lysis of adhesions and cystoscopy for symptomatic fibroid uterus and endometriosis. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid. She had post operative nausea and vomiting that resolved with medication and slow diet. She had a reassuring abdominal exam. 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/acetaminophen/ibuprofen. 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. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H not to exceed 4 grams in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*1 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not drink alcohol or drive RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: symptomatic fibroid uterus and endometriosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
| 1,164
| 472
|
10267099-DS-7
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> fevers <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy <HISTORY OF PRESENT ILLNESS> ___ yo G4P4 presents with 4 days of fevers. Pt also reports anorexia and weakness for approx 1 month. Has been tolerating liquids. +nausea for last 4 days. Occasional HA, unilateral. + RLQ pain, waxing/waning, not taking any pain medications, unchanged for 1 months. + lightheadedness since fever started. Pt reports foul smelling brown discharge for 1 month since uterine artery embolization ___ ___. Was diagnosed with BV and was treated with flagyl a few wks ago. The flagyl did not alter her discharge. Denies change in vision, confusion, vertigo, CP, SOB, diarrhea, leg pain/swelling, dysuria, hematuria, urinary incont. + constipation, chronic, BM q ___ days. <PAST MEDICAL HISTORY> PGYN: pt states had medication induced menses just prior to UAE. otherwise does not thinks has had menses in greater than ___ yr. has not been on hormonal supplementation. Denies hx of STIs. PAP ___ nl. Denies hx abnl PAP. Has not been sexually active in yrs secondary to husband's health problems. POB: G4P4 SVD x 4. uncomplicated pregnancies and deliveries. PMH: benign <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> O: 102.8 ___ 16 96%RA 102.1 98 120/70 16 100%RA NAD, able to move comf in bed, back diaphoretic, does not appear uncomf CTAB RRR no CVAT bilat abd soft, ND, mild uterine fundal tend, most tend in RLQ to R of uterus. -R/G ___ NE SSE with brown tinged white discharge. approx 4 cc in vault. no lesions identified bimanual. no bladder tend. no CMT. mild uterine tend. significant R pelvic wall tend. ovaries not palp bilat. no L adnexal tend. uterus mobile, extends to umbilicus. <PERTINENT RESULTS> ___ 07: 43AM GLUCOSE-101 UREA N-5* CREAT-0.7 SODIUM-141 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14 ___ 07: 43AM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-2.2 ___ 07: 43AM WBC-7.9 RBC-3.57* HGB-9.2* HCT-28.1* MCV-79* MCH-25.8* MCHC-32.8 RDW-13.7 ___ 07: 43AM NEUTS-71.3* ___ MONOS-8.5 EOS-0.4 BASOS-0.2 ___ 07: 43AM PLT COUNT-379 ___ 01: 22AM COMMENTS-GREEN TOP ___ 01: 22AM LACTATE-0.7 ___ 12: 11AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12: 11AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.0 LEUK-TR ___ 12: 11AM URINE ___ BACTERIA-MOD YEAST-NONE ___ 12: 11AM URINE MUCOUS-MOD ___ 09: 35PM GLUCOSE-107* UREA N-6 CREAT-0.9 SODIUM-138 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15 ___ 09: 35PM estGFR-Using this ___ 09: 35PM WBC-9.2 RBC-3.98* HGB-10.4* HCT-31.1* MCV-78* MCH-26.2* MCHC-33.5 RDW-13.5 ___ 09: 35PM NEUTS-69.7 ___ MONOS-7.0 EOS-0.5 BASOS-0.2 ___ 09: 35PM PLT COUNT-407 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp: *40 Tablet(s)* Refills: *1* 2. Percocet ___ mg Tablet Sig: One (1) Tablet PO every ___ hours. Disp: *20 Tablet(s)* Refills: *0* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus, fevers s/p uterine artery embolization, degenerating fibroids Post op temp 101 x 1 <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your physician with any of the following symptoms: fever (temperature greater than 101) chest pain shortness of breath redness/pain/drainage from your incision site nausea/vomiting to the point that you are unable to eat anything
|
Ms. ___ was admitted from the ED for a four day history of fevers. This was thought to be secondary to her degnerating fibroids s/p uterine artery embolization on ___. She was also started on IV antibiotics (Gentamycin and Clindamycin) for questionable endometritis according to the CT scan reading in the ED. On HD #2, she underwent an open total abdominal hysterectomy for her degenerating fibroid uterus. Please see operative note for details. Initially she had some post-op oliguria which resolved with a couple of IV fluid boluses. She also had some mild nausea/vomiting on POD1, which also resolved on its own after she was made NPO for one evening. She had a post-op fever in the PACU and was also started on Ampicillin in addition to the Gent and Clinda. Afterwards, she had no more episodes of fever and remained on the antibiotics for 24 hours post-op. Blood cultures were also taken when she spiked a fever, which were pending at the time of discharge.Blood cultures that were drawn in the ED came back negative. Otherwise she did very well and was discharged home on POD 2 as she was tolerating a regular diet, on oral pain medications and ambulated without difficulty or assistance.
| 1,276
| 266
|
10270602-DS-14
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 at 22w6d GA with pelvic pain since this morning. Describes two types of pain - one is like her period, and the other is an exacerbation of her hip flexor tendonitis pain. She reports that the hip flexor pain in chronic, and she previously took narcotics and had ___ for this. However, she has not been seen for this for approximately ___ years. She has also been experiencing other cramping pain for the past ___, which feels like a period. This pain occurs at night, but normally resolves after taking APAP. The pain did not resolve with APAP this morning, however, and so she presenting to the ED for evaluation. She denies VB, LOF. +AFM. Had 'dry heaves' this AM, but no current N/V. No fevers/chills. Was given 1mg dilaudid in the ED with moderate effect. <PAST MEDICAL HISTORY> PNC: ___ ___ by ultrasound Labs: Rh+/RI/HbsAg neg/RPRNR/HIV neg Genetics screening: declined - U/S on ___ for fetal EF and ?VSD showed an anterior placenta previa, expected to resolve PObHx: G1 PGynHx: No history of LEEP or other cervical procedure PMHx: asthma, ? PCOS with neg w/u per pt, anxiety/OCD PSHx: shoulder surgery <SOCIAL HISTORY> Denies ___, works as ___ <PHYSICAL EXAM> Admission Exam PE: 97.6, HR86, RR18, 100% General: NAD. Does not appear intoxicated or to be having regular painful CTX. Abdomen: abdomen tender throughout, no rebound or guarding, RLQ tenderness > LLQ and rest of abdomen SSE: Normal external anatomy, cervical os 0.5cm dilated/long, no blood in vaginal vault. SVE: deferred TOCO: flat Disharge Exam AVSS NAD, AOx3 Abd: soft, mildly tender, no rebound/guarding Ext: wwp <PERTINENT RESULTS> ___ 11: 45AM GLUCOSE-103* UREA N-9 CREAT-0.5 SODIUM-135 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-20* ANION GAP-15 ___ 11: 45AM estGFR-Using this ___ 11: 45AM WBC-9.2 RBC-4.04* HGB-12.2 HCT-34.3* MCV-85 MCH-30.1 MCHC-35.6* RDW-13.0 ___ 11: 45AM NEUTS-85.3* LYMPHS-11.3* MONOS-2.6 EOS-0.6 BASOS-0.1 ___ 11: 45AM PLT COUNT-172 ___ 11: 35AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 11: 35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-8.5* LEUK-NEG ___ 11: 35AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 11: 35AM URINE AMORPH-OCC ___ 11: 35AM URINE MUCOUS-RARE <MEDICATIONS ON ADMISSION> albuterol, qvar, fluoxetine, fluticasone propionate, fluticasone salmetrol, montelukast, zofran prn, pnv <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler 2 PUFF IH Q4H: PRN shortness of breath 2. Fluoxetine 20 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU BID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. ___ 10 mg PO DAILY 6. Prenatal Vitamins 1 TAB PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO Q6H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q6hrs Disp #*10 Tablet Refills: *0 8. Diazepam 5 mg PO Q12H: PRN pain/anxiety Duration: 1 Dose RX *diazepam 2 mg ___ tablets by mouth every 12 hrs Disp #*30 Tablet Refills: *0 9. Diazepam 5 mg PO ONCE: PRN pain, insomnia <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 23wks abdominal pain left hip flexor pain <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for observation due to abdominal pain and hip flexor pain. Your clinical presentation was most consistent with musculoskeletal pain. You were given medications to control your pain. You had no obstetric concerns during this admission.
|
___ G1 h/o hip flexor tendonitis and abdominal pain who was admitted to antepartum ___ for monitoring. Her repeat WBC the next day normal. She was given tylenol around the clock and oxycodone. Her pain was thought to be likely MSK related. On ___ patient endorsed that dying was better than pain but repeatedly denied SI and initially had a sitter. Ortho saw her on ___ and thought that her differential included flexor tendinitis, femoralacetbular impingement, pelvic musculosketal strain or non-orthopaedic etiology including hernia. Given that this was a chronic issue, ortho recommended outpatient f/u which was scheduled on ___. Patient in stable condition upon discharge with follow up scheduled.
| 1,198
| 158
|
10271299-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Abnormal uterine bleeding, pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy with extensive lysis of adhesions <HISTORY OF PRESENT ILLNESS> ___ yo G5P3 with a long history of AUB and pelvic pain. Underwent an operative hysteroscopy with myomectomy and curettage and Mirena IUD placement in ___. Patient continued to experience abnormal bleeding. She was given a dose of Lupron but continued to have pain. The patient desired definitve management in the form of TLH with removal of bilateral fallopian tubes and preservation of ovaries if normal. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: As above, otherwise noncontributory. OB/GYN HISTORY: Menarche at 9. She is sexually active, uses condoms. She has used Mirena in the past and has persistent spotting. She has had five pregnancies, three cesarean deliveries, all at the ___, ___, ___, ___. She had an ectopic pregnancy in ___, remote history of TAB, all without complications. SURGICAL HISTORY: Cesarean delivery x 3, ectopic pregnancy. She has had her gallbladder removed in ___ and arthroscopic knee surgery in ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: Mother, breast cancer. Father, esophageal cancer, hypertension, heart disease. <PHYSICAL EXAM> On day of discharge: A&O x3 NAD CTAB RRR Ab: ND/NT; incision sites c/d/i ___: ne/nt/no cords GU: minimal spotting on pad <MEDICATIONS ON ADMISSION> Medications - Prescription ETODOLAC - etodolac 400 mg tablet. 1 tablet(s) by mouth twice daily for 7 days then as needed for pain LEUPROLIDE [LUPRON DEPOT] - Lupron Depot 3.75 mg intramuscular syringe kit. 3.75 mg IM monthly TERBINAFINE - terbinafine 250 mg tablet. 1 (One) tablet(s) by mouth once a day - (Prescribed by Other Provider) Medications - OTC MULTIVITAMIN [DAILY MULTI-VITAMIN] - Daily Multi-Vitamin tablet. 1 tablet(s) by mouth once a day - (OTC) <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID Take when taking oxycodone to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain Take with food. Do not take more than prescribed. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain Do not drive or drink with this medicine. Do not take more than 4000mg acetaminophen per day. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every ___ 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 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * 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 ___.
|
Ms ___ underwent an uncomplicated total laparoscopic hysterectomy with lysis of extensive adhesions; see operative report for details. She had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating and voiding without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
| 1,119
| 71
|
10272082-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> codeine / Cipro <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain, diffuse sarcoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion, ___ biopsy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with likely diffuse sarcoma with metastasis to bone and chest, unclear etiology, admitted for pain control after ___ abdominal mass biopsy. She originally presented in ___ with intermittent abdominal pain and underwent MRCP revealing 1.7 cm mucinous cystic lesion in the pancreatic body. Plan was made to follow patient with imaging surveillance at ___. However, she represented in ___ with worsening lower abdominal pain, and underwent repeat MRCP indicating diffuse omental nodularity without evidence of a visible primary. A CT chest on ___ showed multiple small pulmonary nodules measuring up to 6 mm, suspicious for metastases. A CT abd/pelvis on ___ showed bilateral ovarian enlargement (4.3 x 5.1 cm on the left and 4.4 x 4.9 on the right). There were multiple omental lesions, the largest being a 6.0 x 7.7 x 13.4 cm lesion on the anterior abdominal wall. There was also an incompletely imaged left femoral thrombus. She was started on treatment for left femoral thrombus with therapeutic lovenox at that time. On ___ she underwent a biopsy of the anterior abdominal wall mass which showed a malignant poorly differentiated neoplasm, favoring a high grade sarcoma. Multiple immunohistochemistry studies were performed, however the primary source of the sarcoma was not determined and there was not sufficient cell mass to allow any further studies. Repeat MRI on ___ showed large bilateral solid and cystic adnexal masses as well as metastases in the cul-de-sac and anterior abdominal wall. There was a lesion in the right greater trochanter suspicious for metastatic osseous disease. There were multiple prominent pelvic lymph nodes. Based on these findings, decision was made to proceed with biopsy of a separate lesion for further histologic evaluation. On ___, she experienced an episode of severe hypoglycemia to blood glucose level in the ___ in the setting of Lantus 50 units QAM and poor PO intake, requiring hospitalization. She was also found to have an acute-on-chronic kidney injury (Cr to 2.2 from baseline of 1.9) that improved with IV fluids. Due to ___, she was transitioned from lovenox to a heparin gtt with Coumadin bridge. For the past 10 days, she has been on Coumadin 5mg daily. She stopped her Coumadin anticoagulation 4 days ago for planned ___ biopsy. Patient presented today for outpatient biopsy procedure, but was found to have supratherapeutic INR of 2.6. She also complained of ___ abdominal pain. She complains of a sensation of pressure on her pelvic floor. She is taking oxycodone every 4 hours for pain. The pain escalates to ___ with movement. She also reports mild nausea, particularly with meals, though she does feel she has been tolerating adequate PO. She denies vomiting. No chest pain, SOB, urinary symptoms. No vaginal bleeding. <PAST MEDICAL HISTORY> suspected Endometrial Stromal Sarcoma s/p Nissen fundoplication, distal gastrectomy with anastomosis s/p cholecystectomy incisional hernia DVT IDDM GERD Pancreatic cyst <SOCIAL HISTORY> ___ <FAMILY HISTORY> Grandfather had MI and DM, Grandmother had DM, Aunt had esophageal cancer <PHYSICAL EXAM> 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 <PERTINENT RESULTS> ___ 12: 15PM ___ <MEDICATIONS ON ADMISSION> Cybalta, Lovenox, lantus, reglan, metoprolol, pantoprazole, simvastatin, benadryl <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *2 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills: *0 4. Warfarin 2.5 mg PO DAILY RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *0 5. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain. Do not take while driving or drinking. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 6. Acetaminophen 1000 mg PO Q8H: PRN pain Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth three times a day Disp #*50 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> sarcoma, DVT, 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 gynecologic oncology service after undergoing an interventional radiology-guided abdominal mass biopsy. You also received a transfusion of fresh frozen plasma and of packed red blood cells. You were seen by hematology due to your DVT, and were put back on Coumadin on ___ for treatment. You have recovered well and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. You are being discharged on 2.5mg daily Coumadin. Your INR labs will be followed by Dr. ___. You should present to his office in ___ days for an INR lab check. * 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. You should drink a Glucerna Shake three times a day to help with nutrition. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
|
Ms. ___ is a ___ female with likely diffuse sarcoma with metastasis to bone and chest, unclear etiology, admitted to the gynecological oncology service for pain control after ___ abdominal mass biopsy. Her pain was well-controlled on oral oxycodone and acetaminophen. Palliative care was consulted to help guide pain management, and recommended continued use of oxycodone and acetaminophen for pain control. Nutrition was also consulted during Ms. ___ admission, and recommended three times daily Glucerna shakes to assist with adequate nutrition. Ms. ___ abdominal mass biopsy was uncomplicated. She did require a 2 unit transfusion of fresh frozen plasma before her biopsy due to elevated INR. In terms of her anticoagulation for her DVT, which was diagnosed in ___, Ms. ___ received prophylactic heparin on ___ after her ___ biopsy. She also received prophylactic heparin on ___. Her INR remained in therapeutic range. Hematology was consulted to help guide her anticoagulation plan. They spoke with Dr. ___ PCP who manages her anticoagulation outpatient, and recommended restarting Coumadin 2.5 mg daily. This was restarted on ___, and plan was made for patient to continue to follow-up with Dr. ___ outpatient anticoagulation management. Patient was also found to be anemic with hematocrit of 24.4 during her hospitalization. This was thought to be due to nutritional deficits on top of a personal history of anemia. She received a 2 unit packed red blood cell transfusion with appropriate rise in hematocrit. On ___, patient was doing well and was discharged to home with plan for outpatient follow-up.
| 1,490
| 354
|
10273267-DS-9
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Niaspan Extended-Release / simvastatin <ATTENDING> ___. <CHIEF COMPLAINT> endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oopherectomy <HISTORY OF PRESENT ILLNESS> ___ is a ___ yo G0 who presented to her primary gynecologist with complaints of postmenopausal bleeding. An exam for biopsy was attempted, but unable to be performed. Patient was then referred to Dr. ___ for further evaluation. Dr. ___ was able to perform an endometrial biopsy, which showed "Endometrial adenocarcinoma, endometrioid-type, with mucinous differentiation, FIGO grade 1 (of 3), associated with endometrial intraepithelial neoplasia (atypical hyperplasia)." <PAST MEDICAL HISTORY> Past Obstetrical History: G0. Past Gynecologic History: Age of menarche ___, regular periods every 28 days lasting five to seven days until the age of ___. No further bleeding until very recently with cyclical light bleeding, no pain with full bladder or bowel movement. She is virginal. She has never had a Pap smear. She has had normal mammograms. No history of infection. No contraception. <PAST MEDICAL HISTORY> obesity, hypertension, hypercholesterolemia, hypothyroidism Past Surgical History: laparoscopic cholecystectomy, umbilical hernia repair (unsure if mesh) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Both her parents died from heart disease in their ___. Her father's mother was diagnosed with breast cancer at age ___. Patient reports that her paternal grandmother died from an anesthesia complication, ? pseudocholinesterase deficiency, however she had her cholecystectomy without difficulty. <PHYSICAL EXAM> Admission <PHYSICAL EXAM> General: well appearing female in no apparent distress, alert and oriented Lungs: clear to auscultation bilaterally, good inspiratory effort, no wheezing/rales/rhonchi CV: regular rate and rhythm, no murmurs/rubs/gallops Abd: soft, +bowel sounds, non-tender, non-distended, no R/G, scar from umbilicial hernia repair and from lsc chole port sites seen Pelvic: deferred Discharge <PHYSICAL EXAM> VSS General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-tender, non-distended, port site incisions c/d/i <PERTINENT RESULTS> ___ 08: 03AM BLOOD WBC-12.2*# RBC-4.03* Hgb-12.5 Hct-37.1 MCV-92 MCH-31.2 MCHC-33.8 RDW-13.1 Plt ___ ___ 08: 03AM BLOOD Neuts-80.5* Lymphs-13.0* Monos-6.2 Eos-0.1 Baso-0.2 ___ 08: 03AM BLOOD Glucose-104* UreaN-12 Creat-0.6 Na-140 K-4.3 Cl-104 HCO3-26 AnGap-14 ___ 08: 03AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.4 Pathology: Uterus, cervix, bilateral fallopian tubes, and ovaries, total hysterectomy and bilateral salpingo-oophorectomy: - Endometrial adenocarcinoma, endometrioid type, FIGO grade 1 (of 3) with mucinous differentiation, see synoptic report. - Leiomyomata and lipoleiomyoma, up to 1.2 cm. <MEDICATIONS ON ADMISSION> ezetimibe, hydrocholorothiazide, levothyroxine, vitamin D, fish oil <DISCHARGE MEDICATIONS> 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *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> ___ . 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 >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
|
___ was admitted to the gynecologic oncology service after undergoing robot-assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and toradol. Her diet was advanced without difficulty and she was transitioned to PO percocet and ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,378
| 161
|
10274998-DS-8
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Fibroid uterus associated with severe menorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy with left salpingo-oopherectomy exploratory laparotomy with evacuation of hemoperitoneum blood transfusion <HISTORY OF PRESENT ILLNESS> ___ G2P2 presents for total abdominal hysterectomy. The pt has a hx of an enlarged fibroid uterus (~20cm) and severe menorrhagia with resultant blood-loss anemia. She has been counseled regarding options for management, and is certain that she would like to proceed with operative management. She was referred to the minimally invasive gynecologic surgery service at ___ to assess the possibility of a laparoscopic approach, but given the size and location of her fibroids and her body habitus was counseled that the chance of conversion to an open procedure was quite high. She has had endometrial sampling that showed no evidence of malignancy. She is interested in a total hysterectomy, including removal of the cervix, with ovarian preservation as long as the ovaries appear normal intraop. <PAST MEDICAL HISTORY> ObHx: SVD x2 GynHx: reg menses, LMP ___, no abnl Paps, distant hx HSV, not sexually active MedHx: obesity, ?HTN, anemia SurgHx: none <SOCIAL HISTORY> ___ <FAMILY HISTORY> Multiple relatives with heart disease, DM, and HTN. <PHYSICAL EXAM> BP 140/80, 233# Gen NAD Chest CTAB Heart RRR Abd soft, obese, NT, firm mass palpable at umb c/w known fibroid uterus Pelvic nl EGBUS; nl vagina, physiologic discharge, no lesions; nl cervix, closed os, no lesions or discharge; enlarged uterus to umbilicus, multiple masses c/w fibroids; no adnexal masses or tenderness; no CMT, cul-de-sac or forniceal tenderness <MEDICATIONS ON ADMISSION> Prilosec, iron <DISCHARGE MEDICATIONS> 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain: maximum daily Tylenol (acetaminophen) is 4000mg, each Percocet contains 325mg Tylenol (acetaminophen). Disp: *60 Tablet(s)* Refills: *0* 2. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (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) as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp: *30 Tablet Sustained Release 24 hr(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus chronic blood loss anemia likely undiagnosed hypertension possible sleep apnea possible insulin resistance <DISCHARGE CONDITION> stable baseline mental status ambulatory <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.
|
Ms. ___ was admitted ___ after a total abdominal hysterectomy and bilateral salpingo-oopherectomy. She received 4 units of packed red blood cells (pRBCs) intra-operatively for a pre-operative hct of 20. Her post-operative hct was 35. Please see operative note for full details. . On the evening of POD 0, she had decreased urine output. A hematocrit was checked and found to be 21. This value was re-sent for confirmation. Given the sudden drop in hct, patient was consented for an exploratory laparotomy. Re-exploration revealed approximately 1250 cc of intra-abdominal clot. Please see operative note for full details. She was again given 4 units pRBCs intraoperatively for a total of 8 units during her hospitalization. . On POD 1 from TAH-BSO/POD 0 from ex-lap, pt felt subjectively much better. Her hematocrit was checked serially, initially every 4 hours and gradually spaced until it was stable at 28 to 29. On the morning of POD ___, she was noted to be tachycardiac to 108. An EKG revealed sinus tachycardia with lateral wall artifact and questionalble changes in the inferior leads. Pre-operative and current EKGs were faxed to cardiology for review. Her abdominal exam remained stable but her extremity exam was notable for an intermittent left ___ sign. LENIs were negative for clot. Enzymes were sent to rule out MI, which were negative times three. A TTE was recommended by cardiology. This was significant for mild symetric left ventricular hypertrophy and mild left atrial dilitation. A CT angiogram was obtained to rule out pulmonary embolism; no clot was seen in the pulmonary vasculature. She was kept on telemetry but her tachycardia resolved and this was discontinued the following day on POD ___. . On the evening of POD ___, she developed hypertensive urgency with blood pressures in the 180s/80s. She was given 5mg IV lopressor x 2 but her blood pressure did not respond to these medications. A medicine consult was called. Medicine assessed that she was fluid overloaded and recommended 10 mg Lasix IV x 1. This was administered with good effect. She had a urine output of 1000 cc in the following hour and her blood pressure fell to 140/80. At this time, metoprolol 25 mg po bid was initiated for cardio-protection and treatment for hypertension. Throughout her hospitalization, her blood pressures ranged from 130-170/60-90. Per medicine, her goal pressures during hospitalization were 140-160/80-90. She remained asymptomatic. She was strongly encouraged to follow-up with her primary care physician for treatment of likely undiagnosed hypertension. . Given her obesity, fingerstick blood glucose values were monitored throughout her hospitalization. Her fasting values were slightly over 100 and her post-prandial values ranged from 140-190. She was placed on an insulin sliding scale. She was encouraged to follow-up with her primary care physician for possible undiagnosed insulin resistance. . She was ambulating and taking a regular diet. She was discharged home in stable condition on POD ___.
| 1,017
| 699
|
10278210-DS-4
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> PIH eval <MAJOR SURGICAL OR INVASIVE PROCEDURE> - <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 32+2 WGA for ___ eval. Pt reports slight headache, has not taken Tylenol. Pt woke with chest pain at 0400, reports chest pain intermittent, feels like pressure around chest. Reports some epigastric pain. Pt reports some cramping in RUQ, feels smiliar to ctx. Reports some discharge but denies vaginal bleeding, contractions and leaking of fluid vaginally. +FM this morning <PAST MEDICAL HISTORY> PNC: 1)Dating: EDC ___ by LMP 2)Routine testing: O+, Ab neg 3)Issues with this pregnancy: GDMA1- saw ___ previously for monitoring. labile BP's prior to pregnancy OB Hx: G1P0 Gyn Hx: h/o HPV w/HGSIL and LEEP PMH: migraines Surg Hx: LEEP ___ Social Hx: denies tobacco/etoh/drugs <SOCIAL HISTORY> Denies ___ ___ Exam: Admission PE: Gen: NAD, speaking without difficulty VS: BP initial 150/103, has since come down to 120's/80's x multiple BPs HR 89 R 14, O2sats: 99% RA Cardiac sounds WNL, LSCTAB Abd: gravid, soft, nontender No edema noted EFM: 155 ___, mod variability, +accels, no decels, reactive. Toco: occasional ctx pt feels a little crampy BPP ___, AFI 12 cm, cephalic, placenta anterior, no previa, fetal cardiac motion noted. <PERTINENT RESULTS> ___ 11: 09AM BLOOD WBC-11.2* RBC-3.88* Hgb-11.6* Hct-33.9* MCV-87 MCH-29.8 MCHC-34.1 RDW-13.5 Plt ___ ___ 11: 09AM BLOOD Creat-0.5 ___ 11: 09AM BLOOD ALT-17 ___ 11: 09AM BLOOD UricAcd-3.2 ___ 11: 09AM URINE Color-Straw Appear-Clear Sp ___ ___ 11: 09AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12: 58PM URINE pH-6 Hours-24 Volume-3700 Creat-41 TotProt-6 Prot/Cr-0.1 ___ 12: 58PM URINE 24Creat-___ 24Prot-222 <MEDICATIONS ON ADMISSION> PNV, ranitidine <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic hypertension, worsening migraine HAs <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> rest...pt to stop working
|
Ms ___ was admitted to the ___ service at 32 weeks gestational age with elevated blood pressures and feeling unwell (intermittent chest/RUQ pains). The symptoms resolved with admission and did not recur, and her exam and vital signs remained reassuring. She did not have any laboratory or clinical evidence of HELLP syndrome and her 24-hour urine protein collection excluded a diagnosis of preeclampsia. She was therefore discharged home with close followup and blood pressure monitoring.
| 734
| 98
|
10279665-DS-7
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Preterm Premature Rupture of Membranes <MAJOR SURGICAL OR INVASIVE PROCEDURE> spontaneous vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G3P2 at 33w6d called in from home for leaking since approximately 1500. Felt as if she were urinating on herself. In the evening she felt as if the leaking progressed to big gushes of fluid which prompted her presentation to triage. Here she reports continued leaking. Denies VB. +FM. No contractions or cramping. Prior to my evaluation the patient reported a large gush when standing up. PNC: - ___ ___ by ___ trimester ultrasound (confirmed) - Labs Rh+/Abs-/VI/HepC-/GC/CT-/Rub I/RPR NR/HBsAg-/HIV-/GBS- - Screening: declined - FFS: WNL, male - GTT: elevated, nl 3hr - U/S: ___, 5#4, 67% - Issues -- short interval pregnancy: SVD ___ ___, postplacental IUD placed after pregnancy, this pregnancy was not intended, patient desires BTL -- maternal obesity -- desires sterilization, ___ consent signed <PAST MEDICAL HISTORY> OBHx: - G3P2, SVD x 2, larger baby 6#12 GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: former smoker, PTSD, anxiety, epilepsy as a child, no meds since ___ years old PSH: L hand, tonsillectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> On admission VS: ___ 04: 10Temp.: 98.7°F ___ 04: 10Resp.: 18 / min ___ 04: 10BP: 138/80 (90) ___ ___: 105 ___ 04: 35MSpO2: 100% ___ 05: 10MSpO2: 100% ___ ___: 96 Gen: A&O, comfortable CV: extremities warm and well perfused PULM: no increased WOB Ext: no calf tenderness SSE: pooling, +nitrizine,+fern, approximately 1cm on visual inspection SVE: deferred Toco: unable to monitor due to habitus FHT 130/moderate variability/+accels/-decels TAUS: vertex On discharge: 24 HR Data (last updated ___ @ 2337) Temp: 97.9 (Tm 98.3), BP: 133/82 (115-133/69-82), HR: 97 (87-105), RR: 20 (___), O2 sat: 99% (97-99), O2 delivery: ra <PHYSICAL EXAM> General: NAD CV: RRR Resp: no respiratory distress Abd: soft, non-tender, fundus firm below umbilicus Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 06: 50AM BLOOD Hct-34.0 ___ 04: 39AM BLOOD WBC-19.3* RBC-4.31 Hgb-10.9* Hct-35.3 MCV-82 MCH-25.3* MCHC-30.9* RDW-15.9* RDWSD-47.5* Plt ___ ___ 05: 30AM BLOOD WBC-11.2* RBC-4.51 Hgb-11.1* Hct-36.9 MCV-82 MCH-24.6* MCHC-30.1* RDW-15.6* RDWSD-46.5* Plt ___ ___ 05: 30AM BLOOD Neuts-70.9 ___ Monos-6.3 Eos-0.6* Baso-0.2 Im ___ AbsNeut-7.91* AbsLymp-2.37 AbsMono-0.70 AbsEos-0.07 AbsBaso-0.02 ___ 05: 30AM BLOOD ___ ___ 04: 39AM BLOOD Creat-0.4 ___ 05: 30AM BLOOD Creat-0.5 ___ 04: 39AM BLOOD ALT-44* AST-36 ___ 05: 30AM BLOOD ALT-32 AST-23 ___ 04: 39AM BLOOD UricAcd-3.1 ___ 05: 30AM BLOOD UricAcd-3.7 <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild/Fever do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm premature rupture of membranes, spontaneous vaginal delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, ___ on the birth of your baby! You have recovered well and the team now feels that you are ready to go home. Please refer to your discharge packet and the instructions below: - Nothing in the vagina for 6 weeks (No sex, douching, tampons) - Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs - Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
|
Ms. ___ is a ___ year old G3P2 who was admitted to the antepartum service at 33w6d after being diagnosed with Preterm premature rupture of membranes (___). Pregnancy was complicated by morbid obesity (BMI 83). Regarding her PPROM, patient was noted to be nitrazine positive with positive pooling on sterile speculum exam. On ___, patient was noted to be visually closed to 1cm. Latency antibiotics were deferred given her gestational age . Patient was started on betamethasone and was made beta complete by ___. Her work up was negative for infection and toxicology. Recommendation was made to proceed with induction of labor. On ___, patient had a spontaneous vaginal delivery. Her postpartum course was complicated by a spinal headache, for which she received a blood patch. Her vaginal bleeding was within normal limits. She tolerated a regular diet, voided spontaneously without issue, and ambulated independently. Given her social situation, patient was set up with supports by social work in order to help her find housing. By postpartum day 2 after vaginal delivery, she was deemed stable for discharge with a plan set for postpartum follow up.
| 1,435
| 246
|
10281634-DS-8
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> codeine <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> IUD removal ___ <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, minimally TTP, no rebound/guarding Ext: mild b/l calf TTP. no palpable cords, erythema, or edema <PERTINENT RESULTS> LABS -= ___ 02: 50PM BLOOD WBC-9.4 RBC-3.55* Hgb-10.3* Hct-31.7* MCV-89 MCH-29.0 MCHC-32.5 RDW-12.8 RDWSD-42.4 Plt ___ ___ 06: 08PM BLOOD WBC-11.0* RBC-4.13 Hgb-12.3 Hct-37.3 MCV-90 MCH-29.8 MCHC-33.0 RDW-13.2 RDWSD-43.2 Plt ___ ___ 02: 50PM BLOOD Neuts-73.8* Lymphs-14.6* Monos-10.7 Eos-0.0* Baso-0.3 Im ___ AbsNeut-6.91* AbsLymp-1.37 AbsMono-1.00* AbsEos-0.00* AbsBaso-0.03 ___ 06: 08PM BLOOD Neuts-83.3* Lymphs-10.3* Monos-5.3 Eos-0.4* Baso-0.2 Im ___ AbsNeut-9.18* AbsLymp-1.13* AbsMono-0.58 AbsEos-0.04 AbsBaso-0.02 ___ 06: 08PM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-134 K-4.7 Cl-97 HCO3-26 AnGap-16 ___ 06: 08PM BLOOD ALT-13 AST-20 AlkPhos-85 TotBili-0.4 ___ 06: 08PM BLOOD Lipase-25 ___ 02: 50PM BLOOD HBsAg-Negative ___ 02: 50PM BLOOD HIV Ab-Negative ___ 02: 50PM BLOOD HCV Ab-Negative ___ 08: 21PM BLOOD Lactate-1.0 ___ 09: 27PM URINE Color-Straw Appear-Clear Sp ___ ___ 06: 05PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 09: 27PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06: 05PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 09: 27PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-1 ___ 06: 05PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-12 ___ 03: 00AM URINE CT-NEG NG-NEG MICROBIOLOGY -= ___ 6: 05 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. >100,000 CFU/mL. ___ 8: 15 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 8: 20 pm BLOOD CULTURE Blood Culture, Routine (Pending): Time Taken Not Noted Log-In Date/Time: ___ 9: 27 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 2: 50 pm SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. IMAGING -= ___ CT Scan Final Report INDICATION: ___ with LLQ abdominal pain, feverNO_PO contrast// evaluate for diverticulitis or other intra-abdominal proces TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,046 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. The stomach is otherwise unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Scattered diverticular noted in the colon, particularly the sigmoid without evidence of acute diverticulitis. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is trace free fluid in the pelvis. REPRODUCTIVE ORGANS: IUD is identified within the uterus. The right adnexae is unremarkable. There is an oblong cystic structure in the left adnexum measuring 5.6 by 2.9 by 3.4 cm. Given oblong configuration, this may represent a hydrosalpinx. The left adnexae is otherwise unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Sclerosis surrounding the SI joints, more exuberant on the iliac side bilaterally. Moderate degenerative changes seen at the hips bilaterally. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Oblong cystic structure in the left adnexa which given configuration may represent a hydrosalpinx. Consider dedicated exam with pelvic ultrasound, the acuity of which can be determined clinically. 2. Diverticulosis without diverticulitis. 3. Sclerosis abutting the SI joints bilaterally which may represent sacroiliitis of versus osteitis condensans ilii. ___ Pelvic US Final Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman with abdominal pain, fevers// evaluate oblong structure seen on CT a/p, ?evidence of PID Has a Mirena IUD, distant LMP TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: CT of the abdomen and pelvis from ___ at 20: 55 FINDINGS: The uterus is anteverted and measures 7.8 x 3.9 x 5.5 cm. The endometrium is homogenous and measures 4 mm. The IUD was demonstrated within the endometrial cavity. The IUD appears satisfactorily placed. The left ovary measures 5.3 x 3.2 x 3.0 cm. In the left adnexa, two cysts which measure 3.3 x 2.6 x 2.6 cm and 2.0 x 1.7 x 1.8 cm are not seen to definitely communicate, one of which may contain some debris and a represent a hemorrhagic cyst. The right ovary measures 3.0 x 1.9 x 1.5 cm an appears normal. There is a trace amount of free fluid. IMPRESSION: Left ovary containing physiologic cysts, one containing debris/hemorrhage.. ___ LENIS Final Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ G1P1 who presented with worsening abdominal pain, N/V/D, fevers, admitted for tx of presumed left pyosalpinx, now w/ calf pain// eval for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the tibial veins. Evaluation of the peroneal veins bilaterally was limited. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the Gynecology Service with abdominal pain and fevers. You were treated for a pyosalpinx (infection of the fallopian tubes) with IV antibiotics, and have been transitioned to oral antibiotics. Your IUD was removed. You were found to have a urinary tract infection. Please take the amoxicillin as prescribed to treat this infection. You have overall recovered well and are ready for discharge. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks. * 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 Contraception: * You elected to start the patch for birth control and are provided a prescription. Please change the patch once a week. * You may use the patch for three weeks in a row and then take one week off for a period, or you may elect to continuously use the patch. * You are eligible for another IUD should you choose one in 3 months. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ is a ___ yo G2P1 who presented with 3 days of abdominal pain, pelvic cramping, nausea/vomiting/diarrhea/fevers, and was found to have a left adnexal dilated structure on CT scan, with adnexal tenderness on CMT. She was admitted for treatment of a presumed left pyosalpinx. *) Left pyosalpinx: Pt defervesced after her initial presentation, with first afebrile time 18:20 on ___. She was started on IV Gentamicin/Clindamycin (___). Her WBC downtrended from 11 (___) to 9.4 (___). Given that pt remained afebrile and her pain improved, she was transitioned to PO Levofloxacin/Flagyl on ___. Her STI panel was negative for HIV, RPR, Hepatitis B, Hepatitis C, gonorrhea, and chlamydia. *) Bilateral lower extremity tenderness: On ___, pt reported bilateral calf tenderness. She underwent lower extremity venous ultrasounds which did not demonstrate any evidence of DVT. *) GBS UTI: Pt's urine culture grew group B strep. She was started on a 3-day course of amoxicillin (___-) to treat her UTI. *) Contraception: Pt underwent removal of her IUD at the bedside. She elected to use the patch for contraception. Pt was made aware of decreased efficacy of the patch for contraception in the setting of obesity. She remained interested in the patch as she uses this method primarily for cycle control. She is not currently sexually active. By hospital day #3, Ms. ___ was afebrile, her abdominal pain was minimal, she was tolerating a regular diet without nausea/vomiting, and she was ambulating independently. She was discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*1 2. Amoxicillin 500 mg PO Q12H RX *amoxicillin 500 mg 1 tablet(s) by mouth twice daily Disp #*5 Tablet Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*1 4. Levofloxacin 500 mg PO Q24H RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 5. MetroNIDAZOLE 500 mg PO BID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice daily Disp #*28 Tablet Refills:*0 6. Xulane (norelgestromin-ethin.estradiol) 150-35 mcg/24 hr transdermal 1X/WEEK RX *norelgestromin-ethin.estradiol [___] 150 mcg-35 ___ on the skin once a week Disp #*4 Patch Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Pyosalpinx Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
| 2,533
| 787
|
10282990-DS-8
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet <ATTENDING> ___ <CHIEF COMPLAINT> pelvic abdominal pressure, urinary urgency and frequency incontinence, discomfort, and dyspareunia due to uterine fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic myomectomy for symptomatic fibroid <HISTORY OF PRESENT ILLNESS> The patient is a ___ G1, P1-0-0-1, premenopausal, ___ Hispanic female, 6 months postpartum, status post a pregnancy complicated by preterm contractions and pain due to large fibroid uterus. Postpartum pelvic ultrasound (___) revealed the uterus measuring 7.3 cm with a large exophytic fundal fibroid measuring 12.9 x 10.6 cm. EMS 6 mm. Normal ovaries bilaterally. The patient predominantly complained of bulk symptoms including pelvic abdominal pressure, urinary urgency and frequency, incontinent discomfort, and dyspareunia. The patient opted for surgical management prior to trying to conceive again, given the pregnancy-related complications. She did desire future fertility. Informed consent was obtained for a robotically-assisted laparoscopic myomectomy, given the patient's desire for a minimal-invasive approach. <PAST MEDICAL HISTORY> OB History: G1, ___ 1. one term vaginal delivery ___, complicated by preterm contractions and pain due to large fibroid uterus, see above. Gynecologic History: Menarche age ___. LMP ___. PMP ___. At baseline, prior to pregnancy, the patient reports irregular menses to six months with one week of heavy flow consistent with menorrhagia. Lighter menstrual bleeding since delivery. The patient currently breastfeeding and with Mirena IUD placed two weeks ago (inserted ___ for contraception. She reports significant dysmenorrhea with menstrual bleeding and complains of back pain. She does complain of dyspareunia, pain with full bladder or bowel movement. Denies history of abnormal Pap smears. Last Pap smear ___, negative SIL. The patient has not required mammogram screening to date. She is sexually active, prefers opposite sex, currently has the Mirena IUD for contraception. Denies history of STDs. Medical Problems: 1. Fibroids. 2. Surgical history negative. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Reports a mother with hypertension and hypercholesterolemia. Denies any GYN cancer in the family such as breast, ovarian, cervical, vaginal, or colon cancer. Denies any other family medical conditions. <PHYSICAL EXAM> On arrival to floor: VS 99.4 112/68 121 18 99RA NAD Tachy, no murmur CTAB Abd soft, ND, approp TTP, dressing c/d/i GU min VB on pad Ext no edema, no calf tenderness <PERTINENT RESULTS> ___ 09: 00PM WBC-11.5*# RBC-3.75* HGB-11.8* HCT-34.1* MCV-91 MCH-31.4 MCHC-34.5 RDW-13.2 <MEDICATIONS ON ADMISSION> Pantoprazole 20mg QD <DISCHARGE MEDICATIONS> 1. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Please take medication with food. Disp: *60 Tablet(s)* Refills: *0* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid <DISCHARGE CONDITION> Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 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.
|
Ms. ___ underwent an uncomplicated robotic myomectomy for a symptomatic fibroid uterus; see operative report for details. Postoperatvely she was tachycardic in the 100-120s in ___ recovery room. Given the tachycardia, the patient was admitted overnight for observation. She was afebrile with excellent O2 saturations, no symptoms of PE, adequate urine production, well-controlled pain, and a stable hematocrit. Her heartrate subsequently normalized to the ___ shortly after arriving to the floor-- the tachycardia was attributed to postoperative pain and anxiety. She had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
| 1,035
| 172
|
10283863-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim / Penicillins / amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> Two left sided pelvic ___ drains fell out <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ drainage of RLQ pelvic fluid collection. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ s/p robotic assisted TLH-BSO for stage IB endometrioid-type endometrial cancer on ___, ___ s/p ex lap, with washout of pelvic abscess, and wound vac placement by ___ for pelvic abscess, POD#43 and ___ s/p ___ drainage x2 for persistent pelvic fluid collections who presented after her JP drains fell out yesterday. She reported a temp of 99.2 at home, and some mild nausea, however denied vomiting, fevers/chills, chest pain/ SOB, or abdominal pain. She reported that the drain fell out while going to the bathroom yesterday. Since then she has felt well and had no complaints. Last bowel movement was this afternoon, loose, which is baseline for her. <PAST MEDICAL HISTORY> PMH: Endometrial adenocarcinoma, +HPV Obesity IBS Urinary incontinence GERD Osteoarthritis Pulmonary hypertension OSA PSH: - ___ guided drainage of pelvic fluid collections x 2 ___, ___ - Ex-lap, washout of pelvic abscesses ___ - Robotic assisted TLH, BSO ___ - ___, tubal ligation via mini lap at ___. - ___, instillation of InterStim at ___, by Dr. ___. - ___, right total knee replacement at ___ ___. - ___, left total knee replacement at ___. GYN ONC history: * Presented with abnormal Pap +HR HPV * ___ endometrial biopsy showing endometrial adenocarcinoma, endometrioid type grade 1. ECC and colpo negative for lesions * ___: RA-TLH-BSO, BPLND * ___: re-op and admission * ___ readmission <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast, ovarian, uterine or colon cancers. Some family history of high blood pressure and heart disease. <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 or guarding, old ex-lap incision with superficial breakdown, pink granulation tissue, mild serous discharge, ___ drain in RLQ in place with no erythema or induration, LLQ superior incision draining thick, green, non-fouling discharge into ostomy bag, LLQ inferior incision with minimal drainage, dressing clean/dry/intact. ___: nontender, nonedematous <PERTINENT RESULTS> -======== LABS -======== ___ 07: 18PM BLOOD WBC-10.2* RBC-3.85* Hgb-11.0* Hct-34.7 MCV-90 MCH-28.6 MCHC-31.7* RDW-18.4* RDWSD-60.7* Plt ___ ___ 06: 05AM BLOOD WBC-8.5 RBC-3.76* Hgb-10.6* Hct-35.2 MCV-94 MCH-28.2 MCHC-30.1* RDW-18.5* RDWSD-64.2* Plt ___ ___ 01: 05PM BLOOD WBC-13.6*# RBC-3.53* Hgb-10.0* Hct-31.5* MCV-89 MCH-28.3 MCHC-31.7* RDW-18.6* RDWSD-61.2* Plt ___ ___ 06: 00AM BLOOD WBC-9.2 RBC-3.16* Hgb-9.0* Hct-29.3* MCV-93 MCH-28.5 MCHC-30.7* RDW-18.6* RDWSD-63.2* Plt ___ ___ 08: 10AM BLOOD WBC-9.7 RBC-3.09* Hgb-8.9* Hct-27.8* MCV-90 MCH-28.8 MCHC-32.0 RDW-18.4* RDWSD-61.3* Plt ___ ___ 07: 18PM BLOOD Neuts-76.5* Lymphs-10.3* Monos-10.0 Eos-2.2 Baso-0.3 Im ___ AbsNeut-7.99* AbsLymp-1.07* AbsMono-1.04* AbsEos-0.23 AbsBaso-0.03 ___ 06: 05AM BLOOD Neuts-90.8* Lymphs-5.4* Monos-2.1* Eos-0.9* Baso-0.1 Im ___ AbsNeut-7.71* AbsLymp-0.46* AbsMono-0.18* AbsEos-0.08 AbsBaso-0.01 ___ 01: 05PM BLOOD Neuts-94.6* Lymphs-2.6* Monos-2.0* Eos-0.3* Baso-0.1 Im ___ AbsNeut-12.87*# AbsLymp-0.36* AbsMono-0.27 AbsEos-0.04 AbsBaso-0.02 ___ 06: 00AM BLOOD Neuts-81.8* Lymphs-6.2* Monos-5.3 Eos-5.6 Baso-0.3 Im ___ AbsNeut-7.49* AbsLymp-0.57* AbsMono-0.49 AbsEos-0.51 AbsBaso-0.03 ___ 08: 10AM BLOOD Neuts-80.2* Lymphs-5.3* Monos-8.6 Eos-5.1 Baso-0.2 Im ___ AbsNeut-7.79* AbsLymp-0.51* AbsMono-0.83* AbsEos-0.49 AbsBaso-0.02 ___ 07: 18PM BLOOD ___ PTT-28.6 ___ ___ 07: 18PM BLOOD ___ ___ 07: 18PM BLOOD Glucose-89 UreaN-9 Creat-0.8 Na-136 K-2.7* Cl-94* HCO3-28 AnGap-17 ___ 06: 05AM BLOOD Glucose-117* UreaN-7 Creat-0.7 Na-133 K-5.9* Cl-95* HCO3-17* AnGap-27* ___ 01: 05PM BLOOD Glucose-114* UreaN-6 Creat-0.7 Na-137 K-3.4 Cl-100 HCO3-25 AnGap-15 ___ 06: 00AM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-134 K-3.9 Cl-99 HCO3-25 AnGap-14 ___ 08: 10AM BLOOD Glucose-81 UreaN-5* Creat-0.6 Na-139 K-2.6* Cl-96 HCO3-28 AnGap-18 ___ 07: 18PM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.3* Mg-1.3* ___ 06: 05AM BLOOD Calcium-7.7* Phos-3.2 Mg-2.7* ___ 01: 05PM BLOOD Calcium-7.5* Phos-2.4* Mg-2.3 ___ 06: 00AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.0 ___ 08: 10AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.6 -======== MICROBIOLOGY -======== LLQ wound drainage ___ Gram stain 2+ PMNs, 2+ GPCs in pairs and clusters Culture Staph aureus coag+ sparse growth Staph, coag negative rare growth No anaerobes SUSCEPTIBILITY PENDING RLQ pelvic fluid collection ___ Gram stain 1+ PMNs, no microorganism, no aerobic or anaerobic growth Final report pending C. Diff ___ POSITIVE -======== IMAGING -======== CT ABDOMEN/PELVIS W/ CONTRAST ___ IMPRESSION: 1. Minimal decrease in size of pelvic fluid collections after left approach drainage catheter removal. A small amount of fluid persists along the tract of the removed drain. These likely represent residual phlegmonous change. 2. Similar to minimally decreased size of a right pelvic sidewall fluid collection, which could represent a postsurgical seroma; however, superimposed infection cannot be excluded. 3. Minimal increase in size of an intermediate density collection in the left anterior abdominal wall subcutaneous tissue, likely hematoma or developing phlegmon. <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Hydroxychloroquine Sulfate 200 mg PO DAILY 2. DICYCLOMine 10 mg PO DAILY 3. Simvastatin 10 mg PO QPM 4. Nystatin Ointment 1 Appl TP DAILY 5. Omeprazole 20 mg PO BID 6. FLUoxetine 60 mg PO DAILY 7. TraZODone 100 mg PO QHS: PRN home med <DISCHARGE MEDICATIONS> 1. Levofloxacin 500 mg PO Q24H RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills: *0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*42 Tablet Refills: *0 3. Potassium Chloride 40 mEq PO DAILY Hold for K > RX *potassium chloride 40 mEq/15 mL 15 mL by mouth daily Refills: *0 4. Hydroxychloroquine Sulfate 200 mg PO 4X/WEEK (___) 5. Hydroxychloroquine Sulfate 400 mg PO 3X/WEEK (___) 6. Omeprazole 20 mg PO DAILY 7. DICYCLOMine 10 mg PO DAILY 8. FLUoxetine 60 mg PO DAILY 9. Nystatin Ointment 1 Appl TP DAILY 10. Simvastatin 10 mg PO QPM 11. TraZODone 100 mg PO QHS: PRN home med 12.Outpatient Lab Work Please draw CHEM-7 on ___ and fax results to ___ Gynecologic Oncology. ___. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Stage Ib endometrial adenocarcinoma, right pelvic fluid collection and residual phlegmon along the prior left lower quadrant ___ drain site. <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 ___ drainage of right lower quadrant pelvic fluid collection. You have recovered well after your procedure, and the team feels that you are safe to be discharged home. Please follow these instructions: Please continue taking your antibiotics to treat the infection in your abdomen - levofloxacin and metronidazole for 14 days. You were also diagnosed with Clostridium difficile infection in the colon during this hospital stay. These antibiotics also treat this infection. Your potassium level was also found to be low during this hospitalization. Please take potassium daily as directed. A nurse ___ visit your home to assist with wound dressing. Please keep your midline incision covered with telfa and tape down with abdominal dressing pads, one side open to air. For your left sided incision, please continue to use the ostomy bags to drain the fluid. For the drain on your right side, the home nurse ___ monitor the drainage and contact the interventional radiologist to determine when it can be removed. Please follow up with Dr. ___ on ___ at 1: 30pm in ___. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ was admitted to the gynecologic oncology service after the LLQ drains placed by interventional radiology for persistent pelvic fluid collections fell out. Both superior and inferior LLQ incision were found to be draining thick purulent/green drainage. This fluid was sent for culture which revealed 2+ PMNs, 2+ GPCs in pairs and clusters, sparse coagulase positive staphylococcus aureus, and rare coagulase negative staphylococcus. CT abdomen/pelvis with contrast was ordered, which showed minimal decrease in size of pelvic fluid collections after left approach drainage catheter removal; a small amount of fluid was noted to persist along the tract of the removed drain, likely representing residual phlegmonous change. There was also a similar to minimally decreased right pelvic sidewall fluid collection, representing postsurgical seroma though a superimposed infection could not be excluded. There was also a minimally increased intermediate density collection in the left anterior abdominal wall subcutaneous tissue, likely hematoma or developing phlegmon. Upon discussing these findings, interventional radiology felt that the left sided phlegmon could not be drained. Pt then underwent an CT-guided drainage of the right pelvic sidewall fluid collection with interventional radiology on HD#1. An ___ pigtail catheter was placed into a 3.6 x 5.6 cm fluid collection in the right pelvis. 6cc of serous fluid was obtained and sent for culture, which 1+ PMNs with no aerobic or anaerobic growth. She was afebrile throughout her hospitalization, white count was 10.2 on admission, which trended to 13.6 on HD#1. Given the inability to replace the LLQ drain and persistent thick purulent/green drainage, pt was started on PO levofloxacin and flagyl on HD#1, to be continued for a 14-day course. Her white count continued to trend down to 9.2 on HD#2 and remained stable at 9.7 on HD#3. On HD#2, she was noted to have increased stool output, for which C. diff was sent and returned positive on HD#3, for which she was already being treated with PO flagyl. In addition, she was noted to be hypokalemic to 2.7, with a normal EKG. She was placed on telemetry during her hospitalization with no arrhythmias noted. She was repleted with PO and IV potassium. Her serum potassium improved to 3.4 on HD#1 and 3.9 on HD#2. She was found to be hypokalemic to 2.6 on HD#3 and was instructed to take PO potassium 40mEq daily for 5 days until repeat CHEM-7 can be re-drawn by ___. For her hyperlipidemia, she was continued on simvastatin. For her history of high rheumatoid factor, she was continued on plaquenil. She was also continued on omeprazole for GERD. She was continued on Fluoxetine as well. By hospital day 3, she continued to be afebrile with a normal white count. She was tolerating a regular diet, voiding spontaneously, and ambulating independently. She was then discharged home in stable condition with ___ services and outpatient follow-up scheduled.
| 2,798
| 707
|
10283863-DS-7
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> grade 1 endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oopherectomy, and pelvic lymph node dissection. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G3P3 who presented with a Pap smear showing atypical epithelial cells and positive for HR HPV. She underwent a colposcopy and endometrial biopsy on ___ which revealed endometrial adenocarcinoma, endometrioid type grade 1 and her colposcopy was negative for any lesions and ECC was negative. She is entirely asymptomatic and this was picked up on her routine Pap smear. Also, of note, she has been positive for high-risk HPV also in ___ and ___, was negative prior to this in ___. She has never had any postmenopausal vaginal bleeding, no abnormal vaginal discharge, no pelvic discomfort or pain. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Obesity, irritable bowel syndrome, urinary incontinence, gastroesophageal reflux disease, osteoarthritis, a high rheumatoid factor, pulmonary hypertension and sleep apnea. Obstetrical History: Gravida 3, para 3, 3 spontaneous vaginal deliveries in ___ and ___. Largest baby was 8 pounds. Past Gynecologic History: Menarche at age ___, very regular q. monthly periods lasting four to five days with moderate flow. Last menstrual period and age of menopause, ___, roughly age ___. She reports abnormal Paps. Her first abnormal Pap smear was this year, ___. However, as noted in the HPI, she has had a few years of high-risk HPV positive Pap smears. She is not currently sexually active. She does report a distant history of OCP use for one year and a one-year history of hormone replacement at the start of menopause that she was weaned off of and had no further symptoms, thus stopped using. She denies any history of gynecologic infections, does note a history of yeast infections and her history of positive HPV on Pap smears. Past Surgical History: - ___, tubal ligation via mini lap at ___. - ___, instillation of InterStim at ___, by Dr. ___. - ___, right total knee replacement at ___. - ___, left total knee replacement at ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast, ovarian, uterine or colon cancers. Some family history of high blood pressure and heart disease. <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> The Preadmission Medication list is accurate and complete. 1. DICYCLOMine 10 mg PO DAILY WITH LARGEST MEAL 2. Hydroxychloroquine Sulfate 400 mg PO DAILY Q MON, WED, FRI 3. Hydroxychloroquine Sulfate 200 mg PO DAILY Q TUES, THURS, SAT, SUN 4. Simvastatin 10 mg PO QPM 5. Omeprazole 20 mg PO BID 6. FLUoxetine 20 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY <DISCHARGE MEDICATIONS> 1. DICYCLOMine 10 mg PO DAILY WITH LARGEST MEAL 2. FLUoxetine 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Hydroxychloroquine Sulfate 400 mg PO DAILY Q MON, WED, FRI 5. Omeprazole 20 mg PO BID 6. Simvastatin 10 mg PO QPM 7. Acetaminophen 650 mg PO TID pain Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 8. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *2 9. 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 10. Hydroxychloroquine Sulfate 200 mg PO DAILY Q TUES, THURS, SAT, SUN <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrial cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Instructions: * Take your medications as prescribed. Do not take ibuprofen or NSAIDs due to your kidney function, until cleared at your post-op visit. * 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 your post-op 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. * You have steri-strips over your incisions. Please leave them on. If they are still on after ___ days from surgery, you may remove them. . Post-operatively, you had low urine output and bruising around your incision sites. Your labs improved and were overall reassuring during your hospital stay. Please follow-up with your primary care provider who can check your kidney function and blood cell count. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
DISCHARGE SUMMARY BRIEF HOSP COURSE -- Ms. ___ was admitted to the gynecologic oncology service after undergoing a robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oopherectomy, and pelvic lymph node dissection on ___. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and toradol. Her diet was advanced without difficulty and she was transitioned to acetaminophen and oxycodone (pain meds). On post-operative day #1, she had low urine output with a creatinine of 1.3 (up from pre-operative creatinine of 0.9) and a FeNa of 1.09%. She also had a drop in her hematocrit from 35.2 pre-operatively to 31.1 on post-operative day #1. Her torodol and NSAIDs were discontinued. She had a renal ultrasound which was normal and a chest x-ray which demonstrated no evidence of acute cardiopulmonary abnormalities (incidental finding on humerus was followed-up with designated shoulder series showing calcific tendonitis). She was noted to have a large area of ecchymosis in her left lower quadrant, surrounding the incision site. On post-operative day #2 she received 2 units of pRBC and her labs improved and were steady with a creatinine of 0.9 and a hematocrit of 28.1 by time of discharge. 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. She was also recommended to follow-up with her primary care provider to monitor her BUN/creatnine and CBC given her acute kidney injury and acute blood loss anemia.
| 1,486
| 395
|
10284284-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim <ATTENDING> ___ <CHIEF COMPLAINT> increase in her vaginal discharge and occasional spotting since pessary placement <MAJOR SURGICAL OR INVASIVE PROCEDURE> bilateral sacrospinous ligament vault suspension with synthetic graft (uphold lite), anterior colporrhaphy, suburethral sling, cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 4 Para 4 who presents today in the office for a consultation requested by Dr. ___ vaginal prolapse. She is complaining of worsening bulging with BM's and ambulation. Her symptoms have been present for approximately 9 months. She believes that they are now worse. She reports ___ urgency incontinence events per day. She voids ___ times per day and ___ times per night. She uses no pads per day. She admits to urgency, she denies any dysuria and reports bladder emptying with normal flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ also admits to vaginal pressure and palpable prolapse. She also admits to constipation. She is not sexually active and does not experience dyspareunia. She denies any vaginal dryness. Mrs. ___ returns today stating that she is quite uncomfortable since the placement of her size 4 cube pessary. She reports an increase in her vaginal discharge and occasional spotting. She feels that conservative options are not helping her symptoms. She would like to consider surgical options. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Glaucoma 2. HTN 3. DM 4. Arthritis 5. GERD 6. Hypercholesterolemia 7. Low back pain PAST SURGICAL HISTORY 1. BTL 2. TVH 3. B/L knees 4. Right shoulder PAST OB HISTORY ___ Vaginal: 4 PAST GYN HISTORY 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 BP: 154/73 Heart Rate: 93 Weight: 155 (With Clothes; With Shoes) Neuro/Psych: Oriented x3, Affect Normal, NAD. Nodes: No inguinal adenopathy. Heart: No pedal edema Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegaly, No hernia. Ext: No clubbing, cyanosis, edema. Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. Cervix: absent-hysterectomy Uterus: absent-hysterectomy Adnexa: no masses non tender. POP-Q Exam: Aa: 0 Ba: 0 TVL: 6 D: C: -4 ___: 4 PB: 5 Ap: -2 Bp: -2 ___- Walker STAGE Cystocele: 2 Uterus/Cervix: Vault: Ant enterocele: Post enterocele: Rectocele: VAGINAL EXAM - There was moderate vaginal atrophy A SIZE 4 RING PESSARY WAS FITTED TODAY Empty Supine Stress Test was: negative Her (PVR) post void residual was 100 ml assessed by straight catheterization UROFLOW: Maximum flow: 12 ml/s Average flow: 7 ml/s Voiding time: 27 sec Flow time : 20 sec Voided vol : 145 ml Comments: PHYSICAL EXAM ON DATE OF DISCHARGE: <PHYSICAL EXAM> GEN: NAD CV: RRR, no MRG Resp: Course breath sounds but clear bilaterally Abd: Soft, non-distended, mildly tender to palpation in suprapubic region, otherwise non-tender GU: Gauze covering L suprapubic incision site. No discharge on pad. Ext: Warm, no edema, non-tender <MEDICATIONS ON ADMISSION> AMLODIPINE - amlodipine 10 mg tablet. 1 Tablet(s) by mouth once a day ATENOLOL - atenolol 25 mg tablet. 1 Tablet(s) by mouth daily DICLOFENAC SODIUM [VOLTAREN] - Voltaren 1 % topical gel. apply ___ grams to right shoulder ___ as needed for pain FREESTYLE FREEDOM LITE PEN - freestyle freedom lite pen . use as directed to check blood sugars GLIPIZIDE - glipizide ER 5 mg tablet, extended release 24 hr. 1 tablet extended release 24hr(s) by mouth daily Take along with 10mg ER pill, for total dose 15mg daily GLIPIZIDE - glipizide ER 10 mg tablet, extended release 24 hr. 1 tablet extended release 24hr(s) by mouth daily LATANOPROST [XALATAN] - Xalatan 0.005 % eye drops. 1 drop(s) both eyes at bedtime LIDOCAINE - lidocaine 5 % adhesive patch. apply one patch to area of pain for 12 hours each day daily LISINOPRIL - lisinopril 40 mg tablet. one Tablet(s) by mouth daily METFORMIN - metformin 500 mg tablet. 2 (Two) tablet(s) by mouth in the morning, 2 pills in the evening OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule,delayed ___ by mouth twice a day ONE TOUCH ULTRA PEN - one touch ultra pen . one touch ultra pen current pen broken PRAVASTATIN - pravastatin 80 mg tablet. one Tablet(s) by mouth daily SITAGLIPTIN [JANUVIA] - Januvia 50 mg tablet. 1 tablet(s) by mouth daily SOD PHOS,DI & MONO-K PHOS MONO [K-PHOS-NEUTRAL] - K-Phos-Neutral 250 mg tablet. 1 tablet(s) by mouth twice a day TIMOLOL MALEATE - timolol maleate 0.5 % eye gel forming solution. 1 drop(s) both eyes q AM TRAMADOL - tramadol 50 mg tablet. 1 tablet(s) by mouth twice a day as needed for pain - Entered by MA/Other Staff Medications - OTC ACETAMINOPHEN [ACETAMINOPHEN EXTRA STRENGTH] - Acetaminophen Extra Strength 500 mg tablet. ___ Tablet(s) by mouth twice a day ASPIRIN - aspirin 81 mg tablet,delayed release. 1 (One) tablet,delayed release (___) by mouth once a day BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - FreeStyle Lite Strips. Use to test blood glucose twice daily as directed DX: E11.65 BLOOD-GLUCOSE METER [FREESTYLE LITE METER] - FreeStyle Lite Meter kit. use as directed for blood sugar monitoring twice a day DX: E11.65 CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 1,000 unit chewable tablet. 1 Tablet(s) by mouth daily FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 Tablet(s) by mouth once a day LANCETS [FREESTYLE LANCETS] - FreeStyle Lancets 28 gauge. Use up to twice a day as directed with One Touch Ultra 2 glucometer. DX: ___ MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H do not take more than 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth once a day Disp #*5 Capsule Refills: *0 4. TraMADol 25 mg PO Q6H: PRN pain causes drowsiness; do not drink alcohol or drive RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #*15 Tablet Refills: *0 5. amLODIPine 10 mg PO DAILY 6. Carvedilol 25 mg PO BID 7. Januvia (SITagliptin) 50 mg oral DAILY 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Lidocare (lidocaine) 4 % topical DAILY 10. Lidocare (lidocaine) 4 % topical DAILY 11. Lidocare (lidocaine) 4 % topical DAILY 12. Lidocare (lidocaine) 4 % topical DAILY 13. Lidocare (lidocaine) 4 % topical DAILY 14. MetFORMIN (Glucophage) 1000 mg PO BID 15. Omeprazole 20 mg PO DAILY 16. Pravastatin 80 mg PO QPM 17. Timolol Maleate 0.25% 1 DROP BOTH EYES QAM 18. Voltaren (diclofenac sodium) 1 % topical BID: PRN <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> vault prolapse, cystocele, 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. 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 ___. *) 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.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing bilateral sacrospinous ligament suspension, anterior colporrhaphy, TVT sling and cystoscopy for symptomatic pelvic organ prolapse and stress urinary incontinence. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV morphine. 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 100 mL with PVR 580. Her Foley catheter was replaced for 575cc and she was instructed in its care. Her vaginal packing was removed without any bleeding. Her diet was advanced without difficulty and she was transitioned to PO tramadol/acetaminophen and home regimen of voltaren and lidocaine patch. On postoperative day 1, she was also continued on amlodipine and carvedilol for hypertension, omeprazole for gastroesophageal reflux disease, pravastatin for hypercholesterolemia, and lantanoprost and timolol for glaucoma. For her type II diabetes, she was continued on home medications metformin and Januvia and an insulin sliding scale was ordered while inpatient. By the evening of post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home with ___ services for assistance with foley management and Rx for macrobid for UTI PPX. Pt was in stable condition and had outpatient follow-up scheduled for a repeat trial of void in office and post-operative visit.
| 2,685
| 365
|
10289279-DS-3
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abnormal uterine bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 2, para 2, who is status post endometrial biopsy on ___. The results were discussed with the patient, which included benign endometrium with extensive breakdown and changes consistent with progestin effect. There was also a note made of a pseudo-actinomycotic nodule that was present. Actinomycosis was discussed with the patient. This note refers more to possible colonization than infection. IUD remains in place. The patient at the time of the biopsy and today presents with no complaints of fevers or chills or abdominal or pelvic pain. The patient had informed me that she has decided to undergo definitive therapy for the treatment of her symptomatic fibroid uterus. She understands that her uterine fibroids are moderate-sized, largest being 5 cm, but she does have multiple fibroids. She no longer wants hormonal therapy. She does not want multiple myomectomy, uterine fibroid embolization. She would like a total hysterectomy. <PAST MEDICAL HISTORY> OBSTETRIC AND GYNECOLOGIC HISTORY: Menarche at 12. She has a remote history of an abnormal Pap smear, had a colposcopy at the ___ and has had normal Paps since then. She also has a history of herpes simplex virus, diagnosed several years ago, has had no recent outbreaks. She has had two vaginal deliveries at term without complications. MEDICAL HISTORY: Significant for back pain, type 2 diabetes, hypertension, migraine headaches, history of supraventricular tachycardia, cardiomyopathy, diverticulosis, hepatic steatosis. OPERATIVE HISTORY: In ___, left carpal tunnel release, Mirena IUD placement, history of cholecystectomy, breast biopsy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On day of discharge: AFVSS Gen: well appearing, NAD CV: RRR, no murmurs or gallops Resp: CTAB, good air movement Abd: soft, mildly distended, appropriately tender at incision sites, no rebound or guarding Ext: no erythema, tenderness or edema <PERTINENT RESULTS> none <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 3. Paroxetine 40 mg PO DAILY 4. Pravastatin 40 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Aspirin 81 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Paroxetine 40 mg PO DAILY 7. Pravastatin 40 mg PO DAILY 8. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 9. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *2 10. Ibuprofen 600 mg PO Q6H: PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 11. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain do not drive while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * If TLH: Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing a total laparoscopic hysterectomy and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. Due to her history of cardiomyopathy she was monitored on telemetry throughout her stay with out events. She was continued on her home medications for hypertension and type 2 diabetes mellitus. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to percocet and motrin for pain. 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.
| 1,319
| 190
|
10292987-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> aspirin / Penicillins / Ceclor / clindamycin / ibuprofen / Erythromycin Base / naproxen <ATTENDING> ___ <CHIEF COMPLAINT> Vaginal bulging, pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> total vaginal hystertectomy, culdoplasty, perniorraphy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 2 Para ___ who presents today in the office for a consultation requested by Dr. ___ ___ vaginal prolapse. She is in fact complaining of vaginal bulging and pain. Her symptoms have been present for approximately 18 months. She believes that they are now worse. She was very concerned when she had significant bleeding that prompted an ER visit. She reports 0 incontinence events . She voids ___ times per day and ___ times per night. She uses 0 pads per day. She denies any urgency, she denies any dysuria and reports bladder emptying with interrupted flow. She denies any hematuria, kidney stones or pyelonephritis. Mrs. ___ is mostly bothered by the vaginal pressure and pain. she is very emotional about her situation. She also denies any constipation. She is not sexually active and does not experience dyspareunia. She admits to vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Hypertension 2. Degenerative disc disease 3. chronic pain 4. Polycythemia ___ PAST SURGICAL HISTORY 1. Bilateral tubal ligation PAST OB HISTORY Gravida 2 Para ___ Vaginal: 2 PAST GYN HISTORY She denies having Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV She denies having an abnormal Pap test and her last one was in ___ She denies having an abnormal Mammogram and her last one was in ___ She never had a colonoscopy She has been Postmenopausal since age ___ She denies using hormone therapy or vaginal estrogen cream. She admits to post-menopausal bleeding <SOCIAL HISTORY> She is Married and is disabled. She denies tobacco/ethanol/drugs <PHYSICAL EXAM> Pre Operative Exam per Dr. ___: Neuro/Psych: Oriented x3, Affect Normal, bo acute distress. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Normal sounds, no murmurs Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Ext: No edema or varicosities. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skin & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: no lesions FLUSHE WITH VAGINAL EPITHELIUM Uterus: small; non-tender Adnexa: no masses non tender. POP-Q Exam: Aa: +3 Ba: +5 TVL: 8 D: +7 C: +6 ___ PB: 3 Ap: +3 Bp: +5 PROCIDENTIA VAGINAL EXAM - There was severe vaginal atrophy: Ulcerations were present <PERTINENT RESULTS> CBC: ___ 01: 35PM BLOOD WBC-32.2*# RBC-5.08# Hgb-13.7# Hct-45.3# MCV-89 MCH-27.0 MCHC-30.2* RDW-18.4* Plt ___ ___ 06: 15AM BLOOD WBC-28.2* RBC-4.23 Hgb-11.2* Hct-37.5 MCV-89 MCH-26.4* MCHC-29.8* RDW-18.2* Plt ___ ___ 12: 09PM BLOOD WBC-31.0* RBC-4.22 Hgb-11.2* Hct-36.1 MCV-86 MCH-26.6* MCHC-31.1 RDW-18.7* Plt ___ ___ 06: 15AM BLOOD Neuts-92* Bands-1 Lymphs-4* Monos-1* Eos-2 Baso-0 ___ Myelos-0 ___ 12: 09PM BLOOD Neuts-81* Bands-6* Lymphs-5* Monos-5 Eos-1 Baso-2 ___ Myelos-0 Chemistry: ___ 01: 52PM BLOOD Glucose-124* UreaN-8 Creat-0.7 Na-132* K-5.3* Cl-94* HCO3-28 AnGap-15 <MEDICATIONS ON ADMISSION> ESTRADIOL [ESTRACE] - 0.01 % Cream - 1 gram per vagina at bedtime twice weekly ( 2 times a week) GABAPENTIN - (Prescribed by Other Provider) - Dosage uncertain METHADONE - (Prescribed by Other Provider) - Dosage uncertain TIZANIDINE - (Prescribed by Other Provider) - Dosage uncertain ___ 75mg daily Lisinopril 40mg BID <DISCHARGE MEDICATIONS> 1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed 8 tabs in 24 hrs (4000 mg). Disp: *100 Tablet(s)* Refills: *0* 3. methadone 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 4. methadone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours). 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 9. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain for 30 days. Disp: *100 Tablet(s)* Refills: *0* 10. ___ 75 mg Tablet Sig: One (1) Tablet PO once a day. 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *30 Capsule(s)* Refills: *0* 12. Macrobid ___ mg Capsule Sig: One (1) Capsule PO at bedtime for 7 days. Disp: *7 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> procidentia (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. * Do not restart your ___ until ___ Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. *You had a foley catheter placed due to inability to adequately void urine. You will be seen in Dr. ___ office on ___, ___ for catheter removal. You will be taking a daily antibiotic while the catheter is in* To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ was admitted to the GYN service for post operative management after undergoing a total vaginal hysterectomy, ___ vault suspension, posterior colporrhaphy and cystoscopy. Please see Dr. ___ report for further details regarding the procedure. Ms. ___ pain was initially uncontrolled on a Dilaudid PCA. Her exam and vital signs were stable and therefore the decision was made to consult chronic pain for further recommendations regarding pain management for this patient especially given her history of methadone treatment. Per chronic pain recommendations, the patient was continued on a Dilaudid PCA and was restarted on all of her home pain medications including methadone 20mg QID and 10mg daily, ativan prn, Tizanidine 4mg TID and 2mg BID, gabapentin 600mg 6x daily (these dosages were confirmed with the patient's PCP). Her pain significantly improved overnight and she was transitioned to an oral pain regimen on POD#1. She was advanced to a regular diet without difficult on POD#1. On POD#1, Ms. ___ was noted to have a low grade temperature of 100.7. Her WBC at this point was 32.2 (pre operative 18.8) but there was no clinical evidence of an infection and therefore her temperature curve was observed overnight. She had no further febrile temperatures after this. The one time temperature was likely secondary to atelectasis and lack of ambulation as her temperature normalized with incentive spirometery and ambulation. On POD#1, Ms. ___ was also noted to have brief episode of tachycardia and oxygen desaturation to the ___. She was asymptomatic at this time and there was low clinical suspicion for a PE. She was placed on 2LNC with significant improvement in oxygen saturation and was succesfully weaned to room air the following morning. Her tachycardia improved with hydration. Given an estimated blood loss of 1200 from the procedure, her hematocrit was followed daily. Her pre operative hematocrit was noted to be 69.3 (secondary to polycthemia, please see below). Although she did have a significant decrease in hematocrit 37.5 on day of discharge, she was not actively bleeding, had adequate urine output and had stable vital signs. A repeat hematocrit was checked ___ hours later and was noted to be stable at 36.1. Ms. ___ failed a formal voiding trial on POD#1 and again failed a repeat trial on POD#2 and was therefore discharged home with a foley catheter in place and macrobid suppression. With regards to her history of polycythemia ___, Ms. ___ ___ was held post operatively and she was advised to resume it 3 days after discharge from hospital. She was given subcutaneous heparin twice a day while inpatient. Ms. ___ home dose of lisnopril was restarted on POD#1. Her blood pressures were stable throughout her stay. Ms. ___ was discharged home in stable condition on POD#2.
| 2,009
| 639
|
10292987-DS-13
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> aspirin / Penicillins / Ceclor / clindamycin / ibuprofen / Erythromycin Base / naproxen / Hibiclens <ATTENDING> ___ <CHIEF COMPLAINT> vaginal ulcers at the apex of her prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal colpectomy, high perineorrhaphy, Cystoscopy. <HISTORY OF PRESENT ILLNESS> The patient is a ___, gravida 2, para 2, who initially underwent a vaginal hysterectomy for uterine prolapse. Prior to her surgery, she was diagnosed with polycythemia ___, had prophylaxis with Plavix. Her surgery was complicated by excessive blood loss, she later on developped a posterior wall hematoma resulting in the breakdown of the posterior repair which was left to heal by secondary intention. The patient had subsequent recurrence of vault prolapse and ulcerations not amenable to a pessary. The patient has been applying estrogen cream since and eventually elected to proceed with a vaginal colpectomy to address this prolapse <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. HTN 2. Degenerative disc disease 3. Polycythemia ___ PAST SURGICAL HISTORY 1. BTL 2. TVH Mc Call Complications: No PAST OB HISTORY G2P2002 Vaginal: 2 ALLERGIES: Ceclor Erythromycin Base Penicillins clindamycin aspirin ibuprofen naproxen <SOCIAL HISTORY> ___ <FAMILY HISTORY> Not known. The patient's mother and father are deceased. She has three brothers, six sisters and two daughters. She is estranged from all family members and does not know their medical history. <PHYSICAL EXAM> Vital Signs sheet entries for ___: BP: 140/90. Heart Rate: 70. Weight: 212 (With Clothes). BMI: 44.7. 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: no lesions, no discharge Uterus: small; non-tender Adnexa: no masses non tender. POP-Q Exam: TVL: 9 C : + 9 ___ 4.5 PB 3 Ap: -2 Bp: -3 Ulcer at the apex Distal posterior wall with friable tissue <PERTINENT RESULTS> ___ 03: 05PM BLOOD WBC-23.9* RBC-7.44* Hgb-16.9* Hct-58.1* MCV-78* MCH-22.7* MCHC-29.0* RDW-19.7* Plt ___ ___ 06: 42AM BLOOD WBC-26.9* RBC-6.76* Hgb-15.7 Hct-52.7* MCV-78* MCH-23.2* MCHC-29.8* RDW-19.4* Plt ___ <MEDICATIONS ON ADMISSION> ESTRADIOL [ESTRACE] - Estrace 0.01% (0.1 mg/g) Vaginal Cream. 1 gram per vagina at bedtime three times weekly ( 3 times a week) disp 42 g tube GABAPENTIN - gabapentin 600 mg tablet. 1 Tablet(s) by mouth 6x/day - (Prescribed by Other Provider) LISINOPRIL - lisinopril 40 mg tablet. 1 Tablet(s) by mouth twice a day - (Prescribed by Other Provider) METHADONE - methadone 10 mg tablet. 9 Tablet(s) by mouth daily (in split doses) - (Prescribed by Other Provider) PANTOPRAZOLE - pantoprazole 20 mg tablet,delayed release. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) TIZANIDINE - tizanidine 2 mg tablet. 8 Tablet(s) by mouth daily (in split doses) - (Prescribed by Other Provider) Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 Tablet(s) by mouth four times a day - (Prescribed by Other Provider; ___) MULTIVITAMIN - multivitamin capsule. 1 Capsule(s) by mouth daily - (Prescribed by Other Provider; ___) <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *1 2. Gabapentin 600 mg PO TID 3. Gabapentin 900 mg PO BID 4. Tizanidine 4 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Methadone 20 mg PO QID 7. Lorazepam 0.5 mg PO Q4H: PRN anxiety, agitation RX *lorazepam 0.5 mg 1 tablet by mouth every four (4) hours Disp #*15 Tablet Refills: *0 8. VICOdin *NF* (HYDROcodone-acetaminophen) ___ mg Oral every 4 hours RX *hydrocodone-acetaminophen 5 mg-300 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 9. Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN perineal pain RX *lidocaine HCl 2 % Apply to perineum as needed for pain once daily Disp #*1 Tube Refills: *0 10. Lisinopril 10 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal vault prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the gynecology service after undergoing the procedure listed below. You stayed an extra day because you had more bleeding than expected, but this resolved by post-operative day 2. After observing you an extra night we felt that you were meeting all of your post-operative goals and were safe to go home. Please follow these instructions: If you have any questions about these instructions, or if you are having problems, please call us at ___. Activity You have had surgery and your body needs time to heal. It is normal to feel more tired than usual. As you recover, its important to increase your activity gradually, as outlined below. You should expect to be back to your usual level of activity in about six weeks. * Plan to stay at home for the first week after surgery. * Do not lift, push, pull, or carry anything that weighs more than five pounds until your doctor says it is okay usually after about six weeks. * Gradually increase your activity each day over the next few weeks, as your energy increases. * Its okay to climb stairs once or twice a day, and to walk at a slow pace as much as you want, if you feel comfortable. * You may take a shower, but no tub baths until your doctor says it is okay. * You may ride in a car as a passenger; you may drive when you feel comfortable and you are not using a prescription pain medicine. * Its okay to travel out of town or travel by air three weeks after surgery. * Until your doctor says it is okay (usually after about six weeks), please do not: ** do any heavy housework, such as vacuuming, washing floors, carrying laundry or trash, etc. ** participate in exercise classes ** swim ** have sexual intercourse Pain management After any type of surgery, there is a possibility of some pain. Its very important to your recovery to keep your pain well controlled. This is not just for your comfort. Controlling your pain will help you move more easily, breathe deeply, and cough effectively. All of these things are essential in preventing complications such as pneumonia, blood clots, and psychological stress. * Your doctor may select one more types of oral medicine to help you control your pain. * Most patients are advised to take a prescription, narcotic medicine as well as a nonprescription medicine such as ibuprofen (Motrin). The narcotic medicine is used for moderate to severe pain as directed by the doctor. Ibuprofen can then be used in between doses as needed. * If the pain is more mild, ibuprofen alone may be enough to manage the pain effectively. * Do not hesitate to use your medicine as prescribed to make sure you are reasonably comfortable. This is important for your recovery. * Narcotic pain medicines can cause constipation. Be sure to read the important information you were given on preventing constipation as becoming constipated could cause complications in your recovery. * If your pain does not improve or gets worse after taking your pain medicine as prescribed, please call your doctor for advice. Incision care * The incision area, including the vaginal area, may be washed with soap and water. (Remember, no tub baths until your doctor says it is okay.) After showering or gently washing the area, pat the incision dry with a clean towel. * A dressing is not usually needed, but may be used to protect clothing from any discharge. * Stitches do not need to be removed; they will dissolve in about six weeks. * The area around your incision may itch, bruise, or feel numb. You may have a pulling sensation in the area. This is all normal. * If your incision becomes hot, red, swollen, or very painful, or if you develop a fever of 101 or more, please call your doctor. Vaginal bleeding/discharge and urinary issues * Right after surgery, you may have slight vaginal bleeding, which changes to a dark brown discharge. There may be a foul odor to the discharge. This is all normal and may last for four-six weeks after surgery. * Use sanitary pads only. Do not use tampons. * Your doctor may ask you to use an estrogen cream in your vagina, beginning a few weeks after surgery. * Leakage of urine may occur, even if you did not have a problem with this before surgery. This may be due to swelling and should improve as the swelling goes down. Call your doctor if . Call us at ___ if you have any of the following: * temperature of 101 or more * pain that is not well controlled with the medicine you were given * pain that is getting worse instead of better * heavy vaginal bleeding or discharge (soaking a pad every hour) * your incision is hot, red, swollen, or painful, even after taking pain medicine * an increase in bleeding from your incision To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
On ___ Ms. ___ was admitted to the gynecology service after undergoing vaginal colpectomy, high perineorrhaphy, and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV pain medication. The chronic pain service was consulted, who recommended continued pain medications with slight modification (increased tizanidine, addition of ativan) and IV morphine and vicodin as needed for acute pain. Given her history of polycytemia ___, she was given lovenox 6 hours after surgery. On post-operative day 0 to 1, she was noted to have more vaginal bleeding than expected, and thus her lovenox was held and she was observed for an extra day. Her foley was kept in place for monitoring. Her bleeding had slowed by mid-day post-operative day 1, and by post-operative day 2 had resolved. On post-operative day 2, the foley catheter was removed and she passed a urogynecology trial of voiding. 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.
| 2,543
| 271
|
10292987-DS-14
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> aspirin / Penicillins / Ceclor / clindamycin / ibuprofen / Erythromycin Base / naproxen / Hibiclens <ATTENDING> ___ <CHIEF COMPLAINT> vaginal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p rectovaginal fistula repair, revision colpectomy, perineorrhaphy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is now 2 weeks post vaginal colpectomy, high perineorrhaphy, and cystoscopy. She returns today stating that her pain worsened 2 days ago. She reports some vaginal spotting and her pain is controlled only with the vicodin. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. HTN 2. Degenerative disc disease 3. Polycythemia ___ PAST SURGICAL HISTORY 1. BTL 2. ___ Mc Call PAST OB HISTORY G2P2002 Vaginal: 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> On admission: VAGINAL EXAM: Breakdown of perineorrhaphy, no evidence of infection. Musculoskeletal: No clubbing, cyanosis or edema. No cords bilaterally. On discharge: AF VSS Comfortable, NAD CV: RRR Lungs: CTAB Abd: Soft, nontender, nondistended, obese. No rebound or guarding. GU: Pad with dark red spotting. Foley removed. Ext: nontender <PERTINENT RESULTS> ___ 06: 20AM BLOOD WBC-22.4* RBC-5.88* Hgb-14.1 Hct-48.5* MCV-83 MCH-23.9* MCHC-29.0* RDW-19.7* Plt ___ ___ 06: 20AM BLOOD Neuts-89* Bands-0 Lymphs-8* Monos-0 Eos-1 Baso-1 Atyps-1* ___ Myelos-0 ___ 06: 20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL <MEDICATIONS ON ADMISSION> Estrace, gabapentin 600 mg 6xday, lisinopril 40", Methadone 90' (split doses), Tizanadine 16mg'(split doses), pantoprazole 20 ER <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 3. Gabapentin 600 mg PO TID 4. Gabapentin 900 mg PO BID 5. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H: PRN pain 6. Lisinopril 10 mg PO BID 7. Methadone 20 mg PO QID 8. Methadone 10 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Tizanidine 4 mg PO QID 11. Tizanidine 4 mg PO Q24H 12. MetRONIDAZOLE (FLagyl) 500 mg PO BID Duration: 7 Days RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 13. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX *ciprofloxacin [Cipro] 250 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p rectovaginal fistula repair, revision of colpectomy, perineorrhaphy <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 a revision of a colpectomy, perineorrhaphy and fistula repair. You have done well post-operatively. You are safe to be discharged home. You should take antibiotics (cipro and flagyl) for 7 days. Please follow the instructions below. Please order a pelvic binder from the information given to you. 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. * 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing revision of colpectomy and perineorrhaphy and rectovaginal fistula repair. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with vicodin as well as IV morphine for breakthrough pain. She was also continued on her home medications recommended by the Chronic Pain Service, including gabapentin, methadone and tizanidine. She was started on IV flagyl and ciprofloxacin for infection prophylaxis. On post-operative day #1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty. She was transitioned to oral ciprofloxacin and flagyl. 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.
| 1,260
| 215
|
10293193-DS-14
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fever, urinary leakage <MAJOR SURGICAL OR INVASIVE PROCEDURE> None this admission <PERTINENT RESULTS> Labs on Admission: ___ 01: 48AM BLOOD WBC-8.6 RBC-2.90* Hgb-8.5* Hct-25.6* MCV-88 MCH-29.3 MCHC-33.2 RDW-13.0 RDWSD-41.3 Plt ___ ___ 01: 48AM BLOOD Neuts-82.5* Lymphs-12.3* Monos-4.4* Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.05* AbsLymp-1.05* AbsMono-0.38 AbsEos-0.02* AbsBaso-0.02 ___ 01: 48AM BLOOD Plt ___ ___ 01: 48AM BLOOD Glucose-90 UreaN-7 Creat-0.4 Na-137 K-4.1 Cl-104 HCO3-23 AnGap-10 ___ 01: 48AM BLOOD LD(LDH)-158 ___ 01: 48AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.7 ___ 01: 50AM URINE Color-RED* Appear-Cloudy* Sp ___ ___ 01: 50AM URINE Blood-LG* Nitrite-POS* Protein->600* Glucose-100* Ketone-15* Bilirub-LARGE Urobiln-8* pH-8.5* Leuks-LG* ___ 01: 50AM URINE RBC->182* WBC->182* Bacteri-MOD* Yeast-NONE Epi-7 Relevant Labs: ___ 10: 00PM BLOOD WBC-9.6 RBC-3.00* Hgb-8.8* Hct-26.3* MCV-88 MCH-29.3 MCHC-33.5 RDW-13.1 RDWSD-41.1 Plt ___ ___ 10: 00PM BLOOD Neuts-78.3* Lymphs-15.3* Monos-5.7 Eos-0.3* Baso-0.1 Im ___ AbsNeut-7.49* AbsLymp-1.47 AbsMono-0.55 AbsEos-0.03* AbsBaso-0.01 ___ 10: 00PM BLOOD Plt ___ ___ 06: 30AM BLOOD WBC-7.4 RBC-2.82* Hgb-8.2* Hct-25.0* MCV-89 MCH-29.1 MCHC-32.8 RDW-12.8 RDWSD-41.4 Plt ___ ___ 06: 30AM BLOOD Neuts-67.8 ___ Monos-7.9 Eos-0.4* Baso-0.1 Im ___ AbsNeut-4.98 AbsLymp-1.73 AbsMono-0.58 AbsEos-0.03* AbsBaso-0.01 <MEDICATIONS ON ADMISSION> Medications - Prescription DOXYLAMINE-PYRIDOXINE (VIT B6) [DICLEGIS] - Diclegis 10 mg-10 mg tablet,delayed release. 1 tablet(s) by mouth twice a day Medications - OTC BLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA BLUE TEST STRIP] - OneTouch Ultra Blue Test Strip. use for blood gllucose montoring 4x a day. Fasting and one hour after meals BLOOD-GLUCOSE METER - blood-glucose meter kit. to use for blood sugar monitoring fasting and 1 hour after meals LANCETS [LANCETS,ULTRA THIN] - Lancets,Ultra Thin. for glucose monitoring 4x a day PNV ___ FUMARATE-FA [PRENATAL FORMULA] - Prenatal Formula 28 mg iron-800 mcg tablet. tablet(s) by mouth - (Prescribed by Other Provider) --------------- --------------- --------------- <DISCHARGE MEDICATIONS> 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H twice daily for 6 more days RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice a day Disp #*12 Capsule Refills: *0 2. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever 3. Docusate Sodium 100 mg PO BID 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vesicouterine fistula after VBAC <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Reviewed basic instructions and follow-up plan Reviewed instructions for indwelling foley catheter
|
Ms. ___ was re-admitted on ___ with fevers and urinary leakage concerning for endometritis versus UTI following VBAC on ___. CBC was drawn and showed a WBC of 8.6 with a left shift. Urine analysis showed signs of urinary tract infection and urine culture grew E. Coli. Pelvic ultrasound on admission showing no evidence of retained products of conception. She was started on IV gentamicin, clindamycin, and flagyl for presumed endometritis. Urology was consulted given the urinary leakage, and recommended CT urogram followed by CT cystogram. CT urogram showed a 4cm heterogeneous collection anterior to the lower uterine segment that was thought to represent a hematoma versus a collection of blood products within the bladder. CT cystogram was then performed and showed a large bladder defect with contrast seen extending from the bladder via a dehiscent lower anterior uterine incision into the endometrial cavity and vagina. Contrast was also seen extending extra peritoneally supravesical and into the left pelvis. Urology recommended decompression of the bladder with a foley catheter for 2 weeks with follow up CT cytogram to determine whether there continues to be any evidence of active extravasation or fluid collections between the uterus and bladder. Urogynecology was also consulted and agreed with Urology on conservative management with foley catheter. On hospital day #3, patient was transitioned from IV antibiotics to PO nitrofurantoin. She was discharged home with foley in place with follow up scheduled.
| 1,178
| 325
|
10293821-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> dysmenorrhea, dyspareunia, and pain with bm's during menses <MAJOR SURGICAL OR INVASIVE PROCEDURE> -lysis of adhesions -abdominal myomectomy <HISTORY OF PRESENT ILLNESS> Pt states she has had worsening menses for the last year with dysmenorrhea, dyspareunia, and pain with bm's during her periods. She has tried OCs in the past with little releif. Did well for the first two months after last surgery, but feels her rectal and back pain are worsening again. She believes this is due to the fibroids, and would like to undergo open mymomectomy, as the recommendation at the last surgery was that. Pain is mainly right before and during menses, aching dull pain with pressure over rectum, worse with bm's, ___, and also cramping radiating to her back and thighs. Menses still regular, LMP ___. ___ wants to maintain fertility and wants to have surgery relatively quickly as she is planning on opening her own hair salon this ___. Of note, she had an HSG done in the past which showed blocked tubes. She had been told she might never conceive. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Fibroids. 2. GERD. 3. Headaches. 4. Infertility: Blocked tubes on HSG. 5. Heart murmur. PAST SURGICAL HISTORY 1. Orthopedic. 2. laparoscopy with resction fo endometriosis implants, ___ Menstrual History Menses: 13 X Q month X ___ Clots: No. Changes every: 3 hours. Metrorraghia: No. Post coital bleeding: Yes. Dyspareunia: Present. Dysmenorrhea: Yes: Debilitating, misses work for ___ days. Any change: Yes: symptoms had been better for a while, now worsening again. Preventative Maintenance Last pap: ___. Result: Normal. History of abnormal Paps: No. History of abnormal mammograms: No. Infection/STI history: None. Contraception: Nothing. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: DM, HTN, end stage renal failure on dialysis Father: DM. <PHYSICAL EXAM> Pre-operative PE: BP: 118/72. Weight: 212. BMI: 31.1. Pleasant, stately female, NAD Mouth: normal dentition, opens easily 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: RRR, no murmurs No edema or varicosities. Lungs: Normal respiratory effort. CT bilaterally Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skein & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, well supported, Cystocele absent, Rectocele absent, Bladder non-tender, no masses appreciated. Cervix: + CMT, no lesions, no discharge, *Abnormal: Mild CMT in all directions. Uterus: Small, reg, mobile, Prolapse absent, *Abnormal: Tender, ant, 7-8 cm, relatively fixed. Adnexa: Small, non-tender, no masses or nodules. Rectal: Nl anus & perineum, No hemorrhoids, Nl NT, no masses, *Abnormal: no RV nodularity. On Discharge: VSS, afeb RRR CTAB Abd soft, appropriately tender <PERTINENT RESULTS> Pathology report pending at the time of discharge. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *30 Capsule(s)* Refills: *2* 2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. Disp: *40 Tablet, Chewable(s)* Refills: *1* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometriosis fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see nursing instruction sheet
|
Ms. ___ was admitted to the gynecology service after undergoing an open abdominal myomectomy and lysis of adhesions for symptomatic fibroids and endometriosis. For full details of the procedure please see Dr. ___ report. Ms. ___ post-operative course was uncomplicated and she was discharged home on post-operative day #1 in stable condition, voiding, ambulating, tolerating a regular diet with her pain well controlled on oral pain medication.
| 1,166
| 96
|
10294546-DS-14
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___, gravida 2, para 2, with a severely enlarged fibroid uterus and metrorrhagia. Her uterus measured 20.1 cm in greatest dimension in ___. She was also symptomatic with increased bleeding. She desired definitive surgical management via a hysterectomy. She was given leuprolide injections 6 months preoperatively. She had no family history of malignancy, and desired to retain her ovaries if possible, if normal appearing. <PAST MEDICAL HISTORY> PMH: HTN, thrombocytopenia, HbC trait PSH: Pterygium surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of gynecologic malignancy. <PHYSICAL EXAM> On discharge: Gen: NAD CV: RRR Lungs: CTAB Abd: soft, ND, inc c/d/i GU: voiding spontaneously, minimal spotting on pad Ext: WWP, calves nontender <PERTINENT RESULTS> ___ 06: 12AM BLOOD WBC-7.7 RBC-4.10* Hgb-9.4* Hct-30.8* MCV-75* MCH-23.0* MCHC-30.6* RDW-13.5 Plt Ct-87* ___ 01: 35AM BLOOD WBC-11.7* RBC-4.50 Hgb-10.5* Hct-32.9* MCV-73* MCH-23.3* MCHC-31.9 RDW-13.3 Plt Ct-83* ___ 03: 21PM BLOOD WBC-8.9# RBC-4.79 Hgb-11.0* Hct-34.7* MCV-72* MCH-23.0* MCHC-31.7 RDW-13.5 Plt ___ ___ 08: 30AM BLOOD WBC-3.3* RBC-5.33 Hgb-12.4 Hct-38.5 MCV-72* MCH-23.3* MCHC-32.3 RDW-13.5 Plt ___ ___ 03: 21PM BLOOD Glucose-102* UreaN-16 Creat-0.8 Na-141 K-3.5 Cl-103 HCO3-27 AnGap-15 ___ 01: 35AM BLOOD Glucose-134* UreaN-15 Creat-0.7 Na-139 K-4.5 Cl-105 HCO3-26 AnGap-13 ___ 03: 21PM BLOOD CK(CPK)-176 ___ 03: 21PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 01: 35AM BLOOD Calcium-8.4 Phos-5.7* Mg-1.9 ___ 03: 21PM BLOOD TSH-1.6 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID Take with narcotics to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *3 2. Acetaminophen 1000 mg PO Q6H Do not take more than 4000 mg acetaminophen (Tylenol) in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking this medication as it may make you drowsy. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after undergoing an uncomplicated hysterectomy. In the recovery room, you had a heart arrhythmia called (atrial flutter with rapid ventricular response). You were seen by the cardiologists and monitored overnight in the ICU. Your heart rhythm returned to normal spontaneously. It is likely related to the anesthesia medications you received for the operation. You have recovered well and the team now feels you are stable to go 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 3 months or until cleared by Dr. ___ at post-operative appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * chest pain, feeling heart racing or beating abnormally * feeling severely lightheaded or dizzy or passing out/fainting * 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 ___.
|
Ms. ___ underwent an uncomplicated total abdominal hysterectomy on ___. Please see operative reports for full details. An epidural was placed for pain control. In the PACU, she developed aflutter with RVR to 180's. Anesthesia was called and administered esmolol 30mv IV x1, diltiazem 5mg x3. SBP decreased to 90's systolic and patient reported dizziness. She received IVF and 100mcg phenylephrine. Labs were sent. Her HCT was 34, electrolytes were are withing normal limits, cardiac enzymes were negative x 1, and TSH was normal. Diltiazem gtt was initiated and the patient was admitted to the ___ for close monitoring. The cardiology service was consulted for reccomendations. She converted to NSR shortly after transfer to the FICU. Her diltiazem gtt was stopped as her HR remained consistently in the ___. As her Aflutter likely occured in the setting of recent surgery and CHADS score 1, there was determined to be no need for anticoagulation. She remained in NSR and was called out to the floor on post-operative day #1. The remainder of her post-operative course was uncomplicated. A CBC showed her platelets remained stable at her baseline mild thrombocytopenia. Her epidural was removed and she was transitioned to oral pain medications. Her foley was removed after her epidural was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oral pain medications. She was monitored on telemetry and continued to be in NSR. 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.
| 1,439
| 390
|
10296526-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Elevated blood pressures <MAJOR SURGICAL OR INVASIVE PROCEDURE> preterm vaginal birth <HISTORY OF PRESENT ILLNESS> ___ G3P1 at 35+1, sent from ___ appt for ___ eval after pressures elevated today for first time 142/88. Pt also has HA, ___, hasn't taken anything for pain. Denies visual changes, RUQ/epigastric pain. Denies CTX, VB or LOF. +AFM. <PAST MEDICAL HISTORY> PNC: -___: ___ -Labs: B+/Ab-/HBsAg-/RPRNR/RI/HIV-/GBS pend -Screening: abnormal quad T21 1: 17, declined further testing -FFS: WNL, anterior placenta -GLT: 106, passed -EFW: ___, 49%ile -Issues: *late transfer of care at 21 weeks *abnormal quad screen OBHx: -TAB x1 -SVD 39+6, uncomplicated ___ -current PMH: G6PD deficiency PSH: D&C (TAB), right ear keloid removal <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 02: 57PM BLOOD WBC-11.0* RBC-3.45* Hgb-10.3* Hct-31.1* MCV-90 MCH-29.9 MCHC-33.1 RDW-13.4 RDWSD-43.8 Plt ___ ___ 02: 19AM BLOOD WBC-12.2*# RBC-3.78* Hgb-11.2 Hct-34.0 MCV-90 MCH-29.6 MCHC-32.9 RDW-13.2 RDWSD-43.2 Plt ___ ___ 03: 00PM BLOOD WBC-7.8 RBC-3.75* Hgb-11.2 Hct-33.9* MCV-90 MCH-29.9 MCHC-33.0 RDW-13.2 RDWSD-43.5 Plt ___ ___ 05: 46AM BLOOD WBC-8.0 RBC-3.86* Hgb-11.4 Hct-34.4 MCV-89 MCH-29.5 MCHC-33.1 RDW-13.1 RDWSD-42.9 Plt ___ ___ 12: 00AM BLOOD WBC-6.0 RBC-3.44* Hgb-10.2* Hct-31.1* MCV-90 MCH-29.7 MCHC-32.8 RDW-13.0 RDWSD-43.0 Plt ___ ___ 04: 33PM BLOOD WBC-6.6 RBC-3.44* Hgb-10.3* Hct-31.0* MCV-90 MCH-29.9 MCHC-33.2 RDW-13.2 RDWSD-42.7 Plt ___ ___ 02: 57PM BLOOD Creat-0.5 ___ 02: 19AM BLOOD Creat-0.6 ___ 03: 00PM BLOOD Creat-0.5 ___ 05: 46AM BLOOD UreaN-4* Creat-0.4 ___ 12: 00AM BLOOD Creat-0.5 ___ 04: 33PM BLOOD Creat-0.5 ___ 02: 57PM BLOOD ALT-8 AST-15 ___ 02: 19AM BLOOD ALT-10 AST-16 ___ 03: 00PM BLOOD ALT-11 AST-17 ___ 05: 46AM BLOOD ALT-11 AST-21 ___ 12: 00AM BLOOD ALT-9 AST-17 ___ 04: 33PM BLOOD ALT-9 AST-16 ___ 02: 57PM BLOOD UricAcd-5.3 ___ 02: 19AM BLOOD Mg-5.7* UricAcd-5.2 ___ 03: 00PM BLOOD UricAcd-4.9 ___ 05: 46AM BLOOD UricAcd-4.3 ___ 12: 00AM BLOOD UricAcd-4.6 ___ 04: 33PM BLOOD UricAcd-4.6 ___ 04: 33PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 04: 33PM URINE Blood-SM Nitrite-NEG Protein->600 Glucose-TR Ketone-NEG Bilirub-SM Urobiln-2* pH-6.5 Leuks-NEG ___ 04: 33PM URINE RBC-3* WBC-6* Bacteri-FEW Yeast-NONE Epi-1 ___ 04: 33PM URINE CastHy-13* ___ 04: 33PM URINE Mucous-MOD ___ 04: 33PM URINE Hours-RANDOM Creat-338 TotProt-1760 Prot/Cr-5.2* <MEDICATIONS ON ADMISSION> prenatal vitamins iron <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth q 6 hours Disp #*40 Tablet Refills: *2 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *2 3. Labetalol 600 mg PO Q8H RX *labetalol 300 mg 2 tablet(s) by mouth q 8 hours Disp #*90 Tablet Refills: *3 4. NIFEdipine CR 30 mg PO DAILY RX *nifedipine 30 mg 1 tablet(s) by mouth q day Disp #*45 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm vaginal delivery severe pre-eclampsia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> -see nursing packet -pelvic rest for 6 weeks = nothing in the vagina - no sex, no tampons, no tubs/baths, no douching
|
On ___, Ms. ___ was admitted to the antepartum service for elevated blood pressures and headache at 35w1d. She received 10mg of PO Nifedipine with improvement. Her urine P:C ratio was notable at 5.2mg. She received a dose of late preterm betamethasone on ___. She was transferred to antepartum and started a 24 hour urine collection, however, developed persistently severe range blood pressures and persistent headache. She was transferred to L&D for IOL for severe PEC and Magnesium for eclampsia prophylaxis. Upon arrival she was given IV hydralazine 20mg and started on 200mg PO labetalol TID for BP control and started on Magnesium. For her headache, she was given IV reglan, zofran, fioricet, compazine. For persistent severe range pressures, she was given an additional dose of 100mg PO labetalol with increase to 300mg PO labetalol TID. Subsequently, she was given an additional 20mg IV labetalol and uptitrated to 400mg PO labetalol TID. She received 6 vaginal cytotecs and a foley bulb for her induction. On ___, she underwent a vaginal delivery of viable baby girl with placenta requiring manual removal. She also had post-placental Liletta IUD placement under ultrasound guidance. She was continued on Magnesium for 24 hours postpartum. She was given one dose of kefzol for manual removal of placenta. She was then transferred to the postpartum floor. On PPD#0, she was noted to have persistent BPs around 150s/80s-90s and was started on PO Nifedipine 30mg CR. On PPD#1, she had a severe range pressure of 171/114 at which time her scheduled 400mg Labetalol was given with improvement to 142/72. She again had a severe range pressure of 163/78 and repeat 157/101 at which time PO labetalol was uptitrated to 600mg TID and given 1.5 hours early with improvement to 142/60. For her history of G6PD deficiency, NSAIDs were held. She was also kept on Lovenox for VTE prophylaxis. By postpartum day 3, 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.
| 1,550
| 557
|
10296832-DS-3
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Darvocet-N / latex <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain, chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 with hx factor V Leiden mutation and 7.5 weeks GA presents as transfer from ___. She presented there with abdominal pain radiating to her chest, dyspnea on exertion and fever x2 this week at home. At present she reports mild SOB that comes and goes, mild chest pain but seems to originate in epigastrium. Had GI cocktail without effect. Mild N/V for several week. No bowel or bladder complaints, no vaginal bleeding. Found out she was pregnant 2 weeks ago at which time she switched from coumadin -> lovenox. <PAST MEDICAL HISTORY> OB Hx: G2P1 - SVD after IOL of labor at 6 months of gestation, induction recommended after found to have "70 blood clots" in body. Had IVC filter placed at that time. Infant demised after birth, had intracranial hemorrhage. Gyn hx: history of sexual assault age ___ and contracted herpes. denies hx abnl Pap, fibroids, endometriosis. PMHx: factor V Leiden carrier (unsure homozygote or heterozygote) with VTEs from age ___. ___ IVC filter placed ___ and has been on therapeutic anticoagulation. also has panic disorder, bipolar, asthma, hyperglycemia (? unclear if diagnosis of diabetes) Surghx: IVC filter placement, "brainstem surgery" for ___ ___ malformation, open heart surgery for removal of "lipoma", tonsilectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> no family hx of VTE/strokes. mother with mitral valve prolapse <PHYSICAL EXAM> (on admission) VITALS: T 98.7, HR 90, BP 109/73, RR 20, 94% RA ___: NAD, sleeping on my arrival HEART: RRR LUNGS: CTAB no increased WOB or adventitious sounds ABDOMEN: soft, mildly TTP epigastrium, no R/G, morbidly obese legs symmetric, no edema or erythema, no TTP TVUS: live SIUP s=d, CRL corresponds to 8w0d On discharge: Gen - NAD CV - RRR Lungs - CTAB Abd soft, obeset, nontender Ext- no calf tenderness, no edema <PERTINENT RESULTS> ___ WBC-7.5 RBC-4.26 Hgb-12.1 Hct-34.6 MCV-81 Plt-160 ___ Neuts-75.4 ___ Monos-6.3 Eos-1.5 Baso-0.5 ___ ___ PTT-36.1 ___ ___ Glu-89 BUN-12 Creat-0.7 Na-137 K-4.3 Cl-106 HCO3-23 AnGap-12 ___ ALT-10 AST-13 AlkPhos-55 TotBili-0.2 ___ Lipase-20 ___ Albumin-3.7 ___ 12: 03PM BLOOD Heparin-0.70 ___ PELVIC U/S FINDINGS: An intrauterine gestational sac is seen and a single living embryo is identified with a crown rump length of 15.5 mm representing a gestational age of 8 weeks 0 days. This corresponds satisfactorily with the reported date of the 7.5 weeks documented on the ED dashboard. The uterus is normal. The ovaries are normal. IMPRESSION: Single live intrauterine pregnancy with size = dates. ___ CHEST CTA IMPRESSION: Assessment of the subsegmental level is limited due to body habitus and bolus timing.No evidence of central or segmental level pulmonary embolism, however subsegmental pulmonary embolism is not excluded. <MEDICATIONS ON ADMISSION> lovenox ___ daily, written by PCP. PNV. previously was taking abilify and clonipin (stopped with pregnancy) <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler ___ PUFF IH Q4H: PRN wheezing, shortness of breath 2. Enoxaparin Sodium 120 mg SC Q12H 3. Nicotine Patch 14 mg TD DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Chest muscle pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were discharged to the hospital for work-up of blood clots. None were found. You were started on lovenox ___ mg twice daily. Please take as prescribed. Please call the office for any questions or concers.
|
___ yo G2P0 with bipolar d/o, hx factor V Leiden mutation and diffuse VTE, filter in place, transfered from OSH at 7w5d with chest symptoms and concern for pulmonary embolism. On admission, she was hemodynamically stable. Chest CTA revealed no evidence of a large PE, although it was a suboptimal study due to body habitus. Hematology was consulted and recommended increasing her Lovenox to therapeutic dosing (120mg bid), and she had a therapeutic anti-Xa level during this admission. She had a reassuring Ob ultrasound measuring size equal to dates. Given her complex medical history and plan to continue her prenatal care at ___, her medical records from various facilities were obtained. She was discharged to home in stable condition on HD#2 and will return for her scheduled prenatal visit on ___. She will also followup with hematology as an outpatient.
| 1,095
| 188
|
10296832-DS-4
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Darvocet-N / latex / cinnamon / diclofenac <ATTENDING> ___. <CHIEF COMPLAINT> Coordination of care <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ is a ___ G4 P0-1-2-0, due date ___. The plan is for admission to ___ on ___, as she has multiple issues requiring attention. She has been receiving her prenatal care at ___, but has been unable to go for the requisite consultations with various specialists due to difficulties with transportation. She likely will need to deliver at ___. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Multiple PEs and DVTs in the past. She is a known factor V Leiden carrier. This was diagnosed at an outside hospital and it is unclear if she is a homozygote or heterozygote. Her first thrombotic episode reportedly occurred at age ___, when she was undergoing treatment for a pericardial lipoma at ___. She had multiple pericardial clots requiring evacuation and possibly thrombolytics. At age ___, she had a left arm thrombosis and was started on warfarin. She then reportedly developed PEs. She was switched to enoxaparin and reports no issues while on this chronically. She was on fondaparinux during prior pregnancy and did experience thromboses. Due to this, she was induced at 24 weeks and given an IVC filter prior to delivery. Her newborn was born prematurely and died of intracerebral hemorrhage. This delivery occurred at ___. She was then managed on warfarin, but this was switched back to enoxaparin once she became pregnant. At the beginning of this pregnancy, she was on 120 mg of Lovenox once daily, 1 mg/kg. She presented to the ER at ___ on ___ with chest pain and underwent a CTA, which showed no evidence of thrombosis. Since she is a high risk patient, Hematology recommended full therapeutic dosing of enoxaparin at 1 mg/kg b.i.d. She continues on 120 mg of Lovenox every 12 hours and has been asymptomatic since ___. She has been unable to go for followup hematology consultation. 2. Morbid obesity. 3. Bipolar disorder and anxiety. 4. Hyperthyroidism. 5. Hyperglycemia. 6. ___ malformation for which she underwent "brainstem surgery in the past." PAST SURGICAL HISTORY: IVC filter placement, brainstem surgery for ___ malformation, open heart surgery for removal of lipoma, tonsillectomy. PAST OBSTETRIC HISTORY: In ___, 24-week SVD for multiple thromboses with green field IVC filter placed predelivery, ___ SAB, ___ SAB. PAST GYN HISTORY: Abnormal Pap smear ___ years ago, which reportedly showed herpes, though she reports no herpes outbreaks otherwise. Normal Pap smears since. No other STDs. History of sexual assault in teenage years. <SOCIAL HISTORY> ___ <FAMILY HISTORY> no family hx of VTE/strokes. mother with mitral valve prolapse <PHYSICAL EXAM> On admission: BP: 134/86. Weight: 276 (With Clothes; With Shoes). Has significant ___ edema CV RRR no m/r/g Lungs CTAB Ultrasound EFW 70%ile, AC 96%ile. AFI nl. On discharge: VSS Gen: NAD CV: RRR Abd: soft, non-tender <PERTINENT RESULTS> LABORATORY: On admission: ___ 03: 30PM BLOOD WBC-9.9 RBC-3.74* Hgb-10.2* Hct-32.5* MCV-87 MCH-27.3 MCHC-31.4*# RDW-15.1 RDWSD-47.8* Plt ___ ___ 12: 55PM BLOOD ___ PTT-31.9 ___ ___ 03: 30PM BLOOD ALT-12 AST-14 ___ 03: 30PM BLOOD UricAcd-2.9 ___ 03: 43PM BLOOD %HbA1c-5.8 eAG-120 ___ 03: 30PM BLOOD TSH-0.29 ___ 03: 30PM BLOOD T4-8.1 ___ 12: 55PM BLOOD LMWH-0.46 ___ 03: 05PM BLOOD LMWH-0.41 ___ 03: 00PM URINE pH-7 Hours-24 Volume-2975 Creat-53 TotProt-9 Prot/Cr-0.2 ___ 03: 00PM URINE 24Creat-1577 24Prot-268 RADIOLOGY: ___ (ECHO): Suboptimal image quality. Borderline left ventricular hypertrophy with normal cavity size and global systolic function. Right ventricle not well visualized. No pathologic valvular flow. No cardiac masses identified. If clinically indicated, a cardiac MRI would provide better assessment of RV function as well as to rule out any recurrent lipomas (referencing your last note indicating her prior cardiac surgery was for removal of cardiac lipoma). ___ (EKG): Sinus rhythm. Normal ECG. No previous tracing available for comparison. ___ (___): No evidence of deep venous thrombosis in the left lower extremity veins. <MEDICATIONS ON ADMISSION> Lovenox ___ mg p.o. b.i.d. prenatal vitamins albuterol p.r.n <DISCHARGE MEDICATIONS> 1. Acetaminophen w/Codeine 1 TAB PO BID: PRN leg pain 2. Albuterol Inhaler ___ PUFF IH Q4H: PRN wheezing 3. ClonazePAM 0.5 mg PO TID: PRN anxiety 4. DiphenhydrAMINE ___ mg PO QHS: PRN insomnia 5. Prenatal Vitamins 1 TAB PO DAILY 6. FreeStyle Lite Meter (blood-glucose meter) 1 meter miscellaneous 4x/day RX *blood-glucose meter [FreeStyle Lite Meter] Use as directed 4x/day (fasting and 1 hr postprandial) Disp #*1 Kit Refills: *0 7. FreeStyle Lite Strips (blood sugar diagnostic) 1 strip miscellaneous 4x/day RX *blood sugar diagnostic [FreeStyle Lite Strips] use as directed 4x/day Disp #*120 Strip Refills: *3 8. FreeStyle Lancets (lancets) 28 gauge miscellaneous 4x/day RX *lancets [FreeStyle Lancets] 28 gauge use to check fingerstick glucose 4x/day Disp #*120 Each Refills: *3 9. Enoxaparin Sodium 130 mg SC Q12H RX *enoxaparin 150 mg/mL 130 mg sub-q twice daily Disp #*50 Syringe Refills: *2 10. Outpatient Lab Work Please have lab work drawn ___ hours after your lovenox dose. Factor XA Level (Heparin, LMW) Please fax the results to ___. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> History of pulmonary embolus ___ malformation Gestational diabetes Hyperthyroidism <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Mrs. ___, ___ were admitted to the Maternal Fetal Medicine service to help coordinate care. ___ were discharged home after ___ met with several services. To summarize your care: 1) ___ Malformation: ___ were seen by the neurology service. They recommended an outpatient study by cardiology called a bubble study on echo in order to rule out a hole in your heart that might make it so ___ can't push to have a baby. This study will be arranged as an outpatient. 2) Prior heart surgery: ___ had an echocardiogram that revealed no abnormalities that might be from surgery. Your heart valves appeared normal. 3) History of pulmonary embolus: ___ were seen by hematology. They recommended an increased dose of lovenox. ___ should have the Factor XA level checked at a lab near your home ___ hours after a dose of lovenox. Ideally this would be done tomorrow, ___. Please have this faxed to the fax number on the prescription. Regarding the medication, ___ should take this twice daily. ___ should follow-up with hematology on ___. 4) New diagnosis of gestational diabetes: ___ were taught how to use a glucometer to test your glucose levels. ___ should test your glucose levels in the morning before eating anything and 1 hour after each of your meals (breakfast, lunch and dinner). Please keep track of these blood glucose levels on a sheet of paper. ___ should try to limit carbohydrate intake. In addition, if ___ have any sugar readings higher than 200, please call the doctor at ___. 5) Hyperthyroidism: ___ have a history of hyperthyroidism. Your thyroid function tests were normal here at the hospital, so there is nothing different to do about that for now. 6) Desire for postpartum sterilization (prevention of any future pregnancies): ___ signed the ___ sterilization consent form today, and it is in your records 7) Prenatal care: ___ have been scheduled to see Dr. ___ continued prenatal care. See follow-up information below.
|
On ___, ___ year old ___ female was admitted for care coordination. 1. History of pulmonary emboli and DVTs: She was seen by hematology, and therapeutic lovenox was slightly increased given BMI to 130mg BID. A Factor XA level was subsequently checked and was pending on discharge. In addition, she underwent bilateral lower extremity dopplers which were negative for blood clot. 2. History of excision of large anterior mediastinal mass: Per review of operative notes, this was consistent with a lipoma. She underwent an EKG, which was normal, and an echo, which demonstrated globally normal systolic function with borderline left ventricular hypertrophy and no pathologic valvular flow. 3. History of ___ malformation with brainstem surgery: Neurology was consulted and a bubble study was recommended to evaluate for patent foramen ovale. If TTE with bubble study negative, then patient cleared to push if necessary in labor. Anesthesia was also consulted and saw patient during hospitalization. 4. Obesity: BMI 47. Baseline preeclampsia labs were checked and normal. A 24 hour urine was also obtained. 5. Gestational diabetes: She had a GLT test done, which was positive for gestational diabetes. She received a nutrition consult and teaching about how to use a glucometer. 6. History of hyperthyroidism: She had normal thyroid function testing on admission 7. Bipolar disorder: She was continued Klonopin and did see social services on admission. By hospital day 3, she was feeling well. Care regarding her multiple medical problems was coordinated, with a few things pending, including adequate dosing of lovenox (Factor XA level pending). Plan was made for outpatient follow-up with hematology and High risk obstetrics.
| 2,077
| 379
|
10296832-DS-5
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Darvocet-N / latex / cinnamon / diclofenac <ATTENDING> ___. <CHIEF COMPLAINT> Planned cesarean section <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p planned cesarean section <HISTORY OF PRESENT ILLNESS> MS ___ is a ___ yo G4P0210 at 34 ___ weeks with headache and back pain. No contractions, bleeding, or loss of fluid. Reports good fetal movement. No fever. Brought glucometer this visit but then her husband left and he took it with him. Also notes pelvic pain and has hx HSV. Dating: by LMP c/w 8+0 wk US Screening: FFS (at ___): normal, anterior placenta Labs: 12.___.6, B neg/neg, Rub ___, RPR NR, ucx neg, pap wnl, HbsAG neg, HIV neg, HCV Ab neg EFW ___: 2998g (77%ile), cephalic, normal AFI, BPP ___ Issues: --GDM on insulin-currently 8 units NPH at night --Multiple PEs and DVTs in the past. Known factor V Leiden carrier, unclear if homozygote or heterozygote. On 130 mg Lovenox every 12 hours, followed by Dr. ___ Hematology. IVC filter in place. --Morbid obesity. --Bipolar disorder and anxiety. --Hyperthyroidism. --H/o ___ malformation for which she underwent "brainstem surgery in the past." MRI this preg unremarkable for ___ malformation. --Mild fetal pyelectasis, resolved on today's US <PAST MEDICAL HISTORY> OB History: G2P1 - SVD after IOL of labor at 6 months of gestation, induction recommended after found to have "70 blood clots" in body. Had IVC filter placed at that time. Infant demised after birth, had intracranial hemorrhage. Gyn history: history of sexual assault age ___ and contracted herpes. denies history of abnormal Pap, fibroids, endometriosis. PMHx: factor V Leiden carrier (unsure homozygote or heterozygote) with VTEs from age ___. ___ IVC filter placed ___ and has been on therapeutic anticoagulation. also has panic disorder, bipolar, asthma, hyperglycemia (? unclear if diagnosis of diabetes) Surghx: IVC filter placement, "brainstem surgery" for ___ ___ malformation, open heart surgery for removal of "lipoma", tonsilectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family hx of VTE/strokes. Mother with mitral valve prolapse. <PHYSICAL EXAM> <PHYSICAL EXAM> Vital signs stable gen: nad, comfortable cv: rrr resp: cta bilaterally abd: soft, nontender, gravid ext: no edema, no tenderness to palpation <PERTINENT RESULTS> ___ 11: 50AM BLOOD WBC-9.2 RBC-3.17* Hgb-8.2* Hct-26.2* MCV-83 MCH-25.9* MCHC-31.3* RDW-16.7* RDWSD-49.2* Plt ___ ___ 09: 35PM BLOOD WBC-12.4* RBC-3.46* Hgb-9.0* Hct-28.9* MCV-84 MCH-26.0 MCHC-31.1* RDW-16.6* RDWSD-49.1* Plt ___ ___ 06: 42PM BLOOD WBC-9.2 RBC-3.88* Hgb-10.2* Hct-32.0* MCV-83 MCH-26.3 MCHC-31.9* RDW-16.4* RDWSD-47.7* Plt ___ ___ 08: 50PM BLOOD WBC-8.8 RBC-4.03 Hgb-10.4* Hct-33.4* MCV-83 MCH-25.8* MCHC-31.1* RDW-16.1* RDWSD-47.8* Plt ___ ___ 07: 20PM BLOOD WBC-7.6 RBC-3.85* Hgb-10.0* Hct-32.0* MCV-83 MCH-26.0 MCHC-31.3* RDW-15.7* RDWSD-46.5* Plt ___ ___ 07: 30PM BLOOD WBC-8.0 RBC-3.80* Hgb-9.9* Hct-31.3* MCV-82 MCH-26.1 MCHC-31.6* RDW-15.6* RDWSD-45.9 Plt ___ ___ 11: 50AM BLOOD ___ PTT-40.2* ___ ___ 03: 41PM BLOOD ___ PTT-25.8 ___ ___ 10: 20AM BLOOD ___ PTT-27.8 ___ ___ 07: 01AM BLOOD ___ PTT-28.4 ___ ___ 04: 14PM BLOOD ___ PTT-42.4* ___ ___ 07: 30PM BLOOD ___ PTT-28.7 ___ ___ 07: 01AM BLOOD ___ ___ 08: 50PM BLOOD ___ ___ 11: 50AM BLOOD Glucose-107* UreaN-13 Creat-1.2* Na-134 K-3.3 Cl-101 HCO3-23 AnGap-13 ___ 03: 41PM BLOOD Glucose-111* UreaN-8 Creat-1.0 Na-133 K-3.5 Cl-99 HCO3-19* AnGap-19 ___ 07: 01AM BLOOD Glucose-130* UreaN-7 Creat-0.7 Na-137 K-3.7 Cl-102 HCO3-21* AnGap-18 ___ 11: 50AM BLOOD ALT-13 AST-25 LD(LDH)-210 ___ 10: 20AM BLOOD ALT-19 AST-21 LD(LDH)-216 TotBili-0.4 ___ 01: 00PM BLOOD ALT-19 AST-21 LD(LDH)-222 ___ 11: 37AM BLOOD ALT-20 AST-24 ___ 03: 41PM BLOOD proBNP-227* ___ 07: 20PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 11: 50AM BLOOD Calcium-8.1* Phos-6.9* Mg-4.0* ___ 03: 41PM BLOOD Calcium-8.6 Phos-6.9*# Mg-8.4* UricAcd-7.5* Imaging: Echo (___) Very poor image quality. Left ventricular wall thicknesses are normal. The left ventricular cavity size appears normal. Overall left ventricular systolic function may be depressed (LVEF= 40-45 %). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are not well seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, LVEF appearsdepressed now. If indicated, a repeat study with echo contrast (Optison) may help assess regional/global LV systolic function more accurately. *Placental Pathology Pending* <MEDICATIONS ON ADMISSION> PNV, lovenox, insulin <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 2. Enoxaparin Sodium 130 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 150 mg/mL 130 units SQ twice a day Disp #*30 Syringe Refills: *0 3. OxycoDONE (Immediate Release) ___ mg PO Q3H: PRN pain RX *oxycodone 5 mg ___ capsule(s) by mouth q3-6 Disp #*30 Capsule Refills: *0 4. ARIPiprazole 30 mg PO DAILY RX *aripiprazole 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Severe Pre-eclamspsia Factor V Leidin <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> C/S: 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.
|
___ G4P0 with hx multiple PE/DVT (not during this pregnancy), hx neonatal demise, GDMA2, gHTN admitted for rule out pre-eclampsia and anticoagulation mgmt . *) Elevated BP, c/w gHTN, ruled out for pre-eclampsia - ___ labs ___ wnl except plts 133; 24 hour urine neg (240mg) - migraines at baseline; for fioricet prn . *) GDMA2: - NPH 12 units QHS *) h/o PE/DVT, Factor V carrier (heterozygote v. homozygote) - on heparin ___ QID; s/p lovenox ___ BID, heparin gtt (___) - transitioned to ppx heparin dosing prior to IOL *) Fibromyalgia, carpal tunnel pain: Cont oxycodone 5 TID prn *) Bipolar d/o: Cont klonopin 1 mg TID, abilify 30mg daily *) Migraines: Cont fioricet prn *) h/o HSV: acyclovir 400mg BID *) asthma: Cont albuterol PRN She had a failed induction of labor and had a successful cesarean section delivery on ___ along with a bilateral tubal ligation. Her postpartum course was uncomplicated and she was discharged to home in a stable condition.
| 2,115
| 305
|
10301071-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean hysterectomy, bilateral salpingectomy, bilateral oophorectomy <HISTORY OF PRESENT ILLNESS> ___ G3P1 at 26+3 with episode of severe abdominal pain, nausea and 2 loose watery stools 5 days ago. Was evaluated and thought to have gastroenteritis vs. food poisoning and was discharged home. Pt reports feeling mostly well since discharge, no fever, N/V/D. Normal BM 2 days ago. Called today to report that although all other sx are gone she continues to have abdominal "fullness" and left sided pain. Seen today at Dr. ___, PUS showed free peritoneal fluid extending up to ___ pouch. Recommend add'l imaging with MRI. <PAST MEDICAL HISTORY> PNC: ___ ___ by ___ Labs: O+/Ab-/RI/RPRnr/HBsAg-/HIV-/GBS pend Screening: silent carrier alpha thal (FOB also silent carrier), NIPT LR for aneuploidy, no result for fetal sex or monosomy X FFS: LLP (resolved), otherwise WNL, male by U/S GLT: Issues: *AMA *low lying placenta on FFS, resolved *no call fetal sex on NIPT, male on FFS *h/o c/s at 31 wks, LTCS, ok for TOLAC, declines OBHx: ___ pLTCS at 31 wk for hemorrhage in setting of previa ___ SAB x 1 current GYNHx: endometriosis, h/o endometrioma, small fibroid (1.8x0.9x2.0cm) PMH: mild asthma, seasonal allergies PSH: bilateral ovarian cystectomy for endometriomas via mini lap, pLTCS <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Admission physical exam: -VS: ___ ___: 99 ___ 16: 31Temp.: 98.3°F ___ 16: 31BP: 129/64 (80) ___ 16: 31Resp.: 18 / min -Gen: NAD, non-toxic, well appearing -Abd: gravid, soft, moderately TTP just left of umbilicus, also minimally TTP on approximately 8cm to the right of umbilicus with referred pain to the left -NST: 150, mod var, AGA -Toco: flat Discharge: ___ 0310 Temp: 98.6 PO BP: 115/78 HR: 88 RR: 18 O2 sat: 97% O2 delivery: RA ___ 0418 Urine Amt: 400ml ___ Total Output: 1500ml Urine Amt: 1500ml General: NAD, A&Ox3 Lungs: No respiratory distress Abd: softly distended, appropriately tender without rebound or guarding Incision: clean, dry, intact, no erythema/induration Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 06: 25AM BLOOD WBC-9.4 RBC-2.81* Hgb-8.3* Hct-24.8* MCV-88 MCH-29.5 MCHC-33.5 RDW-13.6 RDWSD-43.8 Plt ___ ___ 07: 00AM BLOOD WBC-13.7* RBC-3.28* Hgb-9.8* Hct-29.1* MCV-89 MCH-29.9 MCHC-33.7 RDW-13.9 RDWSD-45.0 Plt ___ ___ 03: 35PM BLOOD WBC-18.9* RBC-3.41* Hgb-10.0* Hct-30.0* MCV-88 MCH-29.3 MCHC-33.3 RDW-14.3 RDWSD-45.1 Plt ___ ___ 07: 10AM BLOOD WBC-20.2* RBC-3.43* Hgb-10.2* Hct-30.3* MCV-88 MCH-29.7 MCHC-33.7 RDW-14.6 RDWSD-46.3 Plt ___ ___ 08: 41AM BLOOD WBC-19.9* RBC-3.30* Hgb-9.7* Hct-28.5* MCV-86 MCH-29.4 MCHC-34.0 RDW-14.7 RDWSD-45.9 Plt ___ ___ 03: 01AM BLOOD WBC-18.3* RBC-3.39* Hgb-9.9* Hct-29.1* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.6 RDWSD-45.2 Plt ___ ___ 06: 15PM BLOOD WBC-18.1* RBC-3.50* Hgb-10.5* Hct-30.1* MCV-86 MCH-30.0 MCHC-34.9 RDW-14.6 RDWSD-45.1 Plt ___ ___ 01: 53PM BLOOD WBC-16.4* RBC-3.78* Hgb-11.3 Hct-32.4* MCV-86 MCH-29.9 MCHC-34.9 RDW-14.5 RDWSD-44.7 Plt ___ ___ 09: 51AM BLOOD WBC-13.9* RBC-3.66* Hgb-10.8* Hct-31.5* MCV-86 MCH-29.5 MCHC-34.3 RDW-14.2 RDWSD-44.3 Plt Ct-97* ___ 04: 55AM BLOOD WBC-11.9* RBC-3.62* Hgb-10.7* Hct-31.1* MCV-86 MCH-29.6 MCHC-34.4 RDW-14.1 RDWSD-44.4 Plt Ct-98* ___ 12: 50AM BLOOD WBC-7.1 RBC-3.50* Hgb-10.5* Hct-30.7* MCV-88 MCH-30.0 MCHC-34.2 RDW-14.1 RDWSD-44.8 Plt Ct-68* ___ 11: 05PM BLOOD WBC-5.3 RBC-3.21* Hgb-9.6* Hct-28.4* MCV-89 MCH-29.9 MCHC-33.8 RDW-14.1 RDWSD-45.3 Plt Ct-58* ___ 10: 15PM BLOOD WBC-5.8 RBC-2.17* Hgb-6.6* Hct-20.1* MCV-93 MCH-30.4 MCHC-32.8 RDW-14.0 RDWSD-47.3* Plt Ct-99* ___ 09: 30PM BLOOD WBC-9.9 RBC-3.01* Hgb-9.2* Hct-27.6* MCV-92 MCH-30.6 MCHC-33.3 RDW-13.6 RDWSD-45.7 Plt ___ ___ 08: 00PM BLOOD WBC-10.4* RBC-3.36* Hgb-10.3* Hct-30.9* MCV-92 MCH-30.7 MCHC-33.3 RDW-13.2 RDWSD-44.0 Plt ___ ___ 05: 49PM BLOOD WBC-8.9 RBC-3.03* Hgb-9.2* Hct-28.1* MCV-93 MCH-30.4 MCHC-32.7 RDW-12.9 RDWSD-43.5 Plt ___ ___ 12: 35PM BLOOD WBC-7.6 RBC-2.86* Hgb-8.6* Hct-26.7* MCV-93 MCH-30.1 MCHC-32.2 RDW-12.8 RDWSD-43.6 Plt ___ ___ 01: 15PM BLOOD WBC-7.7 RBC-2.67* Hgb-8.2* Hct-24.9* MCV-93 MCH-30.7 MCHC-32.9 RDW-12.8 RDWSD-43.2 Plt ___ ___ 06: 12AM BLOOD WBC-7.4 RBC-2.73* Hgb-8.2* Hct-25.3* MCV-93 MCH-30.0 MCHC-32.4 RDW-12.8 RDWSD-43.0 Plt ___ ___ 04: 55PM BLOOD WBC-9.1 RBC-2.98* Hgb-9.0* Hct-27.5* MCV-92 MCH-30.2 MCHC-32.7 RDW-12.9 RDWSD-42.7 Plt ___ ___ 04: 55AM BLOOD Neuts-81.1* Lymphs-6.8* Monos-11.6 Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.63* AbsLymp-0.81* AbsMono-1.38* AbsEos-0.00* AbsBaso-0.01 ___ 01: 15PM BLOOD Neuts-73.0* Lymphs-15.7* Monos-9.7 Eos-1.0 Baso-0.1 Im ___ AbsNeut-5.59 AbsLymp-1.20 AbsMono-0.74 AbsEos-0.08 AbsBaso-0.01 ___ 06: 12AM BLOOD Neuts-68.8 Lymphs-18.2* Monos-10.1 Eos-1.9 Baso-0.3 Im ___ AbsNeut-5.10 AbsLymp-1.35 AbsMono-0.75 AbsEos-0.14 AbsBaso-0.02 ___ 04: 55PM BLOOD Neuts-69.1 ___ Monos-8.8 Eos-2.1 Baso-0.2 Im ___ AbsNeut-6.29* AbsLymp-1.76 AbsMono-0.80 AbsEos-0.19 AbsBaso-0.02 ___ 07: 10AM BLOOD ___ PTT-26.1 ___ ___ 03: 01AM BLOOD ___ PTT-25.0 ___ ___ 06: 15PM BLOOD ___ PTT-24.4* ___ ___ 01: 53PM BLOOD ___ PTT-25.4 ___ ___ 09: 51AM BLOOD ___ PTT-24.1* ___ ___ 04: 55AM BLOOD ___ PTT-24.4* ___ ___ 12: 50AM BLOOD ___ PTT-22.6* ___ ___ 11: 05PM BLOOD ___ PTT-32.0 ___ ___ 10: 15PM BLOOD ___ PTT-25.3 ___ ___ 09: 30PM BLOOD ___ PTT-27.2 ___ ___ 08: 00PM BLOOD ___ PTT-26.8 ___ ___ 05: 49PM BLOOD ___ PTT-26.6 ___ ___ 12: 35PM BLOOD ___ PTT-28.5 ___ ___ 07: 10AM BLOOD ___ ___ 03: 01AM BLOOD ___ ___ 06: 15PM BLOOD ___ ___ 01: 53PM BLOOD ___ ___ 09: 51AM BLOOD ___ ___ 04: 55AM BLOOD ___ 12: 50AM BLOOD ___ 11: 05PM BLOOD ___ 10: 15PM BLOOD ___ 09: 30PM BLOOD ___ 08: 00PM BLOOD ___ ___ 05: 49PM BLOOD ___ ___ 06: 34AM BLOOD Creat-0.9 ___ 06: 25AM BLOOD Creat-1.1 Na-143 K-3.7 ___ 07: 00AM BLOOD Creat-1.2* ___ 03: 35PM BLOOD Glucose-85 UreaN-17 Creat-1.2* Na-141 K-4.1 Cl-103 HCO3-26 AnGap-12 ___ 07: 10AM BLOOD Glucose-91 UreaN-16 Creat-1.2* Na-140 K-3.9 Cl-103 HCO3-25 AnGap-12 ___ 03: 01AM BLOOD Glucose-120* UreaN-12 Creat-1.0 Na-140 K-3.7 Cl-105 HCO3-23 AnGap-12 ___ 06: 50PM BLOOD Glucose-123* UreaN-12 Creat-1.1 Na-137 K-4.0 Cl-105 HCO3-19* AnGap-13 ___ 04: 55AM BLOOD Glucose-118* UreaN-11 Creat-0.9 Na-143 K-4.6 Cl-109* HCO3-21* AnGap-13 ___ 12: 50AM BLOOD Glucose-171* UreaN-8 Creat-0.8 Na-144 K-4.5 Cl-111* HCO3-20* AnGap-13 ___ 04: 55PM BLOOD Glucose-75 UreaN-6 Creat-0.5 Na-140 K-3.7 Cl-106 HCO3-21* AnGap-13 ___ 03: 35PM BLOOD ALT-33 AST-33 ___ 03: 01AM BLOOD ALT-34 AST-41* LD(LDH)-441* AlkPhos-52 TotBili-0.6 ___ 04: 55AM BLOOD ALT-30 AST-56* AlkPhos-40 TotBili-3.6* ___ 12: 50AM BLOOD ALT-24 AST-50* AlkPhos-32* TotBili-2.2* ___ 12: 35PM BLOOD ALT-80* AST-44* Amylase-140* ___ 01: 15PM BLOOD ALT-67* AST-37 ___ 04: 55PM BLOOD ALT-78* AST-39 AlkPhos-85 TotBili-0.2 ___ 03: 35PM BLOOD Calcium-10.0 Phos-4.4 Mg-1.9 UricAcd-8.0* ___ 07: 10AM BLOOD Calcium-10.0 Phos-4.0 Mg-1.8 ___ 03: 01AM BLOOD Albumin-2.5* Calcium-9.5 Phos-5.7* Mg-1.7 ___ 06: 50PM BLOOD Calcium-8.9 Phos-6.0* Mg-1.6 ___ 04: 55AM BLOOD Calcium-10.4* Phos-7.6* Mg-2.0 ___ 12: 50AM BLOOD Calcium-11.1* Phos-7.5* Mg-2.0 ___ 04: 55PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9 ___ 08: 06PM BLOOD Type-ART pO2-132* pCO2-40 pH-7.30* calTCO2-20* Base XS--5 ___ 06: 21PM BLOOD Type-ART pH-7.45 ___ 02: 26PM BLOOD Type-ART Temp-36.7 pH-7.44 ___ 10: 07AM BLOOD Type-ART FiO2-35 O2 Flow-10 pO2-120* pCO2-34* pH-7.40 calTCO2-22 Base XS--2 Intubat-NOT INTUBA Comment-FACE TENT ___ 05: 23AM BLOOD Type-ART pO2-209* pCO2-39 pH-7.40 calTCO2-25 Base XS-0 ___ 01: 07AM BLOOD Type-ART pO2-457* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 ___ 11: 09PM BLOOD Type-ART pO2-229* pCO2-35 pH-7.35 calTCO2-20* Base XS--5 ___ 10: 26PM BLOOD Type-ART pO2-161* pCO2-35 pH-7.35 calTCO2-20* Base XS--5 ___ 09: 38PM BLOOD Type-ART pO2-103 pCO2-39 pH-7.29* calTCO2-20* Base XS--6 ___ 09: 05PM BLOOD Type-ART pO2-115* pCO2-41 pH-7.32* calTCO2-22 Base XS--4 ___ 08: 06PM BLOOD Type-ART pO2-132* pCO2-40 pH-7.30* calTCO2-20* Base XS--5 ___ 06: 21PM BLOOD Lactate-2.4* ___ 02: 26PM BLOOD Lactate-3.9* ___ 10: 07AM BLOOD Lactate-3.0* ___ 05: 23AM BLOOD Lactate-1.8 ___ 01: 07AM BLOOD Glucose-163* Lactate-3.2* ___ 11: 09PM BLOOD Glucose-207* Lactate-3.6* Na-136 K-3.9 Cl-110* ___ 10: 26PM BLOOD Glucose-197* Lactate-2.9* Na-136 K-4.0 Cl-108 ___ 09: 38PM BLOOD Glucose-154* Lactate-1.5 Na-136 K-3.6 Cl-114* ___ 09: 05PM BLOOD Glucose-152* Lactate-1.6 Na-136 K-3.6 Cl-109* ___: 06PM BLOOD Glucose-151* Lactate-1.9 Na-134 K-4.0 Cl-110* ___ 11: 09PM BLOOD Hgb-10.0* calcHCT-30 ___ 10: 26PM BLOOD Hgb-6.7* calcHCT-20 ___ 09: 38PM BLOOD Hgb-9.5* calcHCT-29 ___ 09: 05PM BLOOD Hgb-9.8* calcHCT-29 ___ 08: 06PM BLOOD Hgb-11.0* calcHCT-33 ___ 06: 21PM BLOOD freeCa-1.22 ___ 02: 26PM BLOOD freeCa-1.24 ___ 10: 07AM BLOOD freeCa-1.29 ___ 05: 23AM BLOOD freeCa-1.34* ___ 01: 07AM BLOOD freeCa-1.34* ___ 11: 09PM BLOOD freeCa-1.20 ___ 10: 26PM BLOOD freeCa-0.76* ___ 09: 38PM BLOOD freeCa-1.41* ___ 09: 05PM BLOOD freeCa-1.01* ___ 08: 06PM BLOOD freeCa-1.02* ___ 06: 15PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01: 29AM URINE Color-Red* Appear-Hazy* Sp ___ ___ 06: 15PM URINE Blood-MOD* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM* ___ 01: 29AM URINE Blood-LG* Nitrite-NEG Protein-100* Glucose-100* Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD* ___ 06: 15PM URINE RBC-4* WBC-13* Bacteri-NONE Yeast-NONE Epi-2 TransE-2 ___ 01: 29AM URINE RBC->182* WBC-129* Bacteri-FEW* Yeast-NONE Epi-1 ___ 02: 24PM URINE Hours-RANDOM Creat-117 Na-___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fluticasone Propionate 110mcg 2 PUFF IH BID 2. Albuterol Inhaler ___ PUFF IH Q4H: PRN SOB 3. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Amoxicillin 500 mg PO Q12H Duration: 5 Days RX *amoxicillin 500 mg 1 tablet(s) by mouth twice per day Disp #*10 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID: PRN Constipation - First Line RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *1 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 6. Albuterol Inhaler ___ PUFF IH Q4H: PRN SOB 7. Fluticasone Propionate 110mcg 2 PUFF IH BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometriosis hemoperitoneum urinary tract infection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with abdominal pain. You had an ultrasound and MRI done that showed you were bleeding inside your abdomen. The decision was made to do surgery to look at the bleeding, and it was determined that the safest thing for you and your baby would be delivery and hysterectomy. You have recovered well after your surgery, and the team now feels that you are ready to go home. Your urine culture did come back showing an infection, so we are discharging you home on antibiotics to take for 5 days. Please follow these instructions below. Nothing in the vagina for 12 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking narcotics (i.e. Oxycodone, Percocet) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call your OB doctor 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.
|
Ms. ___ is a ___ y/o G3P1 who presented with abdominal pain and peritoneal free fluid on imaging. She was afebrile, with no leukocytosis. Initially, the differential diagnosis included ruptured ovarian cyst versus appendicitis; the latter was determined to be unlikely based on location of her pain (right abdomen) as well as no fever or leukocytosis, and no anorexia. Her imaging was as follows: - Abdominal US (___): free peritoneal fluid with sepatation/debris - MRI abd/pelvis (___): mild ascites, no organized focal fluid collection. candidate appendix in RLQ mildly prominent with no adjacent inflammation, normal ovaries bilaterally Her pain began to improve. Her hematocrit was trended and remained stable. However, on ___, she underwent repeat pelvic ultrasound and MRI due to worsening pain and abdominal distention: Pelvic ultrasound showed a fluid collection adjacent to uterus, but interval decrease in overall abdominal fluid. MRI was concerning for a fundal uterine defect with increase in size of the hematoma that was visualized on prior imaging. She underwent another pelvic ultrasound at the ___ maternal fetal medicine, which was concerning for bleeding invasive placentation. She received one dose of betamethasone, and subsequently underwent a diagnostic ex lap on ___ with initial intraoperative concerning for ongoing pelvic hemorrhage. The source of the bleeding was the uterine sentosa. She was delivered.IT them became clear that the bleeding was from her extensive stage IV endometriosis. A TAH/BSO was deemed necessary given the extent of the bleeding . Procedure was complicated by massive pelvic hemorrhage and DIC, requiring cell saver 1500cc, pRBCs 13 units, FFP 8 units, plt 5 units, cryo 5 units. She received empiric antibiotics (cefepime and flagyl x1). Please see operative report for full details. She initially recovered in the FICU post procedurally. She was successfully extubated on ___. She received one dose of lasix. Her pain was controlled with a morphine PCA and her hemoglobin remained stable. Post operatively, her pain was controlled with an epidural and dilaudid PCA, but she was transitioned to PO oxycodone and tylenol once she was tolerating POs. Her hematocrit stabilized (settled out at 24.8). She had no signs or symptoms of anemia. She was noted to have ___ (Cr peak 1.2 on ___, which was attributed to her massive hemorrhage. FENA was 0.2%. Her Cr downtrended to 0.9 on ___, and NSAIDs were restarted for pain control. She received DVT prophylaxis with lovenox (and transitioned to heparin with the ___. She was noted to have a urinary tract infection on day of discharge, so was sent home with a course of amoxicillin for treatment. She was discharged home in stable condition with close follow up scheduled.
| 5,385
| 637
|
10301071-DS-8
|
<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> ___ y/o G1P0 at 28+5 weeks who presents to triage from the ATU with CL of 34mm with funneling to 11mm w/ fundal pressure. Pt has a known placenta previa and was hospitalized on ___ for vaginal bleeding and found to be contracting. She received betamethasone and was complete on ___. <PAST MEDICAL HISTORY> PRENATAL COURSE (1)Dating: ___ ___ by 7wk U/S (2)Labs: O+/Ab-,RPRnr,RI,HbsAg-,GLT nl (124) (3)nl FFS (4)posterior marginal previa discovered on FFS (___) - ___ episode VB ___, admitted ___, s/p BMZ (5)exophytic fibroid on right side of uterus, 3.1cm PAST OBSTETRIC HISTORY G1 PAST GYNECOLOGIC HISTORY - exophytic right fibroid PAST MEDICAL HISTORY - none PAST SURGICAL HISTORY - bilateral ovarian cystectomy, mini-laparotomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> GENERAL: NAD VITALS: Temp 98.4 po, BP 129/68, HR 85, RR 18 HEART: RRR S1S2 no m/g/r LUNGS: CTA B ABDOMEN: gravid, soft, nontender; no CVAT EXTREMITIES: - edema B TOCO: ctx q ___ mins w/irritability SVE: deferred [in ATU] FHR: 140 BPM TOCO: 1 contraction in 15 minutes BPP: ___ Cervical length: 3.4 cm initially with placenta at internal os. With fundal pressure, cvx funneled down to closed length of 1.1 cm. Beaking: []absent [x]present Funneling: []absent [x]present Change w/valsalva: []absent [x]present Cerclage: [x]N/A []intact <PERTINENT RESULTS> ___ WBC-9.4 RBC-3.55 Hgb-10.7 Hct-31.6 MCV-89 Plt-265 ___ Neuts-72.3 ___ Monos-7.0 Eos-1.0 Baso-0.2 URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. 10,000-100,000 ORGANISMS/ML.. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 29+6 weeks marginal previa short cervix <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> continue bedrest and pelvic rest at home. NO INTERCOURSE. drink plenty of fluids. call your doctor with any leaking of fluid, vaginal bleeding, regular or painful contractions, or decreased fetal movement.
|
___ y/o G1 with known marginal previa admitted at 28+5 wks gestation with a short cervix. . Ms ___ was found to be contracting irregularly on arrival to triage. She was afebrile and without any signs or symptoms of infection. She reported no vaginal bleeding. Fetal testing was reassuring in the ATU and she was already betamethasone complete. She was started on Nifedipine for the preterm contractions and transferred to the antepartum floor. She had a repeat transvaginal ultrasound on the following day which showed a cervical length of 1.3cm. Placental veins were also noted near the cervix. The decision was made to keep in-house for a week for observation. She was continued on Nifedipine for tocolysis with good result. She remained quite stable without contractions or vaginal bleeding until ___ when she was re-evaluated in the ATU. Her cervical length was 2.7cm without funneling. Again, a ___ was present at the inferior edge of the placenta, as well as a cervical vein in the canal and in the cervical stroma. Since her cervical length was stable, she was discharged home on bedrest and will have close outpatient followup.
| 783
| 267
|
10301071-DS-9
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary low transverse cesarean section <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 31w3d by LMP and U/S with known marginal previa (first bleed ___ presents with ___ episode of vaginal bleeding. The bleeding started at 1830 tonight when going to bathroom, had about 2 tablespoons of blood at home. She put on her pad at ___ and feels like she has been bleeding since then although she hasn't checked her pad. Has felt occasional and mild contractions since bleeding started. She reports active fetal movement. Denies chest pain, shortness of breath, palpitations, dizziness, lightheadedness, or recent trauma. No intercourse. Last ATU ___ (45%), CL 1.0 cm with funneling <PAST MEDICAL HISTORY> PRENATAL COURSE (1)Dating: ___ ___ by 7wk U/S (2)Labs: O+/Ab-,RPRnr,RI,HbsAg-,GLT nl (124) (3)nl FFS (4)posterior marginal previa discovered on FFS (___) - ___ episode VB ___, admitted ___, s/p BMZ (5)exophytic fibroid on right side of uterus, 3.1cm (6)short cervix/PTC - admitted ___, started on Nifedipine 10mg q8 - last CL ___ with funneling PAST OBSTETRIC HISTORY G1 PAST GYNECOLOGIC HISTORY - exophytic right fibroid PAST MEDICAL HISTORY - none PAST SURGICAL HISTORY - bilateral ovarian cystectomy, mini-laparotomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: T 98.6, BP 134/75, HR 92, RR 18, O2 98%RA GENERAL: NAD, flat affect CARDIO: RRR PULM: CTAB ABDOMEN: soft, NT, gravid EXTREMITIES: NT b/l SSE: approximately 150cc clot and maroon-colored blood in vault, cleared with multiple scopettes; anterior lip of cervix visualized - os difficult to visualize ___ patient discomfort; no active bleeding, no lesions Gu exam: pad complete soaked with staining of undergarment underneath -> TOTAL EBL ~250cc FHT: 140, mod var, +accels, no decels -> reactive TOCO: irreg q6-8min BPP: ___, AFI 15.5, vtx, FHR 158 <PERTINENT RESULTS> ___ WBC-10.1 RBC-3.26 Hgb-10.1 Hct-28.6 MCV-88 Plt-247 ___ WBC-10.9 RBC-3.57 Hgb-10.9 Hct-31.8 MCV-89 Plt-303 ___ WBC-15.3 RBC-2.94 Hgb-9.0 Hct-26.3 MCV-89 Plt-296 ___ Hct-25.1 ___ ___ PTT-31.2 ___ ___ ___ PTT-29.7 ___ ___ ___ PTT-29.7 ___ ___ URINE CULTURE (Final ___: NO GROWTH <MEDICATIONS ON ADMISSION> Nifedipine 10mg tid Ampicillin x 7 days for UTI <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. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every 6 hours) as needed. Disp: *60 * Refills: *1* 3. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp: *60 Capsule, Sustained Release(s)* Refills: *2* 4. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp: *30 Tablet(s)* Refills: *0* 5. Breast Pump Device Sig: One (1) Miscellaneous every four (4) hours: Infant Premature in NICU. Disp: *1 1* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p Primary LTCS for bleeding previa <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> See Discharge Instruction Sheet
|
___ G1P0 with marginal previa readmitted at 31w3d with ___ episode of vaginal bleeding. . Ms ___ was not actively bleeding on arrival to labor and delivery. There was an approximately 150cc clot in the vagina on speculum exam. She was contracting irregularly on toco and was continued on Nifedipine. Fetal testing was reassuring and she was already betamethasone complete. Her initial hematocrit was 31 then dropped to 26. Coagulation studies were normal. Since her bleeding resolved, no further labs were followed. After prolonged monitoring on labor and delivery, she was transferred to the antepartum floor. Social services followed her to assist her with coping with another potentially lengthy admission. . MFM was consulted and recommended in-house observation until delivery. Ultrasound revealed a stable cervical length (1.9cm). The placenta remained quite close to the internal os, consistent with a marginal previa. There was no evidence of a retroplacental bleed or subchorionic hematoma. There also was a persistent maternal vein in the cervical canal. Fetal testing was reassuring with a BPP ___ and AFI 12.4cm. . At 32+0 weeks gestation, she developed an acute onset of brisk vaginal bleeding. She was immediately transfered to labor and delivery. Speculum exam confirmed moderately heavy, bright red vaginal bleeding with clots. At that point, it was estimately that she had an EBL of 700ml. The decision was made to proceed with immediate cesarean section given the amount of vaginal bleeding. Liveborn male infant delivered from vertex, weight unknown at the time of delivery, and apgars were 5 and 8. NICU staff present for delivery and transferred the neonate immediately for prematurity. Please see operative report for details. Repeat coagulation studies were normal. . Ms ___ had no postoperative complications and she was discharged home on POD#4.
| 1,083
| 406
|
10301296-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> abnormal uterine bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, left salpingo-oophrectomy, left pelvic lymph node dissection, bladder and bowel implant biopsies, cystoscopy, ureteral stent placement and removal, for recurrent cervical cancer <HISTORY OF PRESENT ILLNESS> Presented with abnormal uterine bleeding, PUS ___ showing a 2.5 cm cystic mass along the mid anterior endometrium with internal vascularity. Cervical biopsies on ___ showed invasive adenocarcinoma, negative for high-risk HPV. Pelvic exam revealed a 3-4 cm mass protruding from the cervical os, and no parametrial involvement. Pelvic MRI ___ showed a 3.4 x 4.1 x 2.3 cm cervical mass with likely early left parametrial invasion => STAGE IIB. PET-CT ___ revealed an avid cervical mass with no lymphadenopathy or distant metastatic disease. S/p external beam rads therapy with concurrent chemo from ___ to ___. On ___, MRI prior to her tandem and ovoid implants revealed a 3.5 x 2.4 x 2.5 cm enlarged heterogeneous cervix with multiple small cystic areas that were similar in size, with a slight interval decrease in restricted diffusion. PET/CT ___ showed a mildly avid cervical mass with an SUV max of 2.96, previously 4.09, significantly less than before. On our review with radiology, the uptake is barely above physiologic levels. Biopsies ___ showed endocervical curettings w/ scant fragments of benign endocervix, cervix biopsy showed atypical glandular foci adjacent to thick-walled vessels suggestive of residual well-differentiated endocervical adenocarcinoma, gastric-type (adenoma malignum). Discussed at tumor board with consensus for close watching. PET/CT on ___ showed persistent low level FDG avidity in the cervix (SUV max 3.7, previously 3.1). No evidence of metastasis. Mild distension of the endometrial cavity is improved from the prior study. There is a persistent apparent 1.2 cm polypoid lesion with background FDG avidity in the endometrial cavity better evaluated on MRI of ___. She returns for scheduled follow-up. She saw Dr. ___ in ___ at which time her exam was felt to be stable. She continues to have clear mucousy discharge, feels it has been stable since completing therapy. She also has had episodes of vaginal spotting, one day she passed a small clot. This was not following dilator use or intercourse. She has noted some "menstrual cramps" that come with the bleeding. Last ___ she went to the emergency room with a panic attack. She had run out of her medications. She feels better now that she is back on her medications. She is participating in group therapy along with seeing a psychiatrist. Her husband has been encouraging her to sign up for the ___ program at the ___. She is chronically constipated, better since starting the colace/senna. She denies rectal bleeding, dysuria, hematuria, urinary frequency, urgency or incontinence, pelvic/abdominal pain, or lower extremity edema. <PAST MEDICAL HISTORY> 1. Coronary spasm status post catheterization in ___ and Plavix for one year. 2. Depression. 3. Panic disorder. 4. Chronic constipation. 5. GERD. 6. C-section and bilateral tubal ligation. 7. Hysteroscopic polypectomy. 8. Cryotherapy for cervical dysplasia in the late ___. OB/GYN HISTORY: G8P6 with two spontaneous abortions. <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Breast cancer and renal cancer in paternal grandmother diagnosed at age ___ - Leukemia in father diagnosed at age ___ - Pancreatic, lung and thyroid cancer in sister, nonsmoker, age ___ - Son with Down's syndrome, another son with autism - No known family history of uterine, ovarian, cervical or colon cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 02: 20PM GLUCOSE-95 UREA N-15 CREAT-1.0 SODIUM-142 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-17 ___ 02: 20PM estGFR-Using this ___ 02: 20PM WBC-4.4# RBC-3.69* HGB-11.3 HCT-33.7* MCV-91 MCH-30.6 MCHC-33.5 RDW-13.7 RDWSD-45.5 ___ 02: 20PM PLT COUNT-242 <MEDICATIONS ON ADMISSION> lamotrigine 150mg, lorazepam 0.5mg, metoprolol succinate 25mg, venlafaxine 150mg, Vitamin D3, Multivitamin, Vitamin B <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild 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 RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*25 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q8H: PRN Pain - Mild Do not exceed 4000mg in 24 hours. 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. LamoTRIgine 150 mg PO QHS 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Venlafaxine XR 300 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> cervical cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
|
Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparotomy, left salpingo-oophrectomy, left pelvic lymph node dissection, bladder and bowel implant biopsies, cystoscopy, ureteral stent placement and removal, for recurrent cervical cancer; plan for radical hysterectomy aborted given extra-uterine spread of disease. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with epidural and dilaudid PCA. Her diet was slowly advanced without difficulty and she was transitioned to IV dilaudid and subsequently to oxycodone/acetaminophen/ibuprofen (pain meds). On post-operative day #2, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She had difficulties with pain control and prn diazepam was added for muscle spasm pain with some improvement. She met with social work for psychosocial support and planned to have continued home meetings for support. 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.
| 1,985
| 265
|
10301296-DS-9
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___ <CHIEF COMPLAINT> dizziness s/p brachytherapy <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p Tandem and ovoid insertion, brachytherapy, same day tandem and ovoid removal <HISTORY OF PRESENT ILLNESS> ___ yo FIGO stage IIB cervical adenoma malignum adenocarcinoma with parametrial invasion, undergoing radiation and chemo (cisplatin), s/p ___ tandem and ovoid insertion/removal, brachytherapy, admitted for dizziness. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Constipation, chronic Esophageal reflux Coronary artery spasm s/p cath ___ and Plavix ___ year Perimenopause Panic disorder without agoraphobia Depression, endogenous Stage II adenocarcinoma of cervix Peptic ulcer associated with Helicobacter pylori infection ONCOLOGY HISTORY: 6 month history of a copious clear vaginal discharge. She has been ___ Hysteroscopy Dr. ___ only an endometrial polyp. Pathology showed an endocervical polyp with no evidence of malignancy and endometrial curettings were read as fragments of an endocervical polyp with fragmented endometrial gland and no intact endometrial tissue present. There was no evidence of malignancy. ___, the patient reported back stating that her discharge had not improved. On exam, she was described as having a large, friable, ectropion. ___, Cervical biopsy. Pathology: Adenocarcinoma. The tumor is similar in all three biopsies. It is comprised of lands with irregular sizes, shapes, and amounts of mucin, with absent to only minimal cytologic atypia, scattered within the stroma and showing a variable desmoplastic response. Some of the glands appeared to connect with the surface. The cells are strongly positive for MUC6, a marker of gastric type mucin, and are variably positive for CEA, negative for P16. The lesion is called adenocarcinoma, minimal deviation (adenoma alignum). The slides were reviewed at ___ and FURTHER EVALUATION: ___, Pelvic MRI, ___: The entire cervix is abnormal. It is enlarged and heterogeneous with multiple cystic spaces. It is bulging posteriorly, filling the entire external os. There s intermittent restricted diffusion throughout the entire length of the cervix, compatible with heterogeneous tumor involvement. It is difficult to differentiate what is adenoma maligna or true adenocarcinoma. Along the left posterior aspect of the cervix, just above the fornix, there is hypoenhancing tumor, which extends to and causes bulging of the cervical margin. In addition, there is abnormal signal in the parametrial tissues adjacent to this hypoenhancing tumor. The dark line of fibromuscular stroma on the T2 weighted images is lost along the left aspect of the cervix in this region. This suggests early parametrial invasion. The right side of the cervix is free of arametrial invasion. The endometrium is fluid filled and thickened, measuring up to 26 mm. Along the anterior inferior aspect, there is a 9 x 6 x 6 mm T2 dark enhancing lesion, which likely represents tumor. There is no evidence of tumor in the myometrium. Both ovaries appear normal with follicular activity. There is no adenopathy in the pelvic side walls or inguinal regions. Imaged portions of the bladder, rectum, and large and small bowel show no abnormality. /___, PET scan, ___: There is only minimal FDG avidity in the cervical tumor. However, there was some uptake in the antrum of the stomach. /___ The patient saw Dr. ___ Dr. ___. Because of the parametrial involvement, she was not felt to be a candidate for a radical hysterectomy, and chemoradiation was recommended. ___ Endoscopy, Dr ___, to evaluate FDG avid area. This showed gastritis and duodenitis/ulcer. PATHOLOGIC DIAGNOSIS (by: ___, Pathologist) A. DUODENAL BIOPSY, BULB: Severe active duodenitis with neutrophilic infiltrate in the lamina propria and surface epithelium and inflammatory exudate consistent with ulcer. .B. GASTRIC BIOPSY, ANTRUM: Antral mucosa with severe chronic active gastritis. No intestinal metaplasia or dysplasia. Immunohistochemistry stain for Helicobacter is POSITIVE (appropriate control slides reviewed). .C. GASTRIC BIOPSY, BODY: Corpus mucosa with mild chronic gastritis. No intestinal metaplasia or dysplasia. Immunohistochemistry stain for Helicobacter is POSITIVE (appropriate control slides reviewed). ___ Port-a-cath placed, ___. ___ Cycle #1 cisplatin with concomitant radiation therapy ___ Cycle ___ cycle ___ Cycle ___ Cycle ___ Cycle #7 XRT session ___ on ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Breast cancer and renal cancer in paternal grandmother diagnosed at age ___ - Leukemia in father diagnosed at age ___ - Pancreatic, lung and thyroid cancer in sister, nonsmoker, age ___ - Son with Down's syndrome, another son with autism - No known family history of uterine, ovarian, cervical or colon cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, non tender, nondistended, no rebound/guarding GU: no spotting on pad ___: nontender, nonedematous <PERTINENT RESULTS> ___ 09: 40PM GLUCOSE-128* UREA N-8 CREAT-0.8 SODIUM-142 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-30 ANION GAP-12 ___ 09: 40PM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-1.6 ___ 09: 40PM WBC-1.5* RBC-3.65* HGB-11.0* HCT-32.7* MCV-90 MCH-30.1 MCHC-33.6 RDW-14.6 RDWSD-45.4 ___ 09: 40PM PLT COUNT-176 <MEDICATIONS ON ADMISSION> 1. Acetaminophen ___ mg PO Q6H: PRN pain 2. ARIPiprazole 5 mg PO DAILY 3. Ciprofloxacin HCl 500 mg PO Q12H 4. Docusate Sodium 100 mg PO BID: PRN constipation 5. LaMOTrigine 150 mg PO QHS 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Venlafaxine XR 150 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain 2. ARIPiprazole 5 mg PO DAILY 3. Ciprofloxacin HCl 500 mg PO Q12H 4. Docusate Sodium 100 mg PO BID: PRN constipation 5. LaMOTrigine 150 mg PO QHS 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Venlafaxine XR 150 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p tandem and ovoid insertion, brachytherapy, and subsequent same day removal of tandem and ovoid implants <DISCHARGE CONDITION> Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service following brachytherapy, in the setting of feeling dizzy and lightheaded. You have recovered well after your treatment, your initial symptoms have resolved, and the team feels that you are safe to be discharged home. . * You may notice some vaginal discharge, which is normal. You will be instructed to douche with warm water twice a day until your follow-up visit. * After your implant has been removed, it is normal to experience mild pelvic discomfort, and some irritation of your vagina. You may also experience some discomfort when you urinate or move your bowels. Please be sure to discuss any changes in your urinary or bowel patterns with your nurse. * Your activities depend on how you feel. It is important to balance your activities at home with frequent rest periods. * Eating a balanced diet and drinking an adequate amount of fluids will help you to heal and regain your strength. Please follow these instructions: . * Tap water douches ___ times per day (morning and evening). * You may eat a regular diet. * Clean your skin after you urinate or move your bowels (use ___ bottle). * Refrain from sexual intercourse until your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ was admitted to the gynecologic oncology service following vaginal brachytherapy, in the setting of feeling dizzy and weak s/p treatment. She underwent placement of a tandem and ovoid implant on ___, with subsequent same day removal following brachytherapy. Please see operative report for full details. . She received brachytherapy on ___ and the tandem and ovoid implant was removed that same day. She was maintained on bedrest, a clear diet, and loperamide throughout this time. Her pain was controlled with a dilaudid PCA and oral acetaminophen. . After removal of the implant, her diet was advanced without difficulty. Her Foley catheter was removed and she voided spontaneously. She was transitioned to oral acetaminophen for her pain, with good effect. Given her dizziness, she underwent a repeat EKG, which was normal. Orthostatic vital signs were negative. She was given IVFs and a regular diet, with subsequent improvement in her symptoms. . By hospital day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and she was no longer requiring pain medications. Her dizziness was resolved. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 2,030
| 260
|
10301933-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> dysfunctional uterine bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic supracervical hysterectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G2P2 who presents with dysfunctional uterine bleeding for total laparoscopic supracervical hysterectomy. ___ years ago was seen at ___ with abnormal vaginal bleeding, heavy cycles, 12 days long, monthly. Ultrasound was done and pt was noted to have a uterine polyp, this was biopsied and normal, was given progestin for 2 months and then had to stop d/t breast tenderness. Then pt lost medical insurance and did not see anyone for ___ years. She has had continued heavy menses. Menstrual History Menses: 13 X 28 X ___ Clots: Yes. Metrorraghia: Yes. Post coital bleeding: No. Dyspareunia: Absent. Dysmenorrhea: No. Any change: Yes: Heavier cycles last ___ years. She presents at this time for surgical management. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. PAST SURGICAL HISTORY 1. Appendectomy. 2. Cholycystectomy. 3. SVD: ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: ___. Deceased: at age: ___. Father: Car accident. Deceased. <PHYSICAL EXAM> INITIAL (PRE-OP) PHYSICAL EXAMINATION WT: 220.7 BP: 122/74 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: Regular rate and rhythm, No edema or varicosities. Lungs: Clear, Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skein & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, well supported, Cystocel absent, Rectocel absent, Bladder non-tender, no masses appreciated. Cervix: No CMT, no lesions, no discharge. Uterus: Small, reg, mobile, NT, Prolapse absent, *Abnormal: 12 cm size. Adnexa: Small, non-tender, no masses or nodules. Rectal: Nl anus & perineum, No hemorrhoids, Nl NT, no masses. DISCHARGE PHYSICAL EXAM: VSS and wnl NAD, comfortable RRR, no m/r/g CTAB Abdomen: soft, non-distended, non-tender Incisions: c/d/i GU: minimal spotting on pad Ext: no edema, no tenderness <PERTINENT RESULTS> Pathology pending at time of discharge. <MEDICATIONS ON ADMISSION> Lisinopril 20mg Daily, Centrum, Metformin 500mg PO Daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4000 mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *2 2. Docusate Sodium 100 mg PO BID Take to prevent constipation while you are taking narcotics. Hold for loose stools. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q8H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 4. Lisinopril 20 mg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO DAILY 6. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> dysfunctional 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 undergoing the procedures listed below. You have recovered well and the team feels you are safe for discharge home at this time. 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing laparoscopic supracervical hysterectomy. 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, acetaminophen, and ibuprofen. Her home medications were restarted. 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.
| 1,405
| 164
|
10302356-DS-19
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Demerol / Erythromycin / Codeine / Percocet / Darvon <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal Bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exam Under Anesthesia with Biopsy of lesion <HISTORY OF PRESENT ILLNESS> ___ with 5 weeks of intermittent vaginal spotting, heavier bleeding two days ago that soaked through her clothing and sheets and subsequently stopped. Was seen by her primary gyn in the office today who attempted to introduce a pediatric speculum into the vagina inducing bleeding again. After initial brisk bleeding, it slowed to a trickle and finally only spotting. Currently, the patient denies any active bleeding and has been wearing the same pad for the last 5 or 6 hours which is not soaked. Her gynecologist felt that the bleeding was coming from a lesion at the top of the vagina but the exam was limited by bleeding and discomfort. Prior workup of this vaginal bleeding includes an transabdominal pelvic ultrasound (unable to tolerate transvaginal ultrasound) that reportedly demonstrated a 2mm endometrial stripe, no fibroids, normal right ovary and unseen left ovary (report not available). Review of systems is positive for intermittent burning with urination earlier today, bilateral pedal and ankle swelling this morning (has resolved). Denies chest pain, shortness of breath, dizziness, lightheadedness, diarrhea, constipation, change in bowel habits, hematochezia, nausea, vomiting, loss of appetite. <PAST MEDICAL HISTORY> OB History: Vaginal delivery x 2, SAb x 1 Gynecologic History: Has never had a Pap smear or regular gynecologic care, denies any gynecologic problems <PAST MEDICAL HISTORY> 1. Hypertension 2. Hiatal hernia 3. Left leg "nerve problem" Past Surgical History: 1. Right inguinal hernia repair ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-Contributory <PHYSICAL EXAM> (On Admission) <PHYSICAL EXAM> Vital Signs: T 99.0, HR 102, BP 140/90, RR 16, O2 sat 97% on RA General: Well appearing Lungs: CTAB CV: RRR Abd: soft, nontender GU: pad examined, only scant blood on pad (~5 x 1 cm stripe); digital/speculum exam deferred to avoid exacerbating bleeding <PERTINENT RESULTS> ___ 03: 55PM BLOOD WBC-7.0 RBC-3.84* Hgb-11.4* Hct-35.6* MCV-93 MCH-29.8 MCHC-32.1 RDW-12.0 Plt ___ ___ 06: 43PM BLOOD WBC-8.3 RBC-3.84* Hgb-11.4* Hct-33.9* MCV-88 MCH-29.6 MCHC-33.5 RDW-12.6 Plt ___ ___ 12: 00AM BLOOD WBC-7.4 RBC-3.53* Hgb-10.8* Hct-31.8* MCV-90 MCH-30.5 MCHC-33.9 RDW-12.3 Plt ___ ___ 06: 43PM BLOOD ___ PTT-24.1 ___ ___ 06: 43PM BLOOD Glucose-108* UreaN-23* Creat-0.7 Na-140 K-3.7 Cl-104 HCO3-27 AnGap-13 <MEDICATIONS ON ADMISSION> 1. Diovan 80mg BID 2. Pantoprazole 10mg daily (has compounded into liquid, cannot swallow pill) 3. Caltrate 4. Centrum multivitamin <DISCHARGE MEDICATIONS> 1. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal Mass <DISCHARGE CONDITION> Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - You may take Tylenol for discomfot - Nothing in the vagina (No sex, tampons or douching) - You may have some coffee-ground discharge from the vagina and this is okay *) Call you doctor @ ___ for: - Fever > 101 or chills - Dizziness, lightheaded - Chest Pain - Shortness of Breath - Severe Abdominal Pain - Inability to tolerate food - Heavy Vaginal Bleeding (saturating 1 pad/hr) - Any other concerns you may have
|
Ms. ___ is an ___ year old female who was admitted to the OB Gyn Service in the setting of vaginal bleeding following a pelvic examination in her primary gynecologists office. Per her physician, ___ lesion was visualized at the top of the vagina as the source of bleeding. Given the amount of vaginal bleeding she was experiencing, it was recommended that she be admitted for further observation. On the evening of her admission, the patient's vaginal bleeding ceased while in the Emergency Department and she remained hemodynamically stable overnight. Her Hct remained stable around 32. Given the lesion noted on her primary gynecologists pelvic examination, the decision was made to obtain an abdominal and pelvic MRI to further characterize the lesion and guide further management. The MRI demonstrated a 4 x 2 cm vaginal mass originating from the posterior wall and growing into the vagina. On MRI, the mass did not appear to involve the bladder, bowel or cervix. Given this finding, the decision was made to proceed to the operating room for an examination under anesthesia and to obtain a biopsy of the lesion. She underwent a general medicine consult for ___ medical clearance. In the operating room, an exam under anesthesia demonstrated a cervical mass originating from the posterior aspect of the cervix. She did well post-operatively and was discharged to home in good condition. She will follow-up with Dr. ___ on ___.
| 1,106
| 278
|
10303920-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lyrica <ATTENDING> ___ <CHIEF COMPLAINT> pelvic organ prolapse, stress urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic-assisted laparoscopic supracervical hysterectomy, bilateral salpingo-oophorectomy, sacrocervicopexy, transvaginal tape suburethral sling, vulvar biopsy, cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ woman who presents with urinary incontinence as well as bulge and tissue protrusion from the vagina. She states that the sensation of bulge and pressure has been going on for several months now. It is intermittent. It is bothersome, however. She is a self described very active person and goes to gym several times a week. She also leaks urine on occasion. She does wear a panty liner. It typically happens when she has been seated on a couch for a while and then stands up. She does go to bathroom frequently, especially in the morning. She describes it as every hour and a half. She does drink coffee in the morning. She wakes up once at night to urinate. She denies recurrent bladder infections, hematuria or dysuria. She has normal urine flow. She has rare constipation and no fecal incontinence. She is not currently sexually active. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Hypertension, low back pain. Past Surgical History: Cholecystectomy in ___, lumbar laminectomy in ___, knee replacement on the right side ___, ablation in ___. Past OB History: Gravida 3, para 3. Birth weight of largest baby delivered vaginally is 7 pounds 15 ounces. Does not know if she has had forceps or vacuum-assisted deliveries. <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> Father had heart attack, hypertension and stroke as well as mental illness. <PHYSICAL EXAM> General: Well developed, well groomed, normal body habitus. Psych: Oriented x 3, affect is normal. Skin: Warm and dry. Normal respiratory effort. Abdomen: Soft, nontender. No masses, guarding or rebound. No hepatosplenomegaly noted. Pulse normal rate and rhythm. No pedal edema or varicosities. External genitalia is normal with no lesions or discharge. Urethral Meatus: No caruncle or prolapse. Urethra is nontender, no masses or exudate. Bladder: Nonpalpable, nontender. Vagina is atrophic, significant for prolapse, see POP-Q below. Cervix normal. Bimanual: No masses or tenderness of the uterus or adnexa. Anus and perineum are normal. Supine empty stress test was negative. Post-void residual volume obtained via catheterization was 100 mL of clear urine. POP-Q: Aa +1, Ba +3.5, C 0. ___ 4, PB 3, TVL 7.5. Ap -2, Bp -2, D -4. Uroflowmetry: The patient voided 160 mL, continuous bell-shaped curve, max flow 8 mL/sec, average flow 5 mL/sec, voiding time 32 seconds, flow time 32 seconds, time to max flow 6 seconds. On day of discharge: afebrile, vital signs stable Gen: NAD Pulm: normal work of breathing Abd: soft, nondistended Ext: no edema <PERTINENT RESULTS> none <MEDICATIONS ON ADMISSION> aspirin 81mg, cod liver oil, multivitamin, vitamin B <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse, stress urinary incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. 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 ___.
|
On ___ Ms. ___ was admitted to the gynecology service after undergoing robot-assisted supracervical hysterectomy, bilateral salpingooophrectomy, sacrocervicopexy, transvaginal tape, vulvar biopsy 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, toradol and acetaminophen. On post-operative day 1, her urine output was adequate so her foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 300 mL with 160 mL straight-cath. 2. Instilled 300 mL, voided 300 mL with 163 mL residual. Her diet was advanced without difficulty and she was transitioned to oral oxycodone, tylenol and motrin. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,361
| 244
|
10304185-DS-21
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> intrauterine fetal demise <MAJOR SURGICAL OR INVASIVE PROCEDURE> induction of labor for intrauterine fetal demise, vaginal delivery <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old G6P3 @ 38 weeks 3 days who presented to clinic today for routine prenatal visit with subjective complaint of decreased fetal movement. Patient last felt fetal movement yesterday. In clinic, patient was diagnosed with IUFD by no fetal heart tones on doppler and confirmed with absent fetal cardiac activity on ultrasound. Since arrival to L&D, she reports spotting and some cramping. No loss of fluid. <PAST MEDICAL HISTORY> PNC: 1. ___: ___ 2. O+/Ab neg/RPR NR/RI/HBsAg neg/HIV neg/GBS neg 3. Normal FFS 4. Low risk Quad OBHx: - SVD x 3, all del at terms - SAB x 2, D&Cx2 (8 wks and 12 wks) GynHx: - h/o ASC suggestive of LSGIL ___, s/p biopsy ___, normal paps since. Most recent ___ negative PMH: Depression/Anxiety not currently on medications PSH: D&C x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: VS: 98.4 88 116/78 20 NAD, appropriately teary Abd: Soft, gravid, NT, EFW 7.5# SVE: ___ Toco: Q3-6 min On discharge: VSS NAD, comfortable RRR, no m/r/g CTAB Abdomen: soft, non-tender, non-distended, +BS, fundus firm 2 cm below umbilicus GU: minimal lochia Ext: no edema, no tenderness <PERTINENT RESULTS> ___ 01: 10PM BLOOD WBC-11.1* RBC-4.42 Hgb-12.6 Hct-36.6 MCV-83# MCH-28.6 MCHC-34.5 RDW-13.9 Plt ___ ___ 01: 10PM BLOOD ___ PTT-30.0 ___ ___ 01: 10PM BLOOD ___ ___ 01: 10PM BLOOD FetlHgb-0 ___ 01: 10PM BLOOD ACA IgG-3.6 ACA IgM-5.9 ___ 01: 10PM BLOOD Glucose-89 Creat-0.6 ___ 01: 10PM BLOOD ALT-15 LD(LDH)-188 ___ 01: 10PM BLOOD UricAcd-4.5 ___ 01: 10PM BLOOD TSH-1.9 ___ 01: 10PM BLOOD ___ ___ 01: 10PM BLOOD PARVOVIRUS B19 DNA-NOT DETECTED ___ 01: 10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ 1: 10 pm Blood (Toxo) TOXOPLASMA IgG ANTIBODY (Final ___: NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final ___: NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. ___ 1: 10 pm Blood (CMV AB) CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 87 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. ___ 1: 10 pm SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Pathology pending. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 4. Lorazepam 0.5 mg PO Q6H: PRN anxiety RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 6 hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> intrauterine fetal demise <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 or ativan Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting or any other concerns
|
Ms. ___ is a ___ year old G6P3 @ 38 weeks 3 days who presented to L&D on ___ with an IUFD which was confirmed on bedside US. Given that the patient was at ___ with contractions, decision was made for induction of labor with pitocin. Patient received an epidural and underwent uncomplicated induction of labor with pitocin. Patient vaginally delivered a non-viable fetus on ___. Patient declined cytogenetics and autopsy. IUFD from unclear etiology. Patient underwent work-up including infectious work-up, thrombophilia evaluation, toxic work-up, all of which were negative. Patient was offered social work and clergy. She had her own pastor, but did accept social work consult, and this service followed her throughout her hospitalization. Patient had an uncomplicated post-partum course. She had initially requested PPTL, but given IUFD and concern by providers for high likelihood of regret, patient agreed to wait until post-partum follow-up visit to decide. Patient was discharged on post-partum day 1 with outpatient follow-up at ___ in 2 weeks and to follow up with ___ behavioral health.
| 1,371
| 235
|
10304185-DS-22
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> decreased FM <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G8P4 at 34w GA with hx 37w IUFD presents to triage with decreased fetal movement since yesterday. Felt "different movements" yesterday and then only one movement this morning, which prompted her to call. She was called into triage. She has felt well otherwise. She denies any vaginal bleeding, cramping/contractions or leaking of fluid. Was last seen in ___ 3 days ago with normal testing. No recent trauma or illness. PNC: ___ ___ by 6wk US O+/ab neg/RPRNR/RI/HBsag neg/HIV neg/GBS unk remote hx anti-I antibodies in ___, neg since LR ___ FFS Elevated GLT, normal 3 hour GTT Followed by ___ for hx of term IUFD, EFW ___ 63% scan on ___: BPP ___, cephalic, AFI 14 <PAST MEDICAL HISTORY> OB History: Term SVD x 3, largest 7#0. Most recently, in ___, Term IUFD with SVD at 37 weeks. Negative work up for IUFD incl neg antiphospholipid antibodies, toxo/parvo/CMV neg, neg FMH, declined autopsy, path showed placenta <10% for GA with villitis. unclear if parental karyotypes ever done. SAB x 3, most recent with normal karyotype 46XX. GYN Hx: Remote hx of abnormal paps, no cervical procedures. Denies STI hx. PMH: Depression (followed at ___ mental health, no meds), bipolar, migraines PSH: D&C x 3 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Physical Exam afebrile 98.5, HR 81 RR 16 125/68 Gen: NAD, well appearing, tearful Abd: soft, NT, gravid s=d, no fundal tenderness ext: wwp, no edema SVE: open external os ~2cm, internal os closed TAUS: cephalic IUP, no FHT confirmed by Dr ___ ___, fluid grossly normal, small amount of ascites around liver On discharge: VSS Gen: NAD, CV RRR Pulm no respiratory distress Abd: soft, approp tender, no R/G ext: no TTP <PERTINENT RESULTS> ___ 11: 00AM BLOOD WBC-10.4 RBC-4.37 Hgb-12.5 Hct-35.3* MCV-81* MCH-28.6 MCHC-35.4* RDW-13.0 Plt ___ ___ 11: 00AM BLOOD Neuts-80.8* Lymphs-12.3* Monos-6.0 Eos-0.4 Baso-0.4 ___ 11: 00AM BLOOD ___ PTT-29.1 ___ ___ 11: 00AM BLOOD ___ ___ 11: 00AM BLOOD Glucose-81 Creat-0.5 ___ 11: 00AM BLOOD ALT-17 LD(LDH)-188 ___ 11: 00AM BLOOD UricAcd-3.6 ___ 10: 27AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG marijua-NEGATIVE ___ 11: 00AM TSH-1.4 ___ 10: 27 am Blood (CMV AB) Source: Venipuncture. **FINAL REPORT ___ CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 60 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. A positive IgG result generally indicates past exposure. Infection with CMV once contracted remains latent and may reactivate when immunity is compromised. Greatly elevated serum protein with IgG levels ___ mg/dl may cause interference with CMV IgM results. If current infection is suspected, submit follow-up serum in ___ weeks. ___ 10: 27 am SEROLOGY/BLOOD Source: Venipuncture. **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. ___ 10: 27 am Blood (Toxo) Source: Venipuncture. **FINAL REPORT ___ TOXOPLASMA IgG ANTIBODY (Final ___: NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final ___: NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. The FDA is advising that the result from any one toxoplasma IgM commercial test kit should not be used as the sole determinant of recent toxoplasma infection when screening a pregnant patient. <DISCHARGE INSTRUCTIONS> Dear Ms. ___, We are sorry for your loss. Please follow the instructions below for your postpartum care. Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs
|
Ms. ___ is a ___ G8P4 who presented with a ___ GA IUFD with a history of a prior term IUFD. She was seen by social work during her stay. Infectious workup and labs were sent. Urine toxicity was negative. She underwent an induction of labor with misoprostol and subsquently had a vaginal delivery of a stillborn infant. Karyotype and autopsy will be done. She had an uncomplicated post partum course and was followed by social work. She was discharged home on post partum day 2 in stable condition with outpatient follow up. Discharge Medications: 1. Acetaminophen ___ mg PO Q4H:PRN Pain not to exceed 4g acetaminophen/Tylenol in 24 hrs RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*1 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 capsule(s) by mouth every 4 hours Disp #*10 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: intrauterine fetal demise Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
| 1,301
| 394
|
10304636-DS-7
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy right salpingo-oophorectomy cystoscopy <HISTORY OF PRESENT ILLNESS> The patient is a ___ G2, P2 sent by Dr. ___ for a consultation regarding a pelvic mass. She presented with lower abdominal discomfort in ___. She had a CT of the abdomen and pelvis, which revealed a 10.8 cm pelvic mass, which was largely cystic. She had a followup pelvic ultrasound on ___, which revealed an 11 cm hypoechoic cyst with low-level echos and thick walls. There was no free fluid. A subsequent CA-125 was 84. The patient was already seen and examined by Dr. ___, who recommended surgical management of the pelvic mass. She felt that given the complex nature of the mass and the elevated CA-125, referral to gynecologic oncology was appropriate. The patient has a history of undergoing TAHBSO in ___ for what she describes as a large but benign ovarian cyst. Of note, she states that her pain has essentially resolved after lasting about two or three weeks. She took some herbal medication and thinks that this may have resulted in resolution of the cyst. Pt had an interval US which showed enlargement of the cyst so the decision was made to proceed with surgical excision of the mass to rule out malignancy. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Significant for hypertension. PAST SURGICAL HISTORY: Appendectomy in ___ for ruptured appendix, open cholecystectomy ___, TAHBSO ___. OBSTETRICAL HISTORY: Vaginal delivery x2. GYNECOLOGICAL HISTORY: Last Pap smear is unknown. Last mammogram was ___ and normal. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for malignancies. <PHYSICAL EXAM> GENERAL APPEARANCE: Well developed, well nourished. HEENT: Sclerae anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. ABDOMEN: Soft and nondistended and without palpable masses. There were multiple healed abdominal incisions with no evidence of hernia. There was no tenderness. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was surgically absent. Bimanual and rectovaginal examination revealed a palpable mass at the vaginal apex, which was somewhat mobile and smooth, measuring about 10 cm. There was no tenderness. There was no associated cul-de-sac nodularity and the rectal was intrinsically normal. <MEDICATIONS ON ADMISSION> metoprolol, flonase prn, asmanex prn, albuterol prn, nasonex prn <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *60 Tablet(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp: *60 Tablet(s)* Refills: *0* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* 4. Albuterol 90 mcg/Actuation Aerosol Sig: ___ Puffs Inhalation Q6H (every 6 hours) as needed. 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal BID (2 times a day) as needed. 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic mass <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> -Please call your physician if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, chest pain, trouble breathing, or vaginal bleeding. Please call if you have redness and warmth around your incision, if you have any pus-like drainage from your incision, or if your incision reopens. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal completely. - Nothing per vagina (no tampons, intercourse, douching) for 4 weeks. - No driving for two weeks; no driving while taking narcotic pain medications as they can make you drowsy. - Please keep your follow-up appointments as outlined below.
|
___ was admitted after exploratory laparotomy, lysis of adhesions, right salpingo-oophorectomy, and cystoscopy done to remove a pelvic mass noted on CT and US. Preliminary frozen pathology was benign intraop. Please see operative report for details. Pt received routine post-op care and was discharged home in good condition on POD#2.
| 1,095
| 78
|
10306584-DS-19
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfonamides <ATTENDING> ___. <CHIEF COMPLAINT> hemorrhoid pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 32+4 WGA (EDC ___ presents to OB triage for evaluation of hemorrhoid pain. Incidentally found to have labile BP's in triage and transaminitis. Reports "always having low blood pressure". Denies headache, visual changes, or right upper quadrant pain. Has had contact with an aunt visiting from ___, who has had a viral URI sx. Denies N/V. Normal fetal movement. No leaking of fluid or contractions. Reports unremarkable pregnancy until today. The patient denies recent infections. Has no abdominal pain. She has not had fevers or chills. <PAST MEDICAL HISTORY> PRENATAL COURSE *) Dating: EDC: ___ by LMP *) Labs: PNC records are unavailable for my review, benign per primary attending and patient. OBSTETRIC HISTORY nullip PAST GYNECOLOGIC HISTORY denies STD's, abnl pap, fibroids PAST MEDICAL HISTORY IBS asthma SURGICAL HISTORY open appendectomy, not ruptured (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 98.2, HR 82, RR 18, BP 121-145/84-100 GENERAL: NAD, well appearing LUNGS: CTA bilaterally HEART: RRR ABDOMEN: soft, gravid, NT. No fundal TTP. SVE: LCP by Dr. ___: NT/NE Rectal: 8cm external hemorrhoids, non-thrombosed, TTP FHT: 140/MOD/ + Accel/ no decel TOCO: some irritability, resolved BPP: ___, vtx, AFI 13.5 <PERTINENT RESULTS> ___ WBC-10.2 RBC-4.75 Hgb-13.3 Hct-39.5 MCV-83 Plt-307 ___ WBC-10.5 RBC-3.99 Hgb-11.4 Hct-32.9 MCV-82 Plt-241 ___ WBC-10.1 RBC-4.52 Hgb-12.4 Hct-37.9 MCV-84 Plt-265 ___ ___ PTT-24.9 ___ ___ ___ PTT-25.0 ___ ___ BUN-10 Creat-0.8 ALT-106 AST-59 UricAcd-7.1 ___ Glu-142 BUN-9 Creat-0.8 Na-135 K-4.3 Cl-106 HCO3-19 ___ ALT-109 AST-59 LD(LDH)-176 TotBili-0.3 UricAcd-7.0 ___ Creat-0.8 ALT-101 AST-51 UricAcd-6.8 ___ Creat-0.7 ALT-122 AST-45 UricAcd-5.6 ___ BLOOD Hapto-40 ___ BLOOD HBsAg-NEG HAV Ab-POS IgM HAV-NEG HCV Ab-NEG ___ URINE Hours-RANDOM Creat-75 TotProt-11 Prot/Cr-0.1 ___ URINE 24Creat-1137 24Prot-134 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG CMV IgG ANTIBODY (Final ___: NEGATIVE FOR CMV IgG ANTIBODY BY EIA. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. ___ VIRUS VCA-IgG AB (Final ___ BY EIA ___ VIRUS EBNA IgG AB (Final ___ BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1: 10 BY ___ <MEDICATIONS ON ADMISSION> prenatal vitamins colace flovent albuterol <DISCHARGE MEDICATIONS> 1. Pramoxine-Mineral Oil-Zinc ___ % Ointment Sig: One (1) Appl Rectal AS NEEDED () as needed for pain. 2. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal BID (2 times a day). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q4H PRN () as needed for pain. Disp: *1 tube* Refills: *2* 5. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pregnancy at 32 wks Elevated liver function tests <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call or return to the hospital if you have a headache, visual changes, pain in the upper ride side of your abdomen, contractions, vaginal bleeding, leakage of fluid, or decreased fetal movement.
|
___ y/o G1 P1 admitted at 32+4 weeks gestation with elevated BP's, noted to have transaminitis, creatinine of 0.8, concerning for atypical HELLP. . Ms ___ was admitted for observation and serial preeclampsia labs. She denied any preeclampsia symptoms and a 24 hour urine collection was negative. In regards to preeclampsia labs, her platelets and LFTs stabilized. Viral studies, including hepatitis serologies, EBV, and CMV were negative. (she has history of Hepatitis A exposure in past) Fetal testing was reassuring. She received a course of betamethasone for fetal lung maturity (complete on ___. A NICU consult was obtained. ___ (Dr ___ was consulted and felt that it was unlikely she had HELLP since she had normal blood pressures, negative protein, and stable platelets and hematocrit. He felt that close outpatient followup of her blood pressures and labs was appropriate. . In regards to her hemorrhoid pain, general surgery was consulted and since her hemorroids were not thrombosed, supportive care was recommended. She received a bowel regimen, TUCKS pads, and po dilaudid prn. . She was discharged home on ___ and will have close outpatient followup. She will get repeat labs on ___. . Of note, Ms ___ is a ___ Witness and declines blood transfusions. She will accept cryoprecipitate, albumin, hespan, cell salvage/cell saver. The Release of Liability for Blood-free treatment was signed by the patient on ___.
| 1,204
| 337
|
10308729-DS-13
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> thimerosal / eggplant <ATTENDING> ___ <CHIEF COMPLAINT> elevated blood pressures <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 36w0d, with a history of cHTN (no meds currently), here for elevated blood pressure in the office today (170/110). She also endorses ___ headache since this AM (does not feel like her normal migraines) and blurry vision since this past weekend. Also endorses some RUQ "discomfort" since this morning. No contractions, no vaginal bleeding, no leaking fluid. Active fetal movement. No SOB or CP. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP - Labs ___ pending (drawn in office today) - Screening low risk ERA - FFS normal - GLT passed - U/S ___ (AMA, cHTN): 2694 grams, 50% - Issues: -->cHTN, on aspirin this pregnancy -->Baseline PEC labs (normal) and 24 hour urine protein 348 --___ normal PIH labs (plt 148), P/C 0.1 OBHx: - G1 current GynHx: - Abn pap ___, growth removed, normal f/u. - denies history of STIs PMH: cHTN (on metoprolol prior to pregnancy), migraines with aura, anxiety/PTSD (sees therapist) PSH: T&A ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: Vitals: ___ ___: 79 ___ 13: 30BP: 147/105 (115) ___ 13: 40BP: 146/92 (106) ___ 13: 45BP: 151/92 (107) Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender (no right upper quadrant tenderness) EFW 6 pounds by ___ Ext: non tender Toco: no contractions FHT 140/moderate varability/+accels/-decels On discharge: Exam: Gen: well-appearing, NAD VS: 130/80, 78, 20, 98.3 BPs ___ Abd: soft, gravid, NT. no RUQ tenderness Ext: no calf tenderness <PERTINENT RESULTS> ___ WBC-8.9 RBC-3.63 Hgb-12.4 Hct-34.5 MCV-95 Plt-133 ___ Creat-0.5 ALT-13 AST-21 UricAcd-4.1 ___ URINE Color-Yellow Appear-Hazy Sp ___ ___ URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-1 ___ URINE Hours-RANDOM Creat-79 TotProt-8 Prot/Cr-0.1 ___ URINE pH-7 Hours-24 Volume-4800 Creat-37 TotProt-5 Prot/Cr-0.1 ___ URINE 24Creat-1776 24Prot-240 R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> PNV aspirin tums/zantac <DISCHARGE MEDICATIONS> Famotidine 20 mg PO BID: PRN reflux, RUQ pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 36w1d chronic hypertension <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for observation due to elevated blood pressures. Your blood pressures improved and you had no evidence of preeclampsia. Fetal testing was reassuring while you were here. You received a course of betamethasone (steroids) for fetal lung maturity. Please follow the instructions below: - Attend all appointments with your obstetrician and all fetal scans - Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Blood pressure >160/110 - Other concerns
|
___ G1P0 with chronic HTN admitted at 36w0d for rule out preeclampsia. On admission, she had mild range blood pressures and normal labs. Fetal testing was reassuring. She received a course of betamethasone for fetal lung maturity (complete ___ and testing was reassuring in the ___ on ___. Her 24 hour urine was negative (240mg). Aside from one severe range BP on HD#1, her blood pressures stayed in the normal to mild range. She had intermittent headaches which responded to po Tylenol. MFM was consulted and recommended outpatient management with close surveillance and induction at 37 weeks. She was discharged home on ___ in stable condition.
| 1,005
| 145
|
10309648-DS-9
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, small bowel oversew <HISTORY OF PRESENT ILLNESS> ___ ___ 4, para 2, who presented for a planned hysterectomy for symptomatic fibroid uterus with menorrhagia and bulk symptoms. She has a known fibroid uterus that measured 18 cm on ___, with multiple fibroids. She was given a one-month Lupron injection in GYN triage on ___ and a three-month Lupron injection in ___ at the followup. Her menopause symptoms were worse with the three-month Lupron so was maintained since ___ on the one-month 3.75mg dose. Since her last Lupron injection, she reported that she has had minimal vaginal bleeding. She has spotting on days right before her next Lupron is due. She continues to have pressure from her fibroid uterus. Endometrial biopsy on ___: Inactive endometrium. Pelvic ultrasound on ___: uterus measuring 18 cm with multiple fibroids. The dominant fibroid was 5.3 cm. The left ovary was normal and the right ovary was not visualized due to an exophytic 2.5 cm fibroid in the way. <PAST MEDICAL HISTORY> 1. Hypertension. 2. Obesity, BMI >40. 3. Unprovoked right calf DVT on ___, s/p 6 months anticoagulation. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She has no family history of uterine, cervical, ovarian, or colon cancer. <PHYSICAL EXAM> On day of discharge: AFVSS NAD CTAB RRR abd: soft, appropriately tender, no rebound or guarding, incision c/d/i ___: nt,nd <PERTINENT RESULTS> ___ 05: 54AM BLOOD WBC-7.5 RBC-3.30* Hgb-10.2* Hct-31.0* MCV-94 MCH-30.8 MCHC-32.7 RDW-13.5 Plt ___ ___ 09: 25AM BLOOD WBC-8.9# RBC-3.48* Hgb-10.7* Hct-32.9* MCV-95 MCH-30.8 MCHC-32.6 RDW-13.1 Plt ___ ___ 05: 54AM BLOOD Glucose-82 UreaN-6 Creat-0.7 Na-140 K-4.2 Cl-105 HCO3-30 AnGap-9 ___ 09: 25AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-136 K-4.1 Cl-103 HCO3-29 AnGap-8 ___ 05: 54AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.7 ___ 09: 25AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 <MEDICATIONS ON ADMISSION> 1. LEUPROLIDE [LUPRON DEPOT] - Lupron Depot 3.75 mg intramuscular syringe kit. 3.75 mg IM monthly stop on ___ 2. NIFEDIPINE - nifedipine ER 60 mg tablet,extended release. 1 tablet extended release(s) by mouth once a day 3. WEIGHT WATCHERS - weight watchers . please start weight watchers on ___ each week OTC 1. FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 (One) Tablet(s) by mouth three times a day 2. KETOTIFEN FUMARATE [ANTIHISTAMINE EYE DROPS] - Antihistamine Eye Drops 0.025 %. 2 drops per eye up to three times a day as needed for itching <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 3. NIFEdipine CR 60 mg PO DAILY 4. Rivaroxaban 10 mg PO DAILY Duration: 4 Weeks RX *rivaroxaban [Xarelto] 10 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills: *0 5. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain Do not drive or combine with alcohol. ___ cause sedation. RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every ___ hours Disp #*50 Tablet Refills: *0 6. Acetaminophen ___ mg PO Q6H: PRN pain Do not take >3000mg acetaminophen in 24h. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office at ___ 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 but if you feel bloated or nauseated, cut back to clear liquids for 24 hours and call if the symptoms persist after that point. * 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. * Your staples will be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms ___ underwent a TAH, complicated by a 1mm small bowel serosal injury repaired with small bowel oversew; see operative report for details. Her recovery was uncomplicated, included conservative diet management and her discharge was contingent upon flatus. IS and pboots were utilized. She was discharged home on postoperative day #2 in good condition: ambulating and voiding without difficulty, tolerating a regular diet, passing flatus and with adequate pain control using PO medication.
| 1,542
| 99
|
10310090-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus, infertility <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy and left ovarian cystectomy <PHYSICAL EXAM> Discharge physical exam Vitals: stable and within normal limits Gen: no acute distress; alert and oriented to person, place, and date CV: regular rate and rhythm; no murmurs, rubs, or gallops Resp: no acute respiratory distress, clear to auscultation bilaterally Abd: soft, appropriately tender, no rebound/guarding; incision clean, dry, intact Ext: no tenderness to palpation <PERTINENT RESULTS> Labs on Admission: ___ 08: 40AM BLOOD WBC-5.0 RBC-5.10 Hgb-14.1 Hct-44.1 MCV-87 MCH-27.6 MCHC-32.0 RDW-13.2 RDWSD-41.5 Plt ___ <MEDICATIONS ON ADMISSION> MY KIND ORGANIC PRENATAL VITAMINS - My Kind Organic Prenatal Vitamins . one tablet daily - (OTC) <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: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *1 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus, infertility <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing an abdominal myomectomy and ovarian cystectomy. Please see the operative report for full details.Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and IV toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, ibuprofen, and acetaminophen. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 986
| 162
|
10310912-DS-2
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Ovarian carcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> TOTAL ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, OMENTECTOMY, TUMOR DEBULKING, RADICAL PELVIC DISSECTION <HISTORY OF PRESENT ILLNESS> ___ who was recently found to have findings highly suspicious for metastatic ovarian malignancy. She presented with lower back pain and lower abdominal pain, especially in the left lower quadrant, to urgent care in early ___. CT scan of the abdomen and pelvis demonstrated evidence of carcinomatosis with peritoneal and omental soft tissue and peritoneal soft tissue nodules and mesenteric stranding as well as perihepatic and subcapsular soft tissue lesions in the liver. There are also mildly enlarged upper abdominal and retroperitoneal lymph nodes as well as a poorly defined uterus and bilateral ovarian low-attenuating lesions. She also had evidence of a 1.3-cm short axis right cardiophrenic lymph node that was concerning for metastatic disease. Tumor markers drawn on ___, revealed a CA-125 of 1261 ___s a CEA of 1.3 and a CA ___ of 16.7, the latter two of which are normal. She has seen Dr. ___ on ___, who is ready to start chemotherapy for her at the appropriate time after consultation with us. Notably, she also had a transvaginal ultrasound on ___, that demonstrated an 11.7 x 7.1 x 6.4 cm uterus with a 7-mm endometrial stripe. The left ovary contained two simple-appearing cysts and extending from the left ovary, there was a region of soft tissue measuring 6.6 cm in greatest dimension. No free fluid was seen. The right ovary was not identified. On 14-point review of systems, ___ also reports low-grade fevers, recent weight changes, changes in her vision, hearing loss, nasal discharge, palpitations, shortness of breath with exertion, abdominal pain, nausea, incontinence of urine, pelvic discomfort, arthralgias and myalgias, limb swelling in the ankles, unwanted hair growth, night sweats, ringing in the ears, paresthesia, anxiety and hot flashes. She notes that she has abdominal distention, especially in the upper abdomen. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> She also has a history of hypothyroidism and hypertension. Past Surgical History: She had her tonsils removed in ___. She had a D&C in the year ___ and a sphincterectomy in ___. Lumpectomy for benign disease. OB History: She is gravida 3, para 2. GYN History: Menarche at age ___. She is premenopausal. Her last menstrual period was on ___. She had previously been on oral contraceptive pills for ___ years. Her last Pap smear was approximately 18 months ago. She has never had an abnormal Pap. She had a breast lumpectomy for benign disease. <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> Extensive for breast cancer. Seven of her cousins have had breast cancer and one died from the disease, one great grandmother on the maternal side also had ovarian cancer. There is no other malignancy known in the family. Hypertension is also in the family. No one in the family has had genetic testing for a cancer causing mutation. Dr. ___ has already discussed with her genetic testing given this extensive family history. <PHYSICAL EXAM> General: NAD, comfortable CV: RRR Lungs: CTA at the apices, crackles in the dependent areas/bases Abdomen: soft, obese, mildly distended and tympanic, appropriately tender to palpation without rebound or guarding, incision clean/dry/intact closed with staples GU: foley draining clear urine Extremities: no edema, no TTP, pneumoboots in place bilaterally Sacrum: bandage in place for concern for pressure sore, improving erythema <PERTINENT RESULTS> ___ 07: 25AM BLOOD WBC-4.6 RBC-3.59* Hgb-10.9* Hct-30.9* MCV-86 MCH-30.4 MCHC-35.3 RDW-19.5* RDWSD-56.4* Plt Ct-89* ___ 12: 58PM BLOOD WBC-11.7* RBC-3.62* Hgb-11.3 Hct-31.8* MCV-88 MCH-31.2 MCHC-35.5 RDW-19.6* RDWSD-57.5* Plt ___ ___ 05: 49AM BLOOD WBC-9.7 RBC-2.99* Hgb-9.3* Hct-26.3* MCV-88 MCH-31.1 MCHC-35.4 RDW-20.2* RDWSD-59.9* Plt Ct-84* ___ 05: 21AM BLOOD WBC-7.7 RBC-2.68* Hgb-8.4* Hct-24.1* MCV-90 MCH-31.3 MCHC-34.9 RDW-20.3* RDWSD-62.2* Plt Ct-67* ___ 01: 03PM BLOOD WBC-9.0 RBC-2.83* Hgb-8.9* Hct-25.2* MCV-89 MCH-31.4 MCHC-35.3 RDW-20.0* RDWSD-61.9* Plt Ct-71* ___ 05: 12AM BLOOD WBC-7.6 RBC-2.90* Hgb-9.0* Hct-26.0* MCV-90 MCH-31.0 MCHC-34.6 RDW-20.4* RDWSD-63.8* Plt Ct-83* ___ 05: 42AM BLOOD WBC-6.3 RBC-2.88* Hgb-9.0* Hct-25.9* MCV-90 MCH-31.3 MCHC-34.7 RDW-20.6* RDWSD-64.0* Plt ___ ___ 05: 21AM BLOOD ___ PTT-25.8 ___ ___ 12: 58PM BLOOD Glucose-275* UreaN-13 Creat-0.7 Na-137 K-3.6 Cl-100 HCO3-24 AnGap-13 ___ 05: 49AM BLOOD Glucose-144* UreaN-12 Creat-0.7 Na-140 K-3.6 Cl-101 HCO3-28 AnGap-11 ___ 05: 21AM BLOOD Glucose-159* UreaN-6 Creat-0.6 Na-135 K-3.6 Cl-99 HCO3-27 AnGap-9* ___ 05: 12AM BLOOD Glucose-150* UreaN-5* Creat-0.4 Na-139 K-3.8 Cl-101 HCO3-27 AnGap-11 ___ 05: 42AM BLOOD Glucose-160* UreaN-9 Creat-0.5 Na-141 K-3.7 Cl-101 HCO3-27 AnGap-13 ___ 05: 21AM BLOOD ALT-62* AST-85* AlkPhos-86 TotBili-0.7 ___ 12: 58PM BLOOD Calcium-8.6 Phos-3.8 Mg-1.2* ___ 05: 49AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.3 ___ 05: 21AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.7 ___ 05: 12AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.6 ___ 05: 42AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.6 <MEDICATIONS ON ADMISSION> Levothyroxine Sodium 300 mcg PO DAILY, Lisinopril 5 mg PO DAILY, LORazepam 0.5 mg PO Q8H: PRN anxiety <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg SC at bedtime Disp #*28 Syringe Refills: *0 3. Ibuprofen 600 mg PO Q6H RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth q6H PRN Disp #*30 Tablet Refills: *0 5. walker miscellaneous ONCE Duration: 1 Dose RX *walker [Ultra-Light Rollator] use as needed for mobility everyday Disp #*1 Each Refills: *0 6. FoLIC Acid 1 mg PO DAILY 7. Levothyroxine Sodium 300 mcg PO DAILY 8. Lisinopril 5 mg PO DAILY 9. LORazepam 0.5 mg PO Q8H: PRN anxiety <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Malignant neoplasm of the ovary. <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. * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. * If you have staples, they will be removed at your follow-up visit. 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 ___. *** 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.
|
Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, interval tumor, debulking, omentectomy, and radical pelvic dissection. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with epidural managed by the Acute Pain Service. During this admission she was found to have thrombocytopenia, hematology-oncology service was consulted, and the thrombocytopenia was attributed to drug-induced thrombocytopenia versus effect of the chemotherapy. Her epidural was capped on post-operative day #2, and once platelets rose to >100 her epidural was pulled. Her diet was advanced slowly over the followed three days due to nausea and anxiety and she was transitioned to oral oxycodone, acetaminophen, and ibuprofen by post-operative day #2. On post-operative day #4, her urine output was adequate and patient felt ready to discontinue the Foley, so her Foley catheter was removed and she voided spontaneously. On post-operative day #2 she had an episode of tachycardia while ambulating, was asymptomatic, and otherwise well, further work-up was deferred During her admission she was seen by physical therapy for her limited mobility, they evaluated her to be able to go home without services, with a rolling walker. She was also seen by social work for her history of abuse in previous relationships and anxiety, the social worker provided support and gave her contact info for the patient to see a counselor in another setting. She was also known to have obstructive sleep apnea at baseline and brought her home CPAP machine for this admission and was kept on telemetry for O2 saturation monitoring. By post-operative day 4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 2,914
| 427
|
10313342-DS-11
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> induction of labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> SVD, D&C, Blood transfusions Bakri Balloon insertion <HISTORY OF PRESENT ILLNESS> ___ yrs. old G7 P2 Ab4 EDC Estimated Date of Delivery: ___, by Ultrasound presents for IOL for advanced maternal age. Contractions q 20 min. Otherwise comfortable. <PAST MEDICAL HISTORY> ___ History: Abnormal Pap smear of cervix Family history of congenital anomalies Comment: first son with pan hypo pituitarianism; optical chiasm hypoplasia GERD Headache Positive PPD, treated Comment: gets regular CXR at work STI Past Surgical History: LAPAROSCOPY ___ Comment: r/o torsion SURG TREATMENT - MISSED ABORTION ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <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> ___ 06: 05AM BLOOD WBC-15.9* RBC-3.30* Hgb-10.1* Hct-29.5* MCV-89 MCH-30.6 MCHC-34.2 RDW-14.1 RDWSD-45.7 Plt ___ ___ 10: 37PM BLOOD WBC-18.3*# RBC-3.19*# Hgb-9.9*# Hct-28.3*# MCV-89# MCH-31.0 MCHC-35.0# RDW-13.8 RDWSD-44.7 Plt ___ ___ 07: 15PM BLOOD WBC-8.7 RBC-1.11*# Hgb-3.5*# Hct-11.1*# MCV-100*# MCH-31.5 MCHC-31.5* RDW-14.4 RDWSD-52.6* Plt Ct-70*# ___ 09: 32AM BLOOD WBC-9.9 RBC-3.94 Hgb-12.2 Hct-35.6 MCV-90 MCH-31.0 MCHC-34.3 RDW-14.0 RDWSD-46.5* Plt ___ ___ 10: 37PM BLOOD ___ PTT-25.7 ___ ___ 07: 15PM BLOOD ___ PTT-95.5* ___ ___ 10: 37PM BLOOD ___ ___ 07: 15PM BLOOD Fibrino-53* <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 (One) capsule(s) by mouth twice a day Disp #*20 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain take with food RX *ibuprofen 600 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal birth of a girl Retained placenta requiring d&C anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per written instructions reviewed by nursing Take the floridix iron you have at home once a day
|
Ms. ___ is a ___ now G7P3 who was admitted to the post partum service after SVD complicated by retained placenta and post partum hemorrhage requiring dilation and curettage in the operating room. Estimated blood loss from delivery was 300 cc's. Estimated blood loss in the operating room during D&C was an additional 1500 cc's, for a total of 1800 cc's. Patient received pitocin, methergine, and cytotec. Ms. ___ had a pre-op hematocrit of 35.6, which decreased to 11.1 immediately post operatively (post operative day zero), then came up to 28.3 on repeat and was stable at 29.5 by post operative day 1. She received three units of pRBCs and 1 unit of FFP on the date of delivery/D&C. She received a dose of ampicillin, gentamicin, and clindamycin for one dose post partum given excessive instrumentation, and also had a Bakri balloon placed on the day of delivery/D&C which was removed on post partum day 1 without difficulty. She was maintained on 40 mg lovenox daily while in the hospital for DVT prophylaxis. By postpartum day 2, bleeding was stable, 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.
| 896
| 321
|
10313377-DS-2
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> dysmenorrhea, irregular bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 0, F-to-M, who has been on testosterone therapy for the last ___ years. He notes that he has had polycystic ovaries. He continues to have irregular vaginal bleeding with worsening dysmenorrhea for which he takes increasing amounts of nonsteroidal anti-inflammatories. We discussed options for treatment including observation and continued hormonal therapy more minor operative procedures or definitive therapy. The patient is requesting definitive therapy. An ultrasound was done on ___ which showed a uterus measuring 7.5 x 3.2 x 4.7 cm. The endometrium appeared normal at 3 mm. The left ovary measured 4.5 x 2.3 x 3.6 cm and contained a 2.1 x 1.7 x 2.0 anechoic structure consistent with a corpus luteum cyst. The right ovary measured 3.9 x 1.8 x 3.3 cm. The impression was a normal pelvic ultrasound. Ovaries demonstrated physiologic activity. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 12. Cycles irregularly. When he does bleed he bleeds for 7 to 14 days during the heaviest bleeding period he changes a pad or tampon every one and a half hours. He sometimes has bleeding after intercourse and has dyspareunia and again worsening dysmenorrhea. Does not recall when his last Pap smear was performed. Denies any history of abnormal Pap smears. He has never had a pregnancy or sexually transmitted disease when sexually active with males he uses condoms. PAST MEDICAL HISTORY: Noncontributory. OPERATIVE HISTORY: Noncontributory, although he is planning top surgery in the future. He has never had a bad reaction to anesthesia. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Notable for diabetes, cardiac heart disease, hypertension, colon cancer. <PHYSICAL EXAM> ADMISSION (PRE-OP) PHYSICAL EXAM: VITAL SIGNS: Blood pressure 122/72, weight 118. ABDOMEN: Soft, nondistended, nontender. No hepatosplenomegaly. No palpable masses. PELVIC: Normal female external genitalia with clitoromegaly. Vaginal vault, normal-appearing discharge. There were no lesions. Cervix, nulliparous, without cervical motion tenderness. Uterus mobile, firm, nontender, normal size. Adnexa without masses or tenderness bilaterally. DISCHARGE PHYSICAL EXAM: VSS and wnl NAD, comfortable RRR CTAB Abdomen: soft, non-tender, non-distended GU: minimal spotting on pad Ext: no edema, no tenderness <PERTINENT RESULTS> Pathology pending at time of discharge. <MEDICATIONS ON ADMISSION> testosterone <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain Do not take more than 4000 mg of acetaminophen in 24 hours. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID Take to prevent constipation while you are taking narcotics. Hold for loose stools. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> dysmenorrhea, irregular bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You were admitted to the gynecology service after undergoing the procedures listed below. You have recovered well and the team feels that 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 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. 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 ___.
|
On ___, Mr. ___ was admitted to the gynecology service after undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and cystoscopy. Please see the operative report for full details. His post-operative course was uncomplicated. Immediately post-op, his pain was controlled with IV dilaudid and toradol. On post-operative day 0, his urine output was adequate and he was ambulatory so his foley was removed. He voided spontaneously although with small frequent voids. Patient was counseled for foley replacement, but refused. Patient continued to have small frequent voids, which he stated was baseline for him. Post void residuals were not concerning for bladder injury. His diet was advanced without difficulty and he was transitioned to PO percocet and ibuprofen. By post-operative day 1, he was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. He was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,280
| 214
|
10314652-DS-12
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fever and left lower abdomen pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy bilateral salpingo-oophorectomy cystoscopy <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ G3P1 who presents with abdominal pain, which started on ___. Patient describes the pain as crampy in nature, waxes and wanes. She also had some nausea but no vomiting. She reports also having a temperature of 100.9. ___ makes the pain better. She denies constipation but endorses some diarrhea, which started this morning. She was seen at ___ and was told to come here to revaluate for recurrence of a tubo ovarian abscess. She was afebrile during the encounter at ___. They performed a pelvic exam at the time and patient rated the pain ___. She received toradol. Gonorrhea and Chlamydia cultures were sent. She currently rates her pain as ___. No current nausea. <PAST MEDICAL HISTORY> OB Hx: G3P1 G1 (___) Primary C-section for arrest ~7lbs G2 AND G3 TAB's GYN Hx: Previous history ___ s/p drainage ___. Denies STI. Hx of fibroids s/p abdominal myomectomy in ___. Pathology came back as STUMP. LMP ___. PMH: anemia PSH: C/Sx1, Abdominal Myomectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies gynecological cancers or fibroids <PHYSICAL EXAM> on admission by Dr. ___: T 97.6 HR 80 BP 90/71 RR 18 Phyical exam: General: In no acute distress Heart RRR no m/r/g Lungs CTAB ABD: S/ND. +BS moderate TTP on deep palpation of LLQ with voluntary guarding. No rebound. Pelvic Exam: Deferred (per Dr. ___ ___ recent exam this AM <PERTINENT RESULTS> ___ 06: 55AM BLOOD WBC-15.4* RBC-4.32 Hgb-11.9* Hct-36.0 MCV-83 MCH-27.5 MCHC-33.0 RDW-17.2* Plt ___ ___ 07: 17AM BLOOD WBC-17.2* RBC-4.30 Hgb-12.0 Hct-35.8* MCV-83 MCH-27.9 MCHC-33.6 RDW-16.8* Plt ___ ___ 12: 45PM BLOOD WBC-16.9* RBC-4.37 Hgb-12.2 Hct-35.7* MCV-82 MCH-28.0 MCHC-34.3 RDW-16.2* Plt ___ ___ 08: 27AM BLOOD WBC-16.9* RBC-4.09*# Hgb-11.5*# Hct-33.4*# MCV-82 MCH-28.1 MCHC-34.5 RDW-17.0* Plt ___ ___ 12: 50PM BLOOD WBC-14.0* RBC-3.18* Hgb-8.6* Hct-26.0* MCV-82 MCH-26.9* MCHC-32.9 RDW-16.0* Plt ___ ___ 06: 38AM BLOOD WBC-12.8* RBC-2.99* Hgb-7.9* Hct-24.1* MCV-81* MCH-26.6* MCHC-33.0 RDW-16.5* Plt ___ ___ 08: 00AM BLOOD WBC-16.6* RBC-3.56* Hgb-9.6* Hct-28.9* MCV-81* MCH-27.0 MCHC-33.3 RDW-16.0* Plt ___ ___ 07: 10AM BLOOD WBC-16.4* RBC-3.71* Hgb-9.8* Hct-30.1* MCV-81* MCH-26.3* MCHC-32.5 RDW-16.8* Plt ___ ___ 10: 19PM BLOOD WBC-14.4* RBC-3.65* Hgb-9.9* Hct-29.1* MCV-80* MCH-27.1 MCHC-33.9 RDW-16.4* Plt ___ ___ 08: 15AM BLOOD WBC-12.2* RBC-3.86* Hgb-10.4* Hct-31.2* MCV-81* MCH-26.9* MCHC-33.3 RDW-16.2* Plt ___ ___ 01: 46PM BLOOD WBC-16.4*# RBC-3.92* Hgb-10.6* Hct-31.9* MCV-82 MCH-27.1# MCHC-33.3 RDW-16.4* Plt ___ ___ 07: 17AM BLOOD Neuts-87* Bands-0 Lymphs-9* Monos-3 Eos-1 Baso-0 ___ Myelos-0 ___ 07: 10AM BLOOD Neuts-81.1* Lymphs-12.8* Monos-5.4 Eos-0.4 Baso-0.3 ___ 10: 19PM BLOOD Neuts-81.8* Lymphs-13.1* Monos-4.0 Eos-0.5 Baso-0.5 ___ 08: 15AM BLOOD Neuts-77.9* Lymphs-15.5* Monos-5.1 Eos-0.5 Baso-0.8 ___ 01: 46PM BLOOD Neuts-76.4* Lymphs-15.6* Monos-6.8 Eos-0.5 Baso-0.7 ___ 08: 15AM BLOOD ___ PTT-27.2 ___ ___ 08: 15AM BLOOD ___ ___ 08: 00AM BLOOD Glucose-92 UreaN-19 Creat-3.2*# Na-144 K-3.7 Cl-105 HCO3-29 AnGap-14 ___ 06: 55AM BLOOD Glucose-82 UreaN-24* Creat-5.0* Na-142 K-3.9 Cl-104 HCO3-28 AnGap-14 ___ 07: 17AM BLOOD Glucose-87 UreaN-23* Creat-5.4* Na-137 K-4.2 Cl-105 HCO3-22 AnGap-14 ___ 12: 45PM BLOOD Glucose-85 UreaN-18 Creat-4.9* Na-137 K-4.2 Cl-103 HCO3-23 AnGap-15 ___ 08: 27AM BLOOD Glucose-85 UreaN-16 Creat-4.6*# Na-138 K-3.8 Cl-104 HCO3-24 AnGap-14 ___ 12: 50PM BLOOD Glucose-96 UreaN-10 Creat-2.9* Na-138 K-3.5 Cl-101 HCO3-28 AnGap-13 ___ 06: 38AM BLOOD Glucose-106* UreaN-9 Creat-2.2*# Na-138 K-3.4 Cl-101 HCO3-28 AnGap-12 ___ 08: 15AM BLOOD Glucose-85 UreaN-5* Creat-0.5 Na-139 K-3.6 Cl-105 HCO3-25 AnGap-13 ___ 01: 46PM BLOOD Glucose-84 UreaN-7 Creat-0.6 Na-137 K-3.3 Cl-102 HCO3-25 AnGap-13 ___ 08: 27AM BLOOD ALT-16 AST-34 AlkPhos-72 TotBili-0.4 ___ 01: 46PM BLOOD ALT-20 AST-23 ___ 08: 00AM BLOOD Calcium-8.4 Phos-5.8* Mg-1.6 ___ 06: 55AM BLOOD Calcium-8.2* Phos-5.8* Mg-1.8 ___ 07: 17AM BLOOD Calcium-8.0* Phos-4.5 Mg-1.8 ___ 12: 45PM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8 ___ 08: 27AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.8 ___ 12: 50PM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8 ___ 06: 38AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8 ___ 08: 15AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.8 ___ PUS: FINDINGS: Transabdominal and transvaginal examinations were performed, the latter for better assessment of endometrial contents and the adnexa. The uterus is 8.7 x 5.5 x 8.8 cm. As before, there is a large fundal fibroid, unchanged from the recent comparison MRI. A small submucosal fibroid was characterized to better extent on the comparison study. The right ovary is visualized on transabdominal imaging only, appearing to measure 3.9 x 1.7 x 2.6 cm. Centered in the left adnexa is an area of complex fluid, with multiple internal septations, most likely representing hemorrhage or purulent fluid within the left tube. The left ovary appears normal. The area of complex fluid in the left adnexa measures approximately 7.1 x 6.0 cm in aggregate. IMPRESSION: 1. 7-cm area of complex fluid with internal septations in the left adnexa, most likely representing hemato- or pyosalpinx. 2. Large uterine fibroids, appearing unchanged from the recent comparison study. ___ CT: FINDINGS: Redemonstrated is a dilated tube on the left containing low density, slightly heterogeneous internal debris. This measures slightly greater than simple fluid in ___ units. This structure has a thick wall with surrounding inflammatory stranding in the fat. It measures approximately 6.0 x 6.9 cm in AP and transverse ___, respectively. The uterus is displaced to the right, enlarged and slightly heterogeneous in appearance, compatible with fibroids. The right ovary appears within normal limits. The left ovary is poorly visualized on CT. There are multiple loops of ileum anterior to the left adnexal lesion and multiple large vessels posterior without a safe window for percutaneous drainage. The bladder is decompressed. There is no significant free fluid in the pelvis. There is no pelvic lymphadenopathy. Osseous structures are within normal limits. Just superior to the umbilicus, there is stranding in the subcutaneous fat, which may relate to nonspecific inflammation. IMPRESSION: Left adnexal lesion measuring 6.0 x 6.9 cm, likely representing a dilated fallopian tube with mild surrounding inflammatory change. This is not amenable to percutaneous drainage as detailed above. ___ Renal US: FINDINGS: The kidneys demonstrate normal corticomedullary differentiation and echogenicity. The right kidney measures 14.1 cm. The left kidney measures 13.7 cm. On the right, there is no hydronephrosis, mass, perinephric fluid collection or renal calculi. On the left, there is dilation of a lower pole calyx. The upper pole collecting system appears within normal limits. There is no perinephric fluid collection, renal calculus or mass. The bladder is decompressed with Foley catheter precluding assessment. IMPRESSION: Mild caliectasis in the lower pole of the left kidney without other evidence of obstructive uropathy. <MEDICATIONS ON ADMISSION> aleve PRN <DISCHARGE MEDICATIONS> 1. Tylenol-Codeine #3 300-30 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *10 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> recurrent tubo-ovarian abscess acute tubular necrosis <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 recurrent tubo-ovarian abscess. You received 5 days of antibiotics, and underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy and cystoscopy. Your pain was controlled with tylenol. 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. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have 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 ___.
|
On ___, Ms. ___ presented with 7cm dilated L fallopian tube concerning for recurrent left tubo-ovarian abscess. She was started on IV ceftriaxone, gentamicin, and flagyl and made NPO in anticipation of ___ drainage. On ___, the ceftriaxone was changed to ampicillin, and the tube was not amenable to drainage due to bowel positioning. She continued to be febrile up to 102.5 despite IV antibiotics, but her vital signs were otherwise stable. The patient was offered and elected for definitive treatment with a TAH/BSO by Dr. ___ Dr. ___. Infectious disease was also consulted, and her antibiotics were changed to vancomycin/zosyn per their recommendations on ___. On ___, the pt had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Please refer to operative report for details of the procedure. Her post-operative course was notable for acute tubular necrosis. On the evening POD2 and morning of POD3, she was oliguric and was triggered for UOP < 50 cc in 4 hours. Her FeNa 0.64%, with Cr 2.2. Renal was consulted, and all nephrotoxic medications (vanc/zosyn/toradol/motrin) were discontinued. During this period the patient was somewhat groggy, but always response with stable blood pressure, pulse, and oxygen saturation. Her narcotic pain medications were subsequently decreased and her pain was controlled with tylenol. Her urine output responded minimally to 1.5L bolus of IVF, and given that her HCT was 24.1, she was premedicated with tylenol and benadryl before transfusion of 2 units pRBCs for volume resuscitation. She tolerated the blood transfusion without any difficulty, and her post-transfusion HCT was appropriate at 33. After blood transfusion, her urine output increased. It was believed that the combination of toradol, gentamicin, zosyn, and vancomycin contributed to the patient's acute tubular necrosis. Her creatinine peaked at 5.4 on ___ and her potassium was always within normal limits. She continued to be afebrile for greater than 72 hours off of any antibiotics, and her clinical exam was reassuring. By POD6 (___), Ms. ___ was tolerating PO, voiding spontaneously, had good bowel function, pain was controlled with tylenol, and was ambulating independently without difficulty. She was then discharged home in good condition.
| 3,154
| 549
|
10315256-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Percocet / clindamycin <ATTENDING> ___. <CHIEF COMPLAINT> Acute onset lower pelvic pain and fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo gravida 1 para ___ who presents as a transfer from ___ ___ presents c/o acute onset pelvic pain. For 3 days she has had diffuse cramping abdominal pain, similar to her premenstrual symptoms, but also notes decreased appetite and nausea. On ___ at approximately 0400 she had acute onset, bilateral, sharp, lower quadrant pain. Intense in nature ___. This started during vaginal intercourse and did not improve with after. She went on to develop subjective fevers, chills, malaise. She took 1mg PO Ativan which helped her sleep x 2 hours but she awoke again with intense pain. She also notes sore throat, nasal congestion. No diarrhea, constipation, vomiting. No chest pain, cough, SOB, DOE. No abnormal vaginal discharge, burning, itching. No new sexual partners. ___ with boyfriend, uses condoms for contraception. No dysuria. No weight loss. No sick contacts. She was seen initially at urgent care and was then transferred to ___. There she received 10mg total IV Morphine, Ceftriaxone and Doxycyline and acetaminophen. She had a pelvic ultrasound there notable for a small amount of pelvic free fluid, a small possible Left dermoid cyst and a possible right mostly simple appearing small dominant cyst. Otherwise unremarkable US. Appendix not visualized. <PAST MEDICAL HISTORY> PGYNHx: LMP: pt unsure ___? Cycle: q ~28 days Fibroids/ Cysts/ STIs: - h/o ? hemorrhagic cyst (pt unsure) - h/o chlamydia in ___, h/o PID with hospitalization - h/o genital HSV, last outbreak ___ year - no Pap hx Contraception: condoms OBHx: G1 tab d&c PMH: - anxiety (daily) - depression (well controlled PSH: - D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <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, nondistended Ext: no TTP <PERTINENT RESULTS> ___ 10: 55AM BLOOD WBC-8.2 RBC-3.60* Hgb-8.8* Hct-28.0* MCV-78* MCH-24.4* MCHC-31.4* RDW-16.0* RDWSD-45.9 Plt ___ ___ 10: 50PM BLOOD WBC-10.4* RBC-3.59* Hgb-8.9* Hct-28.8* MCV-80* MCH-24.8* MCHC-30.9* RDW-16.2* RDWSD-46.9* Plt ___ ___ 10: 55AM BLOOD Neuts-76.0* Lymphs-14.7* Monos-7.3 Eos-1.1 Baso-0.5 Im ___ AbsNeut-6.24* AbsLymp-1.21 AbsMono-0.60 AbsEos-0.09 AbsBaso-0.04 ___ 10: 50PM BLOOD Neuts-77.7* Lymphs-14.4* Monos-7.1 Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.06* AbsLymp-1.49 AbsMono-0.74 AbsEos-0.01* AbsBaso-0.04 ___ 11: 40PM BLOOD Glucose-83 UreaN-5* Creat-0.7 Na-138 K-3.5 Cl-104 HCO3-21* AnGap-17 ___ 12: 01AM BLOOD Lactate-1.3 Imaging: US Appendix (___) IMPRESSION: Appendix not definitely visualized. CT Abdomen and Pelvis (___) IMPRESSION: 1. Moderate hyperdense free pelvic fluid, along with a peripherally enhancing 1.6 cm left adnexal structure. Findings are most compatible with a ruptured hemorrhagic cyst. 2. Normal appendix. <MEDICATIONS ON ADMISSION> Ativan Lexapro <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain, fever RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills: *0 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*28 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN pain, fever RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 4. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*8 Tablet Refills: *0 5. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic inflammatory disease vs. ruptured hemorrhagic cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital given severe abdominal pain and concern for an infection called pelvic inflammatory disease (PID). You were given the appropriate antibiotics through your IV and transitioned to oral antibiotics when you were able to tolerate things by mouth. You are currently able to take pills and tolerate regular food without throwing up or severe pain. It is safe for you to go home. Please take your prescribed antibiotic for 14 days, as prescribed. You may take tylenol and ibuprofen for pain, as needed, as well as Zofran for nausea as needed. Please call your doctor if you develop fever >100.4, shaking chills, severe abdominal pain not relieved by medication, intractable vomiting that does not improve.
|
On ___, Ms. ___ was admitted to the gynecology service for acute onset lower pelvic pain and fever. She was seen at an OSH and given IM Ceftriaxone for concerns of PID. She was transferred to ___ for further management. While in the hospital, she was given IV antibiotics and transitioned to PO antibiotics once tolerating PO. Her pain was controlled with PO pain medications. On hospital day 1, patients pain was improving, she was tolerating PO antibiotics, and she was tolerating a regular diet. She was then discharged home in stable condition with a prescription for a ___nd outpatient follow-up scheduled.
| 1,503
| 131
|
10315656-DS-11
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> labor, neonatal demise <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 39w6d with regular painful ctx since 1000. VB, LOF. +FM. Closed in office on last exam PNC: - ___ ___ by ___ - Labs Rh pos/Abs neg/Rub I/Var equiv/RPR NR/HBsAg neg/HIV neg/GBS neg - Screening low risk ERA - FFS normal - GLT normal - U/S ___ for S>D 31%ile - Issues: denies <PAST MEDICAL HISTORY> OBHx: - G1- current GynHx: - h/o chlamydia, treated, negative this pregnancy - denies abnormal paps, other STIs PMH: denies PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Admission Physical Exam T 97.4 BP 113/54 HR 110 RR 18 Gen: A&O, uncomfortable Abd: soft, gravid, nontender EFW by ___ Ext: no calf tenderness Discharge Physical Exam VSS Gen: A&O Abd: soft, nontender Ext: no calf tenderness <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN fever, pain Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN Constipation 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 Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal delivery, neonatal demise <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please refer to your discharge packet and the instructions below: Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
|
The patient is a ___ G1, who presented at 39 weeks and 6 days in labor. She initially presented on ___ with a cervical exam of 4, 100, with bulging membranes. She made slow change to 8, 100, and -1 around ___ on ___. At that time, she underwent artificial rupture of membranes with meconium noted. Shortly thereafter, she developed a fever and due to fever and maternal tachycardia, was diagnosed with chorioamnionitis and started on ampicillin, gentamicin, and acetaminophen. Two hours later, she had not made change and Pitocin was started. Pitocin was on for approximately an hour and a half, at which time, there was a pattern check and the Pitocin was turned off. The Pitocin remained off and the patient was re-examined around 6:40 in the morning and was still 8, 100, and -1. At this time, the fetal heart tracing was overall reassuring; however, given protracted course, an IUPC was placed with amnio infusion. The Pitocin was restarted around 8:30 a.m. Just before 11 a.m., she made changed to 8 to 9, 100, and 0. Given that there was some change and Pitocin had only been minimally titrated, decision was made to continue with augmentation of labor. At approximately 1 p.m., she was noted to be rim, 100, and 0 to +1, and once again, given overall reassuring fetal status and slow, but measurable progress, decision was made to continue. At 3 p.m., the patient was fully dilated with the fetal vertex at 0 to +1 station. The decision was made to start pushing. The patient pushed on and off for the ___ 2 hours due to some discomfort in the right side. This responded to an epidural bolus and the patient was pushing effectively with excellent progress. Just prior to this 3 hours into pushing, the patient made excellent progress with station of the caput at +5 and the vertex at +3 to +4. At this point, there was excellent progress and vaginal delivery was imminent. Approximately 7 minutes prior to delivery, there was an acute change in the fetal heart tracing with the fetal heart rate jumping to the 200s, and loss of variability. At this point, the patient was crowning and vaginal delivery was deemed to be imminent. The patient delivered the fetal head on the next push; however, the contraction ended prior to delivery of the shoulders. Gentle traction was placed on the shoulders without delivery of the shoulder. The patient was placed in McRobert's position and suprapubic pressure applied. The presenting position was right occiput posterior. This did not immediately relieve the dystocia, at which point, Dr. ___ delivery and did a partial Woods' screw maneuver, at which point, the anterior shoulder delivered without difficulty. Per her report, the shoulder was delivered relatively easily with small change in position. The infant was born without tone and no respiratory effort. The cord was immediately clamped and cut, and the infant handed off to awaiting NICU staff, who was present for meconium. Cord gases were collected. Routine cord blood was collected. The infant had Apgars of 0, 0, and 0 and was coded in the delivery room for over 20 minutes. Please see neonatal documentation for full details of this. The patient herself underwent no trauma and there were no lacerations. The placenta was delivered spontaneously and apparently intact, with no abnormalities noted. The patient's fundus was firm with minimal bleeding. The infant was taken to the NICU in critical condition. Postpartum, the patient was treated with ampicillin and gentamicin for 24 hours for chorio, and remained afebrile. She also received varicella vaccine postpartum. Baby boy ___, after being coded at delivery, died in NICU early ___ AM. Social work followed patient postpartum. She was discharged on ___ with resources for outpatient support.
| 683
| 856
|
10316267-DS-9
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lidocaine <ATTENDING> ___. <CHIEF COMPLAINT> R adnexal cyst and omental caking <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Exploratory laparotomy. 2. Subtotal abdominal hysterectomy. 3. Bilateral salpingo-oophorectomy. 4. Infragastric omentectomy. 5. Optimal tumor debulking <HISTORY OF PRESENT ILLNESS> HISTORY OF PRESENT ILLNESS: The patient is a ___ G4, P3 who has been followed for a pelvic cyst. Most recently, her CA-125 was noted to rise to 1096 on ___. The patient has finally decided to proceed with surgery. Her most recent ultrasound on ___ revealed a large right adnexal cyst measuring 7.2 cm, which had a small mural calcification and irregularity of the adjacent wall. This had increased significantly since ___. The patient also underwent a CT of the torso on ___, and this revealed marked omental caking. There was also evidence of peritoneal nodularity. There was trace free fluid. There was a large right adnexal cystic mass measuring 6.4 cm with possible involvement of the rectal wall. The patient has remained completely asymptomatic. She has been tolerating a regular diet and having normal bowel movements and urinating without difficulty. She has had no vaginal bleeding or discharge. <PAST MEDICAL HISTORY> Hypertension Hypercholesterolemia DM (last A1C 5.8) obese hypothyroidism gallstones depression/anxiety tracheitis Hiatal hernia DCIS of the breast <SOCIAL HISTORY> ___ <FAMILY HISTORY> aunt with MI in her ___, otherwise negative for malignancies <PHYSICAL EXAM> PHYSICAL EXAMINATION: GENERAL: Well developed and obese. HEENT: Sclerae anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular with a ___ holosystolic murmur. BREASTS: No masses. There was a well-healed scar on the right breast. ABDOMEN: Soft and nondistended and without palpable masses. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was normal. Bimanual and rectovaginal examination was very limited by body habitus. There were no palpable masses. There was no cul-de-sac nodularity and the rectal was intrinsically normal. <MEDICATIONS ON ADMISSION> 1. Buspar: One (1) tablet, 5 times DAILY 2. Cozaar 50 mg: One (1) tablet PO DAILY 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY. 4. Albuterol aerosol PRN 5. Flovent PRN 6. Metformin 250 mg: One (1) Tablet PO DAILY. 7. Simvastatin 20 mg: One (1) Tablet PO DAILY. 8. Omeprazole 20 mg: One (1) Tablet PO DAILY <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *60 Tablet(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed. Disp: *40 Tablet(s)* Refills: *0* 3. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: ___ Puffs Inhalation Q6H (every 6 hours) as needed. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 9. Metformin 250 mg: One (1) tablet DAILY 10. Simvastatin 20 mg: One (1) tablet DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> probable ovarian cancer <DISCHARGE CONDITION> stable; afeb, stable vital signs, pain controlled, tolerating po, ambulant, voiding spontaneously <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. Please call if you have redness and warmth around the incision, if your incision is draining pus-like material, or if your incision reopens. - No driving for two weeks and while taking narcotic pain medication as it can make you drowsy. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal adequately. - Nothing per vagina (no tampons, intercourse, douching for 6 weeks. - Please keep your follow-up appointments as outlined below.
|
Ms. ___ is a ___ yo F who underwent an uncomplicated exploratory laparotomy, subtotal abdominal hysterectomy, bilateral salpingo-oophorectomy, infragastric omentectomy, and optimal tumor debulking for presumed ovarian cancer (path still pending). Details of the procedure are available in a separate operative note found elsewhere. Her ___ hospital course was notable for the following: . Ms. ___ postoperative course was generally uncomplicated. The evening after surgery, her oxygen saturation decreased to 90% on RA, checked while patient was asleep. With deep inspirations, oxygen saturation returned to 96%. She was kept on 1L overnight. Given her body habitus and saturation taken while patient supine and asleep as well as it being on postoperative day ___, the leading differential for her decrease in oxygen saturation was possibly shallow breaths combined with sleep apnea. The remainder of her vital signs were normal and she had no symptomatic complaints. She was weaned off of oxygen the following day (POD#1), and did not have any further episodes of desaturation. Otherwise, the patient was tolerating a regular diet by POD#2 and was started on her home medication regimen. She was encouraged to walk and passed flatus on POD #4. Her pain was well controlled on oral medications. The patient was voiding spontaneously. She was discharged home on POD #5 in good condition.
| 1,254
| 291
|
10316343-DS-8
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> shellfish derived <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingo-oophorectomy, lysis of adhesions, oversew of bowel serosa <HISTORY OF PRESENT ILLNESS> H/o extremely heavy periods, ___ days. She is anemic. Was started On lupron in ___ in prep for hysterectomy. She has received two doses so far and continues to have almost daily bleeding. Received iron infusion x 2 in ___. Last myomectomy in ___ EBL: 1300cc Findings: midline incision; 22w uterus with multiple large fibroids. 15 fibroids removed. Multiple fibroids remain, as EBL limited ability to proceed further. Colon adherent to L posterolateral aspect of uterus which was lysed free. Bladder adherent to uterus. Received 5 U PRBC and ___ FFP. Postop complicated by fever and tachycardia. Seprafilm used. PUS ___ at ___ showed: Uterus ~19x11x8 cm (844 cc). Fibroids: Multiple, largest being ~4.6cm Stripe thickness Not seen due to fibroids mm. Ovaries WNL (~4cm L cyst suggestive of hemorrhagic cyst). No free fluid. No hydronephrosis Free fluid None <PAST MEDICAL HISTORY> PMH: fibroids, depression PSH: hysteroscopy, abdominal myomectomy x 2, excision of breast mass <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 08: 45AM BLOOD WBC-13.8* RBC-4.49 Hgb-11.7 Hct-35.0 MCV-78* MCH-26.1 MCHC-33.4 RDW-17.5* RDWSD-48.4* Plt ___ ___ 07: 49AM BLOOD WBC-14.3* RBC-4.01 Hgb-10.6* Hct-31.3* MCV-78* MCH-26.4 MCHC-33.9 RDW-16.9* RDWSD-47.6* Plt ___ ___ 09: 20AM BLOOD WBC-16.5* RBC-3.36* Hgb-8.5* Hct-25.7* MCV-77* MCH-25.3* MCHC-33.1 RDW-16.9* RDWSD-45.8 Plt ___ ___ 12: 55PM BLOOD WBC-12.9* RBC-3.16* Hgb-8.0* Hct-24.8* MCV-79* MCH-25.3* MCHC-32.3 RDW-16.9* RDWSD-47.3* Plt ___ ___ 07: 57AM BLOOD WBC-11.8* RBC-3.17* Hgb-8.0* Hct-24.7* MCV-78* MCH-25.2* MCHC-32.4 RDW-16.8* RDWSD-46.9* Plt ___ ___ 01: 23PM BLOOD WBC-23.5*# RBC-4.10 Hgb-10.4* Hct-32.2* MCV-79*# MCH-25.4*# MCHC-32.3# RDW-17.2* RDWSD-48.1* Plt ___ ___ 08: 45AM BLOOD Neuts-67.2 Lymphs-16.7* Monos-8.6 Eos-6.7 Baso-0.4 Im ___ AbsNeut-9.30* AbsLymp-2.31 AbsMono-1.19* AbsEos-0.93* AbsBaso-0.06 ___ 08: 45AM BLOOD Glucose-100 UreaN-12 Creat-0.9 Na-135 K-3.6 Cl-95* HCO3-23 AnGap-21* ___ 07: 49AM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-134 K-3.7 Cl-98 HCO3-25 AnGap-15 ___ 09: 20AM BLOOD Glucose-103* UreaN-5* Creat-0.8 Na-135 K-3.1* Cl-97 HCO3-28 AnGap-13 ___ 07: 57AM BLOOD Glucose-103* UreaN-9 Creat-0.8 Na-135 K-3.5 Cl-102 HCO3-27 AnGap-10 ___ 08: 45AM BLOOD Calcium-10.1 Phos-4.7* Mg-2.0 ___ 07: 49AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.0 ___ 09: 20AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9 ___ 07: 57AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.6 ___ 12: 15PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. lisinopril-hydrochlorothiazide ___ mg oral daily <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *1 2. 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 3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H: PRN Pain - Moderate No more than 6 tabs in one day. Do not drink alcohol or drive while taking this medication. 4. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. It was a pleasure taking care of you during your stay! Sincerely, Your ___ GYN Care Team
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing exploratory laparotomy, total abdominal hysterectomy and bilateral salpingoophrectomy, extensive lysis of adhesions, and oversew of bowel serosa for symptomatic fibroid uterus. Please see the operative report for full details. Her post-operative course was complicated by postoperative ileus. The decision was made to not advance her diet past clear liquids until patient passed flatus, given the oversewing of bowel serosa during the surgery. Diet was eventually advanced on ___ once patient had passed flatus. She initially had a postoperative oxygen requirement, thought to be due to atelectasis, which resolved. She received one unit of pRBCs post operatively, on ___, for tachycardia and a low hematocrit, thought to be due to surgery and not to active postoperative bleeding. Her hematocrit bumped appropriately. Immediately post-op, her pain was controlled with IV dilaudid PCA and IV toradol and once she was tolerating POs, her regimen was advanced to PO oxycodone, ibuprofen, and acetaminophen. On post-operative day 2, her urine output was adequate so her foley was removed and she voided spontaneously. She was noted to have a leukocytosis post operatively. Urine analysis and urine cultures were negative. By post-operative day 4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,907
| 333
|
10316898-DS-18
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> adnexal mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 0 patient who presents for laparscopic BSO for complex left adnexal mass. Initially, she was seen in the emergency room with right lower quadrant pain and right low back pain back in ___ ___ in ___. The CT scan showed a 5.7 cm left adnexal mass with calcifications. Reportedly, there was no other evidence of pathology on the CT scan. Since that time, the patient has had spontaneous improvement of the right lower quadrant pain. She subsequently had a pelvic ultrasound that did show some thickening of the endometrium and confirmed the 5.7 cm left adnexal mass with calcifications. There was no free fluid seen. Notably, the CT scan did not show any adenopathy and her CA-125 was reportedly negative. On transvaginal ultrasound, the endometrium was thickened and so her prior gynecologist, Dr. ___ who did perform endometrial biopsy, which was benign per report. The patient has been in her usual state of health otherwise and although she does have some continued intermittent left lower abdominal discomfort, she is overall feeling stable. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> 1. Hypertension. 2. Type 1 diabetes. 3. Coronary artery disease status post CABG x 3 at ___ in ___, on Plavix 4. Hyperlipidemia. OB History: She is gravida 0. Gynecologic History: She underwent menopause in her ___ and has not had any postmenopausal bleeding. She has never had an abnormal Pap smear. She has never been on hormone replacement therapy. Health maintenance. She had a mammogram in ___. However, denies ever having had a colonoscopy or bone density scan. Past Surgical History: CABG x 3 with stents as above. <SOCIAL HISTORY> She denies tobacco, alcohol or drug use. She is a ___ and will be soon retiring, which is prompting the move from ___. She lives with her wife and feels safe at home. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable Comfortable, No acute distress. Woman who appears stated age. CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, obese, appropriately tender, nondistended, incisions clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 04: 45AM BLOOD Glucose-210* UreaN-20 Creat-0.8 Na-136 K-3.9 Cl-102 HCO3-24 AnGap-14 ___ 04: 45AM BLOOD WBC-10.8* RBC-3.99 Hgb-10.8* Hct-34.5 MCV-87 MCH-27.1 MCHC-31.3* RDW-14.9 RDWSD-47.6* Plt ___ <MEDICATIONS ON ADMISSION> AMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) ATORVASTATIN - atorvastatin 40 mg tablet. 1 tablet(s) by mouth at bedtime - (Prescribed by Other Provider) DABIGATRAN ETEXILATE [PRADAXA] - Pradaxa 150 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) FUROSEMIDE - furosemide 20 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous solution. 60 units SC at bedtime - (Prescribed by Other Provider) INSULIN LISPRO [HUMALOG] - Humalog 100 unit/mL subcutaneous cartridge. 30 units SC three times a day - (Prescribed by Other Provider) LISINOPRIL - lisinopril 40 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) METFORMIN - metformin 1,000 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) SERTRALINE - sertraline 100 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) SOTALOL - sotalol 120 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) TROSPIUM - trospium 20 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 325 mg tablet. 1 tablet(s) by mouth daily as needed for pain - (Prescribed by Other Provider) ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) <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 six (6) hours Disp #*40 Tablet Refills: *0 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Dabigatran Etexilate 150 mg PO BID 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 7. Glargine 74 Units Bedtime Humalog 30 Units Breakfast Humalog 30 Units Lunch Humalog 30 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Lisinopril 40 mg PO DAILY 9. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 10. Sertraline 100 mg PO DAILY 11. Sotalol 120 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Adnexal mass Atrial fibrillation <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 were also observed for your suspected atrial fibrillation, which resolved. 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 3 weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . 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
|
Ms. ___ was admitted to the gynecologic oncology service after undergoing a laparoscopic bilateral salpingo-oophorectomy with pelvic washings. Please see the operative report for full details. Her post-operative course is detailed as follows: She was planned to be an outpatient surgery but immediately post operatively she was noted to have a significant oxygen requirement. She was recently diagnosed with sleep apnea. Her breathing improved with diuresis and she was transiently on CPAP. She was admitted for closer monitoring. Immediately postoperatively, her pain was controlled with PO oxycodone and acetaminophen. Her diet was advanced without difficulty. On post operative day #1 she was noted to have an brief episode of possible paroxysmal atrial fibrillation. She was asymptomatic at the time and otherwise had stable vital signs. She received her home sotalol and converted to sinus rhythm. She remained without rhythm changes for 12+ hours as documented on several 12-lead EKGs and was thus deemed appropriate for discharge home. Cardiology reviewed her EKGs and recommended that she continue her home medications and follow-up as scheduled with her cardiologist Dr. ___. 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 encouraged to follow up with her PCP for further optimization of her multiple co-morbidities. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,918
| 337
|
10322775-DS-6
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lisinopril <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain, vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, umbilical hernia repair blood transfusion <HISTORY OF PRESENT ILLNESS> ___ yo G2P2 with known fibroid uterus presents to ED initially for evaluation of shortness of breath who also has continued fibroid pain. She was seen in the office today by her PCP and GYN for fibroid management where she reported shortness of breath and subsequent D-dimer was elevated. Initial work-up in the ED with CT chest was neg for PE. GYN was consulted for further evaluation of her pain and fibroids. Patient reports she was dx with fibroids 4 mos ago and they have acutely grown and become painful over this time period. In the office today she had HCT 29. Other labs checked ___ include TSH 1.29, neg HCG. She is currently planning for hysterectomy. GC/chlamydia neg ___ and back in ___. Her last pelvic u/s was ___ which showed "Enlarged, bulky, heterogeneous fibroid uterus extending to the umbilicus. 3 discrete uterine fibroids are demonstrated of these, the 3 largest fibroids demonstrated extensive central non-enhancement suggesting necrosis or calcification. Only the 2 smallest fibroid in lower uterine segment both on the right and posteriorly demonstrates central enhancement." She reports chills and maybe fever at home- has not taken temperature. Decreased appetite but denies n/v. Feels week and tired. Denies chest pain, SOB (resolved), dizziness, dysuria, constipation (last BM this am), diarrhea, numbess <PAST MEDICAL HISTORY> POB/GYNH: - LMP two weeks ago, regular monthly menses, heavy with pain, lasts 7 days - Fibroids as above - G2P2: SVD x2, full term - Denies hx of STIs, abnormal Paps, last ___ normal - Married, sexually active with one male partner, condoms PMH: asthma, HTN SHX: ___ <FAMILY HISTORY> Denies hx of breast, ovary, colon, uterine cancers <PHYSICAL EXAM> On admission: T-100.5, 100.7 HR- 125->102 BP-127/74 RR-14 O2-100% RA CV-RRR Pulm: CTAB Abd: +BS, soft, nondistended, uterine fundus palpated 1 cm above umbilicus. Tenderness present over fibroids. No rebound or guarding Pelvic: normal appearing external genitalia, inner labial folds, urethral meatus. Bimanual exam reveals enlarged uterus as found on abd exam, no CMT. On day of discharge Gen - NAD, comfortable CV - RRR Pulm - CTAB Abd - +BS, soft, nontender Inc - midline vertical incision, c/d/i Ext - nontender, nonedematous <PERTINENT RESULTS> ___ 06: 45PM WBC-21.1*# RBC-3.50* HGB-9.2* HCT-27.8* MCV-80* MCH-26.4*# MCHC-33.2 RDW-14.1 ___ 07: 00AM WBC-15.0* RBC-2.91* HGB-7.6* HCT-24.0* MCV-83 MCH-26.1* MCHC-31.6 RDW-14.1 ___ 07: 00AM GLUCOSE-89 UREA N-12 CREAT-0.6 SODIUM-138 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-29 ANION GAP-10 <MEDICATIONS ON ADMISSION> Hydrochlorothiazide 25 mg daily, losartan 50 mg daily, albuterol prn <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 2. Hydrochlorothiazide 25 mg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Albuterol Inhaler 2 PUFF IH Q6H: PRN SOB 5. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4000 mg acetaminophen in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth 6 hours Disp #*60 Tablet Refills: *0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth four hours Disp #*60 Tablet Refills: *0 7. Ibuprofen 600 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth 6 hours Disp #*60 Tablet Refills: *0 8. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*60 Tablet Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> total abdominal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, and umbilical hernia repair for rapidly enlarging fibroid uterus, possible leiomyosarcoma anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. 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 To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. 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. * Leave your steri strips on over your incision. 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service for management of her abdominal pain. Although she initally presented with shortness of breath and elevated d-dimer a CT chest was negative for PE. She was febrile in the Emergency Department and was started on IV antibiotics. She reamined afebrile after admission and antibiotics were stopped on ___ when she had been afebrile for 24 hours. The gynecology oncology service was consulted. Given the history of a large fibroid uterus that had been rapidly enlarging with increasing pain over several months in the setting of fever and leukocytosis, the recommendation was made for for hysterectomy for tissue diagnosis and relief of symptoms. The patient was counseled that the risk risk of malignancy (sarcoma) in hysterectomy specimen for enlarging fibroids is thought to be 1-2% but she might be at higher risk given the rapid enlargement and severe pain. The patient strongly desired surgical managment and was taken to the operating room on ___ for an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy and repair of umbilical hernia. Intraoperative findings were concerning for leiomyosarcoma. Please see operative report for full details. Immediately post-operatively her blood pressure was elevated to 190s/90s. She recieved 5 mg IV metoprolol and 10 mg IV hydralazine and her blood pressure returned to a normal range. An EKG was stable compared to her baseline. She was restarted on her home blood pressure medications and remained normotensive throughout the rest of her admission. Immediately postoperatively, her pain was controlled with a diluadid PCA and IV tylenol/toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone/tylenol/motrin. On post-operative day 1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Social work was consulted for support for her new diagnosis. She declined social work at this time. 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. Heme/onc was consulted at time of initial admission for anemia and mildly elevated INR. For her anemia, labs were consistent with anemia of chronic disease. For her mildly elevated INR, her LFTs and factor levels were normal and her INR trended down from 1.5 to 1.3. to 1.2. On post-operative day 2, her HCT was 23.8. She was asymptomatic and exam benign. She was offered prophylactic transfusion given that she may be undergoing chemotherapy in the near future and declined. Pt was d/c'ed home with iron and colace.
| 1,664
| 620
|
10322940-DS-6
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic organ prolapse, stress urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic assisted supracervical hysterectomy, colpopexy and tension free vaginal tape <HISTORY OF PRESENT ILLNESS> ___ yo Gravida 2 Para 1011. She was seen in ___ and again yesterday for uterine prolpase. She is in fact complaining of vaginal pressure and palpating something at the entrance ofher vagina. She reports 0 incontinence events per day. She voids ___ times per day and ___ times per night. She uses 0 pads per day. She denies any urgency, she denies any dysuria and reports bladder emptying with normal flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ also admits to some vaginal pressure and palpable prolapse. She also denies any constipation. She is sexually active and does not experience dyspareunia. She denies any vaginal dryness. She had a pelvic ultrasound which showed and enlarged uterus and 13mm endo stripe and possible polyp. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. HTN 2. GERD PAST SURGICAL HISTORY 1. denies PAST OB HISTORY G2p1011 Vaginal: 1 PAST GYN HISTORY She is Premenopausal, her LMP was on ___. Her menses are irregular. She denies having Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV. She denies having an abnormal Pap test. She reports having an abnormal Mammogram <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Breast/Ovarian or Colon cancer <PHYSICAL EXAM> on ___ by Dr. ___: Neuro/Psych: Oriented x3, Affect Normal, NAD. Abdomen: Non tender, Non distended, Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skin & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: no lesions, no discharge Adnexa: no masses non tender. POP-Q Exam: Aa: 0 Ba: 0 TVL: 9 D: -4 C: +3 ___: 3.5 PB: 3 Ap: -2 Bp: -2 <PERTINENT RESULTS> ___ 07: 05AM BLOOD WBC-7.7 RBC-3.85* Hgb-9.6* Hct-31.9* MCV-83 MCH-24.8* MCHC-30.0* RDW-13.7 Plt ___ <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 ___.
|
Ms. ___ underwent robotic assisted laparoscopic supracervical hysterectomy, colpopexy and tension free vaginal tape. Please see operative report for full details. She was admitted to they GYN service post-operatively. By post-operative day one she was ambulating, tolerating a regular diet, controlling her pain with oral pain medications and voiding spontaneously. She passed her urogyn voiding trial with her first PVR of 10 and her second of 0. She was discharged home in good condition on POD1 with follow-up. Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*1* 4. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* 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: ___
| 866
| 346
|
10323390-DS-6
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Keflex / Duricef / lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> pelvic organ prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> total vaginal hysterectomy, bilateral salpingo-oophorectomy, vault suspension, anterior colporrhaphy, perineorrhaphy, cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 4 Para ___ who presents today in the office for a consultation requested by Dr. ___ vaginal prolapse. She is complaining of daily vaginal pressure that is interfering with her ability to exercise. She is avoiding her ___ and aerobics classes due to this prolapse. She work as a ___ and also has to avoid any heavy lifting. Her symptoms have been present for approximately 18 months. She believes that they are now worse. She declines any vaginal pressure She reports ___ mixed incontinence events. She voids 15+ times per day and ___ times per night. She uses ___ pads per day. She admits to some urgency, she denies any dysuria and reports bladder emptying with interrupted flow. She denies any admits to hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ also admits to vaginal pressure and palpable prolapse. She also admits to "splinting" with BM's. She is not sexually active and does not experience dyspareunia. She admits to vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. h.o LCIS 2. Asthma 3. HTN 4. OSA 5. Hypothyroidism 6. GERD 7. Varicose veins PAST SURGICAL HISTORY 1. Mastectomies, TRAM FLAP with mesh 2. BTL 3. Nissen fundoplication 4. Sinus <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Ovarian or Colon cancer. + paternal aunt and sister with 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> ___ 05: 10PM BLOOD WBC-9.7# RBC-4.10 Hgb-12.1 Hct-36.9 MCV-90 MCH-29.5 MCHC-32.8 RDW-12.3 RDWSD-40.3 Plt ___ ___ 05: 10PM BLOOD Plt ___ <MEDICATIONS ON ADMISSION> albuterol prn, flovent, esomeprazole 40', levothyroxine 112' <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth q6hrs Disp #*30 Tablet Refills: *3 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hrs Disp #*30 Tablet Refills: *3 3. Levothyroxine Sodium 112 mcg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H: PRN pain do not drive while taking this medication RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q4hrs Disp #*30 Tablet Refills: *0 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 7. Polyethylene Glycol 17 g PO DAILY: PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth once a day Disp #*30 Packet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cystocele, 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 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. No tub baths for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing Total Vaginal Hysterectomy, Bilateral Salpingo-oophorectomy, vault suspension, anterior repair, perineorrhaphy, and cystoscopy. Please see the operative report for full details. Case was uncomplicated. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV pain medication. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. She successfully passed her voiding trial. She was backfilled 300cc, voided 350cc with a PVR of 50cc. Her diet was advanced without difficulty and she was transitioned to oral pain meds. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,242
| 203
|
10323492-DS-16
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone <ATTENDING> ___. <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> diagnostic laparoscopy converted to exploratory laparotomy, en bloc radical hysterectomy/bilateral salpingo-oophrectomy/rectosigmoid resection, small bowel resection and anastomosis, omentectomy, bilateral pLND, end colostomy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ woman seen today in consultation for a pelvic mass. She reports 2 weeks of constipation and cramping lower abdominal pain that radiates to the groin. The pain slightly improved after a bowel regimen (PO dulcolax) but still present. She presented to her PCP and was noted to have moderate R adnexal tenderness on exam. CT A/P was performed on ___ and revealed: Complex multiloculated predominantly cystic 11.5 x 9 x 8.7 cm pelvic mass w/ intracystic mural solid subcomponents. Highly suspicious for ovarian neoplasm. No pelvic ascites is visualized. Central uterine low-attenuation - ?endometrial cavity of fluid. Crescent of low-attenuation likely intrinsic to L ovary. Liver w/ several variable sized lesions - large one ones w/ Hounsfield attenuation coeff c/w cysts. ROS: She denies unintentional weight changes, chest pain, shortness of breath, nausea, vomiting, bloating, increased abdominal girth, early satiety, diarrhea, dysuria, or abnormal discharge. She reports an episode of vaginal bleeding following attempted cervical polypectomy/cauterization in the office on ___, but otherwise denies PMB. <PAST MEDICAL HISTORY> PMH: - benign positional vertigo - thyroid nodule - osteopenia - tinnitus - Denies hypertension, diabetes, asthma, thromboembolic disease PSH: - ___ arthroscopy of right knee - ___ vulvar cyst excision POB: G2P1 - ___ TAB - ___ SVD PGYN: - LMP ___, mod flow lasting ___ days - Denies postmenopausal bleeding - Currently sexually active with husband - Using ___ x ___ yrs, no other hormonal replacement therapy - Denies history of abnormal Pap smears; last Pap/HPV neg/neg ___ - Used OCP ___ yrs and diaphragm in past for birth control - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Mother had MI age ___ - Father died of myeloma age ___ - MGM diagnosed with colon cancer in her ___ - Maternal first cousin diagnosed with breast cancer in her early ___ - No known family history of uterine, ovarian, or cervical cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 08: 55PM GLUCOSE-171* UREA N-11 CREAT-0.6 SODIUM-138 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-18* ANION GAP-18 ___ 08: 55PM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.8 MAGNESIUM-1.5* ___ 08: 55PM WBC-11.8* RBC-3.32* HGB-10.1*# HCT-30.5* MCV-92 MCH-30.4 MCHC-33.1 RDW-12.6 RDWSD-42.0 ___ 08: 55PM PLT COUNT-247 ___ 08: 55PM ___ PTT-24.8* ___ ___ 08: 55PM ___ 06: 38PM TYPE-ART PO2-310* PCO2-36 PH-7.28* TOTAL CO2-18* BASE XS--8 ___ 06: 38PM GLUCOSE-136* LACTATE-1.4 NA+-138 K+-4.0 CL--113* ___ 06: 38PM HGB-13.7 calcHCT-41 ___ 06: 38PM freeCa-1.18 ___ 06: 20PM WBC-13.9*# RBC-4.37 HGB-13.2 HCT-39.7 MCV-91 MCH-30.2 MCHC-33.2 RDW-12.7 RDWSD-41.7 ___ 06: 20PM PLT COUNT-340 ___ 06: 20PM ___ PTT-28.1 ___ <MEDICATIONS ON ADMISSION> - meclizine prn for BPV (has not yet taken) - ___ (removed yesterday) - fluticasone prn allergies - MVI - Calcium/Vit D - Zyrtec <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Ciprofloxacin HCl 500 mg PO Q12H Please take the full course of this medication. RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily Disp #*19 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 4. Enoxaparin Sodium 40 mg SC DAILY Take this medication for 28 days from the date of your surgery, ending ___ RX *enoxaparin 40 mg/0.4 mL 40 mL SC daily Disp #*21 Syringe Refills: *0 5. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Moderate Do not drink alcohol or drive. RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 6. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Take with food or milk. RX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ Diagnosis: ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * 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. . UTI: * You were found to have a urinary tract infection. Please take the full course of your antibiotics. . Foley Catheter: * You were discharged with a foley catheter in place. This catheter will remain in place until your follow-up visit on ___. . 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
|
Ms. ___ was admitted to the gynecologic oncology service after undergoing diagnostic laparoscopy converted to exploratory laparotomy, en bloc radical hysterectomy/bilateral salpingo-oophrectomy/rectosigmoid resection, small bowel resection and anastomosis, omentectomy, bilateral pLND, end colostomy, cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Her procedure was complicated by an estimated blood loss of 2300cc, so she was given 3 units of packed red blood cells and 2 units of fresh frozen plasma post-operatively. Her post-operative Hct was 30.5. On post-operative day 1, her Hct was stable at 29.6. On post-operative day 2, her Hct decreased to 22.4, she had mild tachycardia and hypotension, and experienced some dizziness. She was given 2 units of packed red blood cells, and her post-transfusion Hct was 28.7. Immediately postoperatively, her pain was controlled with Dilaudid PCA and IV Tylenol. Her diet was advanced slowly, and by post-operative day 3 she was tolerating clears liquids and crackers. She experienced nausea and vomiting, which was thought to be due to an ileus, so she was transitioned back to NPO and IV fluids and an NGT was placed. The NGT fell out overnight, and the patient's symptoms of nausea and vomiting had improved. On post-operative day #4, her urine output was adequate so her Foley catheter was removed, however she was unable to void spontaneously. Her Foley catheter was then replaced. She was kept NPO for her presumed ileus, and she remained asymptomatic. On post-operative day #5 she underwent another voiding trial, however the patient was unable to void, so the decision was made to keep the foley catheter in place for 7 days and repeat voiding trial at that time. Her diet was advanced to clears and crackers, which was well-tolerated. By post-operative day #7, she was tolerating a regular diet and was transitioned to oral oxycodone/acetaminophen/ibuprofen (pain meds). While showering, she experienced dizziness and had BP 86/60, HR 60. Symptoms resolved spontaneously and her BP improved to 110/75, HR 89. Orthostatics were negative. Labs were notable for a new leukocytosis to 16, and she was found to have a UTI. She was started on Ciprofloxacin for a total of 10 day course. On post-operative day #8, her leukocytosis had improved to 12. She was asymptomatic from her UTI. She underwent another trial of void, however she was unable to void spontaneously so the foley catheter was replaced with a plan to discharge patient home with catheter and repeat trial of void in 4 days. She was also seen by Social Work and Nutrition during her admission. By post-operative day #8, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was discharged home with Foley catheter in place, in stable condition with outpatient follow-up scheduled.
| 2,046
| 690
|
10323492-DS-17
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone <ATTENDING> ___. <CHIEF COMPLAINT> nausea/vomiting, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ s/p en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, end colostomy, for stage IIIC possible fallopian tube primary adenocarcinoma, intestinal type, on ___ presenting with N/V, abdominal pain x 1 day. Reports that she started having mid abdominal pain last night just above her umbilicus. She reports this pain as colicky in nature, with max severity of ___, no radiation. She took 1g tylenol last night with no improvement. She had 2 episodes of non-bloody emesis overnight with last episode at around 0500. She took 8mg zofran and her nausea/vomiting has improved. Of note, she had noted no gas or stool from stoma yesterday but has since had both since coming to the ED. Also reports that her abdominal pain has improved since coming to the ED and is now ___. Reports chills last night but no fevers. Denies CP/SOB, vaginal bleeding, abnormal vaginal discharge, urinary symptoms. Of note, patient was scheduled for her first cycle of FOLFOX today. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: - benign positional vertigo - thyroid nodule - osteopenia - tinnitus - Denies hypertension, diabetes, asthma, thromboembolic disease PAST SURGICAL HISTORY: - ___ en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, end colostomy - ___ arthroscopy of right knee - ___ vulvar cyst excision POB Hx: G2P1 - ___ TAB - ___ SVD PGYN: - LMP ___, mod flow lasting ___ days - Used estring x ___ yrs, no other hormonal replacement therapy - Denies history of abnormal Pap smears; last Pap/HPV neg/neg ___ - Used OCP ___ yrs and diaphragm in past for birth control - Denies history of pelvic infections or sexually transmitted infections <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Mother had MI age ___ - Father died of myeloma age ___ - MGM diagnosed with colon cancer in her ___ - Maternal first cousin diagnosed with breast cancer in her early ___ - No known family history of uterine, ovarian, or cervical cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: normoactive bowel sounds, soft, nontender, mildly distended, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 09: 55AM BLOOD WBC-8.5 RBC-4.30 Hgb-12.7 Hct-39.3 MCV-91 MCH-29.5 MCHC-32.3 RDW-13.0 RDWSD-43.5 Plt ___ ___ 02: 45PM BLOOD WBC-7.9 RBC-3.90 Hgb-11.5 Hct-36.1 MCV-93 MCH-29.5 MCHC-31.9* RDW-12.9 RDWSD-43.7 Plt ___ ___ 09: 55AM BLOOD Neuts-85.8* Lymphs-9.0* Monos-4.3* Eos-0.1* Baso-0.4 Im ___ AbsNeut-7.31* AbsLymp-0.77* AbsMono-0.37 AbsEos-0.01* AbsBaso-0.03 ___ 02: 45PM BLOOD Neuts-63.4 ___ Monos-6.4 Eos-1.1 Baso-0.9 Im ___ AbsNeut-5.03 AbsLymp-2.21 AbsMono-0.51 AbsEos-0.09 AbsBaso-0.07 ___ 09: 55AM BLOOD Glucose-109* UreaN-11 Creat-0.7 Na-140 K-4.0 Cl-97 HCO3-28 AnGap-19 ___ 02: 45PM BLOOD UreaN-11 Creat-0.7 Na-141 K-4.5 Cl-102 HCO3-27 AnGap-17 ___ 09: 55AM BLOOD ALT-20 AST-22 AlkPhos-97 TotBili-0.6 ___ 02: 45PM BLOOD ALT-20 AST-23 LD(LDH)-172 AlkPhos-82 TotBili-0.3 ___ 09: 55AM BLOOD Lipase-38 ___ 09: 55AM BLOOD Albumin-4.4 Calcium-9.8 Phos-4.2 Mg-2.0 ___ 02: 45PM BLOOD Calcium-9.4 Phos-3.4 Mg-2.1 ___ 02: 45PM BLOOD CEA-2.9 CA125-9 ___ 10: 52AM BLOOD Lactate-1.6 ___ 02: 45PM BLOOD CA ___ -PND ___ 06: 55AM BLOOD WBC-6.8 RBC-3.71* Hgb-10.9* Hct-34.3 MCV-93 MCH-29.4 MCHC-31.8* RDW-12.7 RDWSD-43.0 Plt ___ ___ 06: 55AM BLOOD Neuts-70.2 Lymphs-18.6* Monos-8.6 Eos-1.5 Baso-0.7 Im ___ AbsNeut-4.75 AbsLymp-1.26 AbsMono-0.58 AbsEos-0.10 AbsBaso-0.05 ___ 06: 55AM BLOOD Glucose-80 UreaN-7 Creat-0.6 Na-141 K-4.0 Cl-104 HCO3-25 AnGap-16 ___ 06: 55AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.9 <MEDICATIONS ON ADMISSION> ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for pain - (Prescribed by Other Provider) CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ Diagnosis: partial or early 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 nausea, vomiting, and abdominal pain. A CT scan of your abdomen showed that some of your small bowel (intestine) was "narrowed" but that there was no clear evidence of a blockage. We controlled your pain with IV pain medication and kept you on IV fluids to hydrate you while you were not able to take in any food or drink by mouth. Your symptoms improved, your diet was advanced, and you tolerated food and drink without further symptoms. The team believes it is now safe for you to be discharged home. Please feel free to call Dr. ___ office with any questions or concerns. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ is a ___ who underwent en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, and end colostomy, for stage IIIC possible fallopian tube primary adenocarcinoma, intestinal type (___), who presented to the emergency department with nausea, vomiting, and abdominal pain concerning for early partial small bowel obstruction and was admitted to the gynecologic oncology service for monitoring. In the emergency department, her abdominal pain was treated with IV Tylenol and her nausea resolved spontaneously. Her labs were reassuring with a normal lactate. CT scan ___ showed gradual tapering of dilated small bowel towards the distal anastomosis site, with no discrete transition point. She was made NPO and kept on maintenance IV fluids for hydration overnight. On the floor, her pain was well controlled with IV Tylenol as needed and she received IV pepcid. She had no further episodes of emesis. By hospital day 1, her diet was slowly advanced, and her abdominal pain improved. Her vitals signs were stable, and she maintained good output from her ostomy. She met with a nutritionist to discuss maintaining a low residue diet at home. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,790
| 267
|
10323492-DS-18
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone <ATTENDING> ___ <CHIEF COMPLAINT> epigastric pain, nausea, vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, end colostomy, for stage IIIC possible fallopian tube primary adenocarcinoma, intestinal type, on ___ s/p cycle 1 of FOLFOX, presenting with N/V, abdominal pain x 1 day starting ___ AM. She had been having mild abd discomfort ___ weeks ago with N/V and was seen in ED with CT c/f enteritis. She was started on Cipro/Flagyl ___ and is completing a 2 week course with improvement of her N/V and pain. This AM, she had breakfast and soon after had significant epigastric pain with an episode of emesis and nausea around 1130. No futher emesis since. She presented to the ED for eval. She continues to have epigastric pain that comes in waves, improved with APAP. No CP/SOB, F/C, diarrhea, Dizziness, dysuria, hematuria, vaginal bleeding, rectal bleeding. She did not have flatus today and minimal stool on her ostomy bag until after her PO contrast, which led to passage of some loose stool. no known sick contacts. ROS otherwise neg <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: - benign positional vertigo - thyroid nodule - osteopenia - tinnitus - Denies hypertension, diabetes, asthma, thromboembolic disease - stage IIIC possible fallopian tube primary adenocarcinoma PAST SURGICAL HISTORY: - ___ en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, end colostomy - ___ arthroscopy of right knee - ___ vulvar cyst excision POB Hx: G2P1 - ___ TAB - ___ SVD PGYN: - LMP ___ - Used estring x ___ yrs, no other hormonal replacement therapy - Denies history of abnormal Pap smears; last Pap/HPV neg/neg ___ - Denies history of pelvic infections or sexually transmitted infections <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Mother had MI age ___ - Father died of myeloma age ___ - MGM diagnosed with colon cancer in her ___ - Maternal first cousin diagnosed with breast cancer in her early ___ - No known family history of uterine, ovarian, or cervical cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, non tender, nondistended, normoactive bowel sounds, incision, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 05: 37AM BLOOD WBC-5.7 RBC-3.89* Hgb-11.1* Hct-34.3 MCV-88 MCH-28.5 MCHC-32.4 RDW-14.1 RDWSD-45.0 Plt ___ ___ 06: 14AM BLOOD WBC-6.6 RBC-4.05 Hgb-11.7 Hct-35.6 MCV-88 MCH-28.9 MCHC-32.9 RDW-14.1 RDWSD-45.1 Plt ___ ___ 03: 10PM BLOOD WBC-10.9*# RBC-4.39 Hgb-12.6 Hct-38.3 MCV-87 MCH-28.7 MCHC-32.9 RDW-14.1 RDWSD-43.8 Plt ___ ___ 05: 37AM BLOOD Neuts-42.5 ___ Monos-11.8 Eos-0.9* Baso-1.0 Im ___ AbsNeut-2.44 AbsLymp-2.50 AbsMono-0.68 AbsEos-0.05 AbsBaso-0.06 ___ 06: 14AM BLOOD Neuts-42.8 ___ Monos-9.6 Eos-1.2 Baso-0.8 Im ___ AbsNeut-2.82# AbsLymp-2.96 AbsMono-0.63 AbsEos-0.08 AbsBaso-0.05 ___ 03: 10PM BLOOD Neuts-79.7* Lymphs-15.3* Monos-3.9* Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.69*# AbsLymp-1.67 AbsMono-0.42 AbsEos-0.01* AbsBaso-0.04 ___ 05: 37AM BLOOD Glucose-81 UreaN-4* Creat-0.6 Na-143 K-4.0 Cl-105 HCO3-24 AnGap-18 ___ 06: 14AM BLOOD Glucose-102* UreaN-5* Creat-0.6 Na-143 K-3.6 Cl-105 HCO3-28 AnGap-14 ___ 03: 10PM BLOOD Glucose-102* UreaN-7 Creat-0.6 Na-142 K-3.8 Cl-101 HCO3-25 AnGap-20 ___ 03: 10PM BLOOD ALT-79* AST-49* AlkPhos-92 TotBili-0.4 ___ 03: 10PM BLOOD Lipase-77* ___ 05: 37AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1 ___ 06: 14AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.3 ___ 03: 10PM BLOOD Albumin-3.6 ___ 03: 16PM BLOOD Lactate-1.0 <MEDICATIONS ON ADMISSION> Medications - Prescription CIPROFLOXACIN HCL [CIPRO] - Cipro 500 mg tablet. 1 tablet(s) by mouth twice a day IBUPROFEN - ibuprofen 400 mg tablet. 1 tablet(s) by mouth every four (4) hours -6 hours/last dose was ___ - (Prescribed by Other Provider) LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three times a day as needed for nausea, anxiety METRONIDAZOLE [FLAGYL] - Flagyl 500 mg tablet. 1 tablet(s) by mouth twice a day ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for nausea ICD 10 Code: C57.00 Malignant neoplasm of unspecified fallopian tube PNV W/O CALCIUM-IRON FUM-FA [M-VIT] - M-Vit 27 mg-1 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for nausea Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for pain - (Prescribed by Other Provider) CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Ciprofloxacin HCl 500 mg PO Q12H 2. MetroNIDAZOLE 500 mg PO BID <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ 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. You were managed conservatively, with a NG tube and with backing down on your diet. Your symptoms resolved. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: . 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 . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
Ms. ___ was admitted to the gynecologic oncology service for management of a small bowel obstruction. On admission a CT scan showed a small-bowel obstruction with the transition point at the anastomosis in the left lower quadrant. A nasogastric tube was placed. She was kept NPO and put on maintenance IV fluids. Once her nausea resolved and her NG tube output decreased, her NG tube was clamped, which she tolerated well. Her NG tube was removed on ___ (day after admission), and her diet was gradually advanced. She was tolerating a regular diet by ___. She was seen by nutrition for dietary counseling. Of note, she was continued on her 2-week course of cipro/flagyl through ___ for her enteritis, diagnosed prior to admission. By ___, she was tolerating a regular diet and was symptomatically improved. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 2,060
| 191
|
10323492-DS-19
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone <ATTENDING> ___. <CHIEF COMPLAINT> small bowel obstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> nasogastric tube placement <HISTORY OF PRESENT ILLNESS> ___ with stage IIIC possible fallopian tube primary adenocarcinoma, intestinal type s/p tumor debulking in ___ currently in cycle 3 of chemotherapy, which was held on ___ due to neutropenia, presenting with abdominal pain. She was evaluated in the ED on ___ with nausea and emesis, which resolved and she was discharged home. Today she reports onset of abdominal pain coinciding with absence of ostomy output (stool nor flatus) since the morning. Her abdominal pain fluctuates in intensity up to ___. Denies fevers, chills, chest pain, shortness of breath, dysuria, leg swelling, rash. One episode of emesis in ED prior to CT scan. Now status post NGT placement in ED after CT scan showed high grade SBO with immediate output of 500cc greenish fluid, patient reports feeling significant improvement in abdominal pain and has started to notice ostomy output as well. <PAST MEDICAL HISTORY> ONCOLOGIC HISTORY: - ___: had constipation, abdominal pain, CT scan that showed a complex multiloculated predominantly cystic 11.5 x 9 x 8.7 cm pelvic mass w/ intracystic mural solid subcomponents that was highly suspicious for ovarian neoplasm. No pelvic ascites was visualized. The liver had several variably sized lesions that appeared most consistent radiographically with cysts. - ___: negative endometrial biopsy - ___: CA125 of 58, a CEA of 10.2 and a ___ of 16,480. - ___: diagnostic laparoscopy that was converted to laparotomy with type 2 radical oophorectomy inclusive of an en bloc radical hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with an omentectomy, bilateral pelvic lymph node dissection, small bowel resection, end colostomy, and cystoscopy. Pathology of her tumor tissue returned as metastatic adenocarcinoma, intestinal type. Adenocarcinoma was present in the bilateral ovaries, bilateral fallopian tubes and omentum. The tumor showed transmural mesorectal infiltration without a mucosal lesion. Metastatic mesenteric implants were present on the small bowel mesentery and cecum without mucosal lesions. The umbiical nodule was positive for disease. Six of 30 pericolonic lymph nodes and 1 of 5 pelvic lymph nodes were positive for disease. Washings were also positive. While a fallopian tube primary was favored, evaluation for an intestinal or pancreaticobiliary primary was recommended. - ___: negative colonsocopy - ___: port placed - ___ - ___: admitted for partial SBO (conservative management) - ___: C1D1 FOLFOX - ___: C1D15 FOLFOX - ___ - ___: ED for abdominal pain, nausea, given antibx for colitis - ___ - ___: admitted for SBO (conservative management with NGT) - ___: C2D1 FOLFOX - ___: C3D1 FOLFOX - ___: C3D15: held FOLFOX fro neutropenia, received neulasta ROS otherwise negative except as noted in the HPI PAST MEDICAL HISTORY: - benign positional vertigo - thyroid nodule - osteopenia - tinnitus - Denies hypertension, diabetes, asthma, thromboembolic disease - stage IIIC possible fallopian tube primary adenocarcinoma PAST SURGICAL HISTORY: - ___ en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, end colostomy - ___ arthroscopy of right knee - ___ vulvar cyst excision POB Hx: G2P1 - ___ TAB - ___ SVD PGYN: - LMP ___ - Used estring x ___ yrs, no other hormonal replacement therapy - Denies history of abnormal Pap smears; last Pap/HPV neg/neg ___ - Denies history of pelvic infections or sexually transmitted infections <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies bleeding/clotting disorders, gyn/GI malignancies, breast cancer <PHYSICAL EXAM> On day of discharge: Gen - NAD CV - RRR Lungs - CTAB Abd - soft, NT, ND, no r/g, +bowel sounds, + gas and brown stool in ostomy bag, osotmy pink Ext - nontender, no edema <PERTINENT RESULTS> ___ 05: 50AM BLOOD WBC-15.2* RBC-3.74* Hgb-10.7* Hct-32.9* MCV-88 MCH-28.6 MCHC-32.5 RDW-18.8* RDWSD-59.4* Plt ___ ___ 05: 50AM BLOOD Glucose-88 UreaN-5* Creat-0.6 Na-144 K-3.7 Cl-106 HCO3-26 AnGap-16 ___ 06: 57AM BLOOD ALT-39 AST-36 ___ 05: 50AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.0 ___ 06: 57AM BLOOD WBC-24.3* RBC-3.77* Hgb-10.9* Hct-32.9* MCV-87 MCH-28.9 MCHC-33.1 RDW-18.6* RDWSD-57.8* Plt ___ ___ 07: 45PM BLOOD WBC-24.5*# RBC-4.33 Hgb-12.7 Hct-37.7 MCV-87 MCH-29.3 MCHC-33.7 RDW-18.3* RDWSD-56.6* Plt ___ CT Abd/Pelvis ___ FINDINGS: LOWER CHEST: There is bibasilar atelectasis. Heart size is normal. There is no pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Again seen, are multiple simple hepatic cysts with the largest at the dome measuring 3.1 x 2.9 cm. No suspicious hepatic lesions are seen. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There are subcentimeter hypodensities in the upper pole of the right kidney, too small to characterize but statistically likely simple cysts. There is no perinephric abnormality. GASTROINTESTINAL: The distal esophagus is unremarkable. The stomach is distended and fluid-filled. The small bowel is dilated and fluid-filled measuring up to 4.2 cm. There is decompression to completely decompressed loops of small bowel, likely at the left lower quadrant anastomosis, similar to ___. Postsurgical changes from partial colectomy with ileostomy. Right colon is normal in caliber. Left lower quadrant ostomy is unremarkable. There is no intra-abdominal free fluid or free air. There is no pneumatosis or mesenteric gas. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The patient is status post hysterectomy. Small amount of fluid is noted in the surgical bed. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. Previously described omental nodularity, it not well seen on the current examination. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There are mild multilevel degenerative changes. Lucent lesion in the L4 vertebral body most likely represents a hemangioma, and is unchanged since ___. SOFT TISSUES: Surgical changes are noted along the anterior abdominal wall. IMPRESSION: High-grade small bowel obstruction with the transition point at the left lower quadrant anastomosis, similar to prior ___. <MEDICATIONS ON ADMISSION> HYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by mouth every ___ hours as needed for pain LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three times a day as needed for nausea, anxiety ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for nausea ICD 10 Code: ___ Malignant neoplasm of unspecified fallopian tube PRENATAL VITS-IRON FUM-FOLIC [M-VIT] - M-Vit 27 mg-1 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for nausea Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for pain - (Prescribed by Other Provider) CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) CETIRIZINE [ALL DAY ALLERGY (CETIRIZINE)] - All Day Allergy (cetirizine) 10 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider; ___) DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> HYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by mouth every ___ hours as needed for pain LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three times a day as needed for nausea, anxiety ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for nausea ICD 10 Code: ___ Malignant neoplasm of unspecified fallopian tube PRENATAL VITS-IRON FUM-FOLIC [M-VIT] - M-Vit 27 mg-1 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for nausea Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for pain - (Prescribed by Other Provider) CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) CETIRIZINE [ALL DAY ALLERGY (CETIRIZINE)] - All Day Allergy (cetirizine) 10 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider; ___) DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ 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 gynecology oncology service for management of a small bowel obstruction. You were managed conservatively with antiemetics, pain medications, and an NG tube. You had return of bowel function and your diet was advanced. You have recovered well and the team feels that you are safe to be discharged home. Please follow the instructions: . * 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 take more than 4000mg acetaminophen (tylenol) in 24 hrs. * Please continue a low residual diet (avoid high-fiber foods, like whole-grain breads and cereals, nuts, seeds, raw or dried fruits, and vegetables). If symptoms resume such as pain and cramping, please resume low residual diet and call office. * 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 ___.
|
Ms. ___ was admitted to the gyn/onc service with an SBO. A CT scan showed a transition point in her right lower quadrant, similar to prior episodes of SBO. An NGT was placed for bowel rest/decompression in the ED prior to transfer. Her abdominal exam showed no peritoneal signs during her stay and she remained afebrile. Her white blood cell count was noted to be elevated, but there was no evidence of infection or bowel ischemia on exam, imaging, or other lab tests (normal lactate). Her leukocytosis was thought to be due to a recent Neulasta injection received for preparation for chemotherapy. Her WBC was trended and improved during her hospital day. On the day following her admission, she began noticing more stool and gas in her ostomy. She had minimal residual on an NGT clamp trial. Her NGT was removed and her diet was slowly advanced. On hospital day #2 she was tolerating a regular diet. She was discharged home in stable condition with outpatient follow-up planned.
| 3,062
| 216
|
10323492-DS-20
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone <ATTENDING> ___. <CHIEF COMPLAINT> small bowel obstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> NGT placement and removal <HISTORY OF PRESENT ILLNESS> ___ with stage IIIC possible fallopian tube primary adenocarcinoma, intestinal type s/p ex-lap, radical hysterectomy, BSO, small bowel resection, rectosigmoid resection, omentectomy, pelvic LND, end colostomy, cysto on ___ currently in cycle 4 of chemotherapy (FOLFOX) s/p recent high grade SBO managed conservatively with NGT ___. Today she reports onset of abdominal pain coinciding with absence of ostomy output (stool nor flatus) since the morning, similar to previous presentation. She began to experience nausea and emesis x2 over the course of the day prompting her presentation for care. Still with no ostomy output s/p NGT placement for 400cc. Denies fevers, chills, chest pain, shortness of breath, dysuria, leg swelling, rash. <PAST MEDICAL HISTORY> ONCOLOGIC HISTORY: - ___: had constipation, abdominal pain, CT scan that showed a complex multiloculated predominantly cystic 11.5 x 9 x 8.7 cm pelvic mass w/ intracystic mural solid subcomponents that was highly suspicious for ovarian neoplasm. No pelvic ascites was visualized. The liver had several variably sized lesions that appeared most consistent radiographically with cysts. - ___: negative endometrial biopsy - ___: CA125 of 58, a CEA of 10.2 and a ___ of 16,480. - ___: diagnostic laparoscopy that was converted to laparotomy with type 2 radical oophorectomy inclusive of an en bloc radical hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with an omentectomy, bilateral pelvic lymph node dissection, small bowel resection, end colostomy, and cystoscopy. Pathology of her tumor tissue returned as metastatic adenocarcinoma,intestinal type. Adenocarcinoma was present in the bilateral ovaries, bilateral fallopian tubes and omentum. The tumor showed transmural mesorectal infiltration without a mucosal lesion. Metastatic mesenteric implants were present on the small bowel mesentery and cecum without mucosal lesions. The umbiical nodule was positive for disease. Six of 30 pericolonic lymph nodes and 1 of 5 pelvic lymph nodes were positive for disease. Washings were also positive. While a fallopian tube primary was favored, evaluation for an intestinal or pancreaticobiliary primary was recommended. - ___: negative colonsocopy - ___: port placed - ___ - ___: admitted for partial SBO (conservative management) - ___: C1D1 FOLFOX - ___: C1D15 FOLFOX - ___ - ___: ED for abdominal pain, nausea, given antibx for colitis - ___ - ___: admitted for SBO (conservative management with NGT) - ___: C2D1 FOLFOX - ___: C3D1 FOLFOX - ___: C3D15: held FOLFOX fro neutropenia, received neulasta - ___: NGT placement for high grade SBO with resolution, discharged ___ - ___ C4D1: FOLFOX <SOCIAL HISTORY> ___ <FAMILY HISTORY> denies bleeding/clotting disorders, gyn/GI malignancies, breast cancer <PHYSICAL EXAM> Admission exam: Gen: NAD HEENT: NGT in place with 400cc brown/green output CV: RRR Pulm: CTAB, normal work of breathing Abd: soft, mildly distended, tympanic with hyperactive bowel sounds. Ostomy bag without air or stool, last changed this morning, ostomy pink. Pelvic: deferred Ext: no edema Discharge exam: Gen - NAD CV - RRR Lungs - CTAB Abd - soft, NT, ND, no r/g, +bowel sounds, + gas and brown stool in ostomy bag, osotmy pink Ext - nontender, no edema <PERTINENT RESULTS> ___ 05: 27AM BLOOD WBC-4.9 RBC-3.04* Hgb-8.9* Hct-27.6* MCV-91 MCH-29.3 MCHC-32.2 RDW-17.5* RDWSD-58.2* Plt ___ ___ 05: 00AM BLOOD WBC-5.4# RBC-3.39* Hgb-9.9* Hct-29.7* MCV-88 MCH-29.2 MCHC-33.3 RDW-17.8* RDWSD-57.1* Plt ___ ___ 07: 41PM BLOOD WBC-17.9*# RBC-3.92 Hgb-11.5 Hct-35.0 MCV-89 MCH-29.3 MCHC-32.9 RDW-18.1* RDWSD-59.1* Plt ___ ___ 05: 00AM BLOOD Neuts-64.2 ___ Monos-4.3* Eos-0.2* Baso-0.6 Im ___ AbsNeut-3.44# AbsLymp-1.61 AbsMono-0.23 AbsEos-0.01* AbsBaso-0.03 ___ 07: 41PM BLOOD Neuts-92.0* Lymphs-4.9* Monos-2.3* Eos-0.0* Baso-0.2 Im ___ AbsNeut-16.48*# AbsLymp-0.87* AbsMono-0.42 AbsEos-0.00* AbsBaso-0.03 ___ 07: 41PM BLOOD ALT-29 AST-28 AlkPhos-133* TotBili-0.8 ___ 05: 27AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-140 K-3.7 Cl-107 HCO3-25 AnGap-12 <MEDICATIONS ON ADMISSION> Active Medication list as of ___: Medications - Prescription HYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by mouth every ___ hours as needed for pain LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three times a day as needed for nausea, anxiety OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth once a day ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for nausea ICD 10 Code: C57.00 Malignant neoplasm of unspecified fallopian tube PRENATAL VITS-IRON FUM-FOLIC [M-VIT] - M-Vit 27 mg-1 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for nausea Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for pain - (Prescribed by Other Provider) CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) CETIRIZINE [ALL DAY ALLERGY (CETIRIZINE)] - All Day Allergy (cetirizine) 10 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider; ___) DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ 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. ___, . It is always a pleasure to take care of you and we are glad you are feeling improved and ready to go home. You were admitted to the gynecology oncology service for management of a small bowel obstruction. You were managed conservatively with antiemetics, pain medications, and an NG tube. You had return of bowel function and your diet was advanced. You have recovered well and the team feels that you are safe to be discharged home. Please follow the instructions: . * 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 take more than 4000mg acetaminophen (tylenol) in 24 hrs. * Please continue a low residual diet (avoid high-fiber foods, like whole-grain breads and cereals, nuts, seeds, raw or dried fruits, and vegetables). If symptoms resume such as pain and cramping, please resume low residual diet and call office. * 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 ___.
|
Ms. ___ was admitted to the gyn/onc service with an SBO. Given her symptoms were similar to prior recent presentations and she had no peritoneal signs on examination, imaging was referred. An NGT was placed for bowel rest/decompression in the ED. Her white blood cell count was noted to be elevated, but there was no clinical evidence of infection (normal exam, normal lactate). A repeat CBC on hospital day 1 showed a normal WBC She was managed conservatively during her admission with an NG tube. On hospital day 3, she began noticing more stool and gas in her ostomy. She had minimal residual on an NGT clamp trial. Her NGT was removed and her diet was advanced without issue. On hospital day #3 she was tolerating a regular diet. She was discharged home in stable condition with outpatient follow-up planned.
| 2,191
| 177
|
10323492-DS-21
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain, nausea and vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ with stage IIIC possible fallopian tube primary adenocarcinoma, intestinal type s/p ex-lap, radical hysterectomy, BSO, small bowel resection, rectosigmoid resection, omentectomy, pelvic LND, end colostomy, cysto on ___ currently in cycle 4 of chemotherapy (FOLFOX) s/p recent high grade SBO managed conservatively with NGT ___ and ___. She reports she has been doing very well since discharge. However today she developed crampy abdominal pain at 12: 30pm, which felt like her prior SBOs. Has noted decreased air in her ostomy but it is still putting out stool and air. She last ate breakfast, and then did not have any further PO intake as she felt she was developing an SBO. Has some discomfort across her upper abdomen, but denies abdominal pain. She had one episode of emesis in the ED and now her abdominal discomfort and nausea are significantly improved. <PAST MEDICAL HISTORY> ONCOLOGIC HISTORY: - ___: had constipation, abdominal pain, CT scan that showed a complex multiloculated predominantly cystic 11.5 x 9 x 8.7 cm pelvic mass w/ intracystic mural solid subcomponents that was highly suspicious for ovarian neoplasm. No pelvic ascites was visualized. The liver had several variably sized lesions that appeared most consistent radiographically with cysts. - ___: negative endometrial biopsy - ___: CA125 of 58, a CEA of 10.2 and a ___ of 16,480. - ___: diagnostic laparoscopy that was converted to laparotomy with type 2 radical oophorectomy inclusive of an en bloc radical hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with an omentectomy, bilateral pelvic lymph node dissection, small bowel resection, end colostomy, and cystoscopy. Pathology of her tumor tissue returned as metastatic adenocarcinoma,intestinal type. Adenocarcinoma was present in the bilateral ovaries, bilateral fallopian tubes and omentum. The tumor showed transmural mesorectal infiltration without a mucosal lesion. Metastatic mesenteric implants were present on the small bowel mesentery and cecum without mucosal lesions. The umbiical nodule was positive for disease. Six of 30 pericolonic lymph nodes and 1 of 5 pelvic lymph nodes were positive for disease. Washings were also positive. While a fallopian tube primary was favored, evaluation for an intestinal or pancreaticobiliary primary was recommended. - ___: negative colonsocopy - ___: port placed - ___ - ___: admitted for partial SBO (conservative management) - ___: C1D1 FOLFOX - ___: C1D15 FOLFOX - ___ - ___: ED for abdominal pain, nausea, given antibx for colitis - ___ - ___: admitted for SBO (conservative management with NGT) - ___: C2D1 FOLFOX - ___: C3D1 FOLFOX - ___: C3D15: held FOLFOX fro neutropenia, received neulasta - ___: NGT placement for high grade SBO with resolution, discharged ___ - ___ C4D1: FOLFOX - Admitted ___ for SBO, managed conservatively PAST MEDICAL HISTORY: - benign positional vertigo - thyroid nodule - osteopenia - tinnitus - Denies hypertension, diabetes, asthma, thromboembolic disease - stage IIIC possible fallopian tube primary adenocarcinoma PAST SURGICAL HISTORY: - ___ en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, omentectomy, end colostomy, cysto - ___ arthroscopy of right knee - ___ vulvar cyst excision <SOCIAL HISTORY> ___ <FAMILY HISTORY> denies bleeding/clotting disorders, gyn/GI malignancies, breast cancer <PHYSICAL EXAM> On admission: T 99, HR84, 147/71, 16, 100% RA Gen: NAD, comfortable appearing CV: RRR Pulm: CTAB, normal work of breathing Abd: soft, mildly distended and tympanitic, hyperactive bowel sounds. Ostomy bag with minimal air and +stool, last changed this morning, ostomy pink. Pelvic: deferred Ext: no edema On discharge: Gen: NAD, comfortable CV: RRR Lungs: CTAB Abd: soft, nondistended, ostomy bag with stool and gas, stoma pink Ext: nontender, no edema <PERTINENT RESULTS> ___ 06: 15AM BLOOD WBC-2.4* RBC-2.87* Hgb-8.6* Hct-26.4* MCV-92 MCH-30.0 MCHC-32.6 RDW-18.1* RDWSD-61.6* Plt ___ ___ 06: 15AM BLOOD Glucose-81 UreaN-7 Creat-0.5 Na-144 K-3.5 Cl-110* HCO3-27 AnGap-11 ___ 06: 15AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.1 <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology oncology service for a small bowel obstruction. You were conservatively managed. Your nausea was treated with antiemetics. You were afebrile with stable vital signs and monitored closely for resolution of symptoms. When signs of return of bowel function were present your diet was advanced without incident and you are discharged home on a low residual diet. Your home medications were continued. You have recovered well and the team now feels it is safe for you to be discharged home. Please follow these instructions: * Take 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 combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * Please continue on your low residual diet
|
Ms. ___ was admitted with concern for recurrent SBO given cramping abdominal pain and nausea vomiting. She had labs done without evidence of infection or electrolyte derangement. She was managed conservatively by being kept NPO with IVF. The night of her admission, upon arrival to the floor from the ED, her symptoms began to improve. She began to have ostomy output (gas, stool) and had no further nausea or vomiting. Her diet was advanced and she tolerated a regular diet. She was discharged home in stable condition on hospital day 2 with outpatient follow-up arranged. Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*50 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
| 1,446
| 210
|
10323608-DS-18
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Erythromycin Base <ATTENDING> ___. <CHIEF COMPLAINT> preeclampsia evaluation <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 35w4d presents to OB triage after being found to have BP 140/80 and 1+ urine protein in clinic earlier today. This is her ___ presentation to OB triage for hypertension during this pregnancy, with 24-hour urine negative for preeclampsia on ___. Has been taking BP at home several times per day, ranging 120s-130s/90s-105. Denies LOF, vaginal bleeding, contractions. Endorses + fetal movement. Denies headaches, vision changes, right upper quadrant pain, chest pain, and shortness of breath. <PAST MEDICAL HISTORY> GYN hx: LMP: ___ No hx abnormal paps OB hx: G1P0 PMH: None PSH: L breast lumpectomy - benign L ACL repair <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Temp: BP ___, 148/99, ___ RR 20, T 98.1, HR 83 GENERAL: Well-appearing, no acute distress HEENT: No obvious facial swelling CV: RRR Resp: Clear to auscultation bilaterally. No crackles or wheezes. Abdomen: Gravid. Soft. Non-tender. No hepatomegaly. Extremities: 1+ ___ non-pitting edema Neuro: 2+ patellar, brachioradialis reflexes. No ankle clonus. FHT 145 ___, pos accels, no decels, mod var, reactive TOCO no contractions noted TA U/S BPP ___, AFI 12.5cm, cephalic, placenta anterior no preiva, FHT 150 by M mode <PERTINENT RESULTS> ___ WBC-11.9 RBC-4.26 Hgb-13.4 Hct-41.0 MCV-96 Plt-196 ___ Creat-0.6 ALT-20 UricAcd-5.4 ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ URINE Hours-RANDOM Creat-67 TotProt-11 Prot/Cr-0.2 ___ URINE pH-6 Hours-24 Volume-2250 Creat-49 TotProt-6 Prot/Cr-0.1 ___ URINE 24Creat-1103 24Prot-135 R/O GROUP B BETA STREP (Pending): <MEDICATIONS ON ADMISSION> PNV, ranitidine <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Ranitidine 150 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 36 weeks gestation gestational hypertension <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for gestational hypertension. While you were here, your blood pressures were mildly elevated. You had no evidence of preeclampsia. Fetal testing was reassuring. You were discharged home in stable condition, and you will need to get close outpatient followup.
|
___ y/o G1P0 with gestational HTN admitted at 35w4d for preeclampsia evaluation. Her blood pressures were mostly 140s/90-100s in triage. She denied any preeclampsia symptoms and her labs were normal. Fetal testing was reassuring. Given her persistently elevated blood pressures, she was admitted to the antepartum service for observation, 24 hour urine collection, and ___ consult. Her blood pressures remained in the mild range and her 24 hour urine was negative (135mg). ___ was consulted. She had a reassuring fetal ultrasound with an estimated fetal weight in the ___ percentile. Given she had no evidence of preeclampsia, she was discharged home and will have close outpatient follow up with twice weekly fetal testing and weekly visits in the office.
| 777
| 172
|
10324612-DS-20
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> LOF, exacerbation of bipolar/schizophrenia <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary LTCS <HISTORY OF PRESENT ILLNESS> ___ F with unclear parity at 25w5d with ___ pregnancy by 19-week U/S w/ hx of bipolar disorder brought to the ED by her mother and aunt due to c/f leakage of fluid and worsening psychosis. Pt hesitant to engage in conversation, but admits that she lives in a shelter and would like assistance finding stable housing. She states that her "water broke" some time within the last 24 hours. On further questioning, she reports that she was taking a shower and she felt wet afterwards. Denies VB, contractions. +FM. She reports that she currently has a twin pregnancy, despite having been told by multiple providers that she has ___ pregnancy. Pt's report of medical history limited by acute psychotic episode. Unclear how reliable she is, however she reports the following: - denies any medical issues, surgeries, medications, allergies <PAST MEDICAL HISTORY> PNC: - ___: ___ by 19 week ultrasound, consistent with LMP ** she had an ultrasound on ___, those records are unavailable but are pending - Labs: No prenatal care labs available - FFS: 311g 39%, oligo, posterior placenta, transverse, 3 vessel cord OBHx: Unclear historian. At times, will say that she has been pregnant 4 times, and that she has delivered 2 babies but they are not in her custody. At other times, she will say that this pregnancy started with 4 babies, and now she has a twin pregnancy. GynHx: - Unable to obtain PMH: - Bipolar disorder - Schizophrenia <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, no edema FHR: present at a normal rate <PERTINENT RESULTS> ___ WBC-8.1 RBC-4.25 Hgb-11.8 Hct-36.2 MCV-85 Plt-255 ___ WBC-10.0 RBC-3.84 Hgb-10.7 Hct-33.2 MCV-87 Plt-186 ___ WBC-9.2 RBC-3.94 Hgb-10.9 Hct-34.0 MCV-86 Plt-198 ___ WBC-5.7 RBC-3.83 Hgb-10.5 Hct-33.0 MCV-86 Plt-154 ___ WBC-6.8 RBC-3.92 Hgb-10.9 Hct-33.7 MCV-86 Plt-158 ___ WBC-19.8 RBC-4.22 Hgb-11.7 Hct-36.1 MCV-86 Plt-208 ___ Glu-79 ___ Glu-124 ___ Glu-79 BUN-12 Cre-0.7 Na-136 K-4.1 Cl-100 HCO3-25 Gap-11 ___ 10: 52PM BLOOD Calcium-9.4 Phos-4.4 Mg-1.8 ___ BLOOD CK(CPK)-27 ___ BLOOD CK-MB-<1 cTropnT-<0.01 ___ BLOOD HBsAg-NEG ___ BLOOD HIV Ab-NEG ___ BLOOD HCV Ab-NEG ___ URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG ___ URINE RBC-3* WBC-6* Bacteri-NONE Yeast-NONE Epi-9 TransE-<1 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ OTHER BODY FLUID CT-NEG NG-NEG URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION R/O GROUP B BETA STREP (Final ___: Negative for Group B beta streptococci. SMEAR FOR BACTERIAL VAGINOSIS (Final ___: Indeterminate. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE RUBELLA IgG SEROLOGY (Final ___: POSITIVE BY EIA VARICELLA-ZOSTER IgG SEROLOGY (Final ___: POSITIVE BY EIA URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> none <DISCHARGE DISPOSITION> Extended Care <DISCHARGE DIAGNOSIS> preterm premature rupture of membranes cesarean delivery due to breech presentation and preterm labor <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Post partum instructions as follows: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking narcotics (i.e. Dilaudid, 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 100.4 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
|
___ G1P0 w/ Bipolar I disorder w/ mania w/ psychotic and catatonic features admitted at 25w5d with acute psychotic episode and PPROM. *) PPROM: Patient admitted with PPROM, confirmed with +nitrizine and ferning. She was 2cm dilated with bulging membranes w/ valsalva, and per review of records she had likely been ruptured for several weeks prior to presentation. An ultrasound was notable for AFI 4.0, consistent with oligohydramnios found on 19 weeks U/S (311g 39%, oligo, posterior placenta, transverse, 3 vessel cord). Given that patient was declining standard latency antibiotics, a modified regimen was administered with azithromycin 250mg for 4 days, and IV Ampicillin x 48 hours. The patient declined amoxicillin. She received a course of betamethasone for fetal lung maturity (complete on ___. Genital cultures were negative for gonorrhea, chlamydia, and yeast. BV was indeterminate. Ms ___ declined various interventions including a peripheral IV. She was monitored for signs and symptoms of infection and abruption and remained stable until delivery at 32w3d. *) Acute psychotic episode: Patient was seen and followed by the psychiatry team. She had a 1:1 sitter due to elopement risk and was not allowed to leave the floor. She refused all psychiatric medications. On a couple occasions, she became quite loud and angry after phone conversations. A code purple was called on a couple of occasions, but she never required any physical or medical restraint. Guardianship was granted to her mother during the course of her hospital stay. At ___ she went into preterm labor. She was transferred to labor and delivery for a cesarean section for breech presentation. She was calm and cooperative during the transfer as well as the delivery. She underwent an uncomplicated primary LTCS at 32w3d and delivered a liveborn male from breech presentation weighing 1820 grams with Apgars of 4 and 7. Neonatology staff was present for delivery and transferred the neonate immediately for prematurity. Please see operative report for details. . Ms ___ had an uncomplicated postoperative course. She remained afebrile and recovered well. She remained on a ___ with a 1:1 sitter. Social services and psychiatry continued to follow her closely. She declined any psychiatric medication but was in agreement for inpatient psychiatric admission.
| 1,380
| 527
|
10325532-DS-8
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> headache, brain mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ brain biopsy, Dr. ___ ___ of Present Illness: HPI: ___ yo G2P1 at 33w1d with HA onset ___ morning, described as throbbing right sided pain unchanged with conservative measures at home (Tylenol). Was in town visiting family for the weekend, went to ___ where HA was unresponsive to reglan, IVF, Benadryl and responsive only to morphine. MR showed ___ new brain lesion in the frontal lobe and she was transferred to ___ for neurosurgery evaluation. ___ labs were negative per ED records including normal LFTs, negative urine protein and normal BPs. She has mild photophobia but denies weakness, numbness or tingling. Denies ctx, VB, LOF. +FM. Denies N/V, CP, SOB, fevers, chills, constipation. Multiple BMs daily due to known Crohn's disease. <PAST MEDICAL HISTORY> PNC: (prenatal records not yet available ,PNC per patient report) - ___ ___ vs ___ by first trimester ultrasound per patient - Labs Rh /Abs /Rub /RPR /HBsAg /HIV /GBS - Screening LR NIPT, girl - FFS normal - GTT elevated 1hr, normal 3hr - U/S at 33w 4#13oz - Issues *) h/o c/s: planning repeat section with GI surgery on standby given Crohn's and prior surgeries *) Crohn's: troublesome this pregnancy, not on meds. Has been seen for IVF during pregnancy *) possible h/o portal vein thrombosis: on prophylactic lovenox during this pregnancy OBHx: - G1 pLTCS due to crohn's and prior abdominal surgeries, recommended by her GI MD, uncomplicated pregnancy, 7#5oz boy - G2 current, planning repeat section GynHx: - h/o abnormal Pap, s/p cryo with normal since per patient - denies fibroids, STIs - endometriosis per patient, no prior surgeries but reports "chocolate cysts" - irregular menses PMH: - Crohn's disease - s/p total colectomy now with J pouch, has had issues with pouchitis - possible portal vein thrombosis - equivocal diagnosis following her total colectomy, s/p 3 months of anticoagulation and was maintained on prophylactic anticoagulation during her previous pregnancy (not continued postpartum). Was taking lovenox during this pregnancy as well. PSH: - total colectomy with ostomy - ostomy takedown and creation of J pouch - c/s x1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> AdmittingPhysical Exam VS: T 99.6, 97.9 HR 116 -> 84 BP 118/73 RR 16 SpO2 96%RA Gen: A&O, comfortable Neuro: CNII-XII grossly intact, grossly normal strength and sensation throughout CV: RRR PULM: normal work of breathing, CTAB Abd: soft, gravid, nontender, palpable fetal movement Ext: no calf tenderness SVE: deferred Discharge Physical Exam Gen: A&O Neuro: CNII-XII grossly intact; scalp sutures in place PULM: normal work of breathing Abd: soft, gravid, nontender, palpable fetal movement Ext: no calf tenderness <PERTINENT RESULTS> ___ 06: 00PM estGFR-Using this ___ 06: 00PM GLUCOSE-92 UREA N-4* CREAT-0.5 SODIUM-136 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-18* ANION GAP-19 ___ 06: 00PM estGFR-Using this ___ 06: 00PM NEUTS-78.8* LYMPHS-12.0* MONOS-5.7 EOS-1.6 BASOS-0.2 IM ___ AbsNeut-13.77* AbsLymp-2.10 AbsMono-0.99* AbsEos-0.28 AbsBaso-0.04 ___ 06: 00PM PLT COUNT-217 <MEDICATIONS ON ADMISSION> PNV Lovenox <DISCHARGE MEDICATIONS> 1. Acetaminophen 325-650 mg PO Q6H: PRN Pain - Mild don't take more than 4000mg in 24hrs RX *acetaminophen 325 mg ___ capsule(s) by mouth every 6 hrs Disp #*100 Capsule Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth every 12 hrs Disp #*60 Capsule Refills: *0 3. LevETIRAcetam 500 mg PO BID RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth every 12 hrs Disp #*60 Tablet Refills: *1 4. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron 4 mg ___ tablet(s) by mouth every 12 hrs Disp #*40 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate take this only if Tylenol is not enough RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hrs Disp #*15 Tablet Refills: *0 6. FoLIC Acid 1 mg PO DAILY 7. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Brain mass <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Discharge Instructions Dear. Ms. ___, You were admitted to the hospital for the work-up of your brain mass. You had your brain biopsy on ___, and you were observed for pain control until today. All of your fetal testing have been reassuring. We think it is now safe for you to go home but please follow-up with your OB (or the OB you wish to transfer care to) within the week. All of your records have been provided to you (images and notes) Please follow the instructions below: - Attend all appointments with your obstetrician and all fetal scans - Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns From the neurosurgery team, the instructions are as follows · You underwent a biopsy. A sample of tissue from the lesion in your brain was sent to pathology for testing. · Please keep your incision dry until your sutures are removed. · You may shower at this time but keep your incision dry. · It is best to keep your incision open to air but it is ok to cover it when outside. · Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. · No driving while taking any narcotic or sedating medication. · If you experienced a seizure while admitted, you are NOT allowed to drive by law. · No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications · ***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. · You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication.
|
Ms. ___ was admitted on ___ for the expedited work-up of a brain mass, which was detected on MRI when she presented for a headache. The patient was evaluated by our neurosurgery team, and had a MRI spectroscopy on ___. She then underwent a CT-guided stereotactic brain biopsy on ___. The patient had intraoperative fetal monitoring. She had a post-operative CT scan which did not show evidence of large intracranial hemorrhage. She was transferred to the antepartum floor, where she was observed until POD#1. The patient's pain was controlled with oxycodone 5mg q4-6 hrs and acetaminophen with good effect. She was also started on Keppra 500mg BID as recommended by the neurosurgical team for seizure prophylaxis given her brain mass. For fetal monitoring, she had daily reassuring NSTs. Betamethasone was deferred, as there was no concern for immediate need for delivery, and the Neurosurgery team was concerned that it may affect the brain biopsy results. For her history of portal vein thrombosis, she was taken off of the lovenox prior to the brain biopsy. Per the patient, the diagnosis of portal vein thrombosis was never confirmed. Her anticoagulation was not restarted given her recent brain biopsy and a questionable history of thrombosis. On ___, the patient was discharged home with planned follow-up with her regular OB in ___ and with the Neurosurgery team at ___. All records and image discs were provided to her.
| 1,873
| 322
|
10326504-DS-6
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lisinopril / losartan <ATTENDING> ___ <CHIEF COMPLAINT> postmenopausal bleeding fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingo-oophorectomy <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. amLODIPine 5 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. Hydrochlorothiazide 25 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID Do not take more than 4000mg in 24 hours RX *acetaminophen 325 mg 2 tablet(s) by mouth three times per day 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 #*50 Tablet Refills: *1 3. Ibuprofen 400 mg PO Q6H: PRN Pain - Moderate Please take with food RX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Mild ___ 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. amLODIPine 5 mg PO DAILY 6. Hydrochlorothiazide 25 mg PO DAILY 7. Simvastatin 40 mg PO QPM <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> postmenopausal bleeding 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid. 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 tylenol, ibuprofen and oxycodone. Overnight, she was noted to desaturate to 86-88% on room air while sleeping. Her O2 saturation improved to 96% with 2 liters nasal cannula. Her other vital signs remained stable although she was noted to have mild basilar crackles bilaterally. She was encouraged to increase her incentive spirometer use and ambulate frequently. By POD#2, she was able to wean to room air with saturations of 95-97% and did not have further overnight desaturations. For her history of type 2 diabetes, fasting blood glucose was monitored for 24 hours. They ranged from 96 to 155. She was continued on her home amlodipine and hydrochlorothiazide for her history of hypertension. 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.
| 874
| 316
|
10327753-DS-14
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> codeine / generic percocet <ATTENDING> ___. <CHIEF COMPLAINT> symptomatic uterine prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> TOTAL VAGINAL HYSTERECTOMY, HIGH UTEROSACRAL VAGINAL VAULT SUSPENSION, BILATERAL SALPINGECTOMY, POSTERIOR REPAIR, MID URETHRAL SLING, CYSTOSCOPY <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 4 Para 3 who presents today in the office for a consultation requested by ___, MD regarding uterine prolapse. Her symptoms have been present for approximately ___ years. Mrs. ___ reports vaginal pressure and palpable prolapse. She currently uses a pessary but is interested in surgical management. Her treatment has included: Pelvic floor exercises Pessary - currently uses ring pessary with support She reports rare urinary incontinence events. She denies urinary urgency, frequency and dysuria. She voids about 6 times a day, nocturia x 0. She reports bladder emptying with normal uninterrupted flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. She does need ambien for sleep but is not awoken from sleep. She has a history of insomnia and depression. She reports constipation from narcotic use. She currently takes Amitiza for 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 not currently sexually active because her husband has had a recent prostatectomy. She denies dyspareunia or vaginal dryness. She does not use estrogen cream. She is very physically active and does exercise and hike consistently. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> BACK PAIN HYPERTENSION GLUCOSE INTOLERANCE ATTENTION DEFICIT DISORDER WITHOUT HYPERACTIVITY BIPOLAR AFFECTIVE DISORDER DEGENERATIVE DISK DISEASE UTERINE PROLAPSE FIBROCYSTIC CHANGES IN BREAST FIBROMYALGIA Myofascial syndrome PAST SURGICAL HISTORY TONSILLECTOMY CESAREAN SECTION <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with breast ca Negative for colon or ovarian ca <PHYSICAL EXAM> Vitals: stable and within normal limits General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended,no remarkable tenderness. Bowel sounds auscultated. GU: pad with minimal spotting, incisions on mons are clean, dry and intact, foley with clear urine Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> none <MEDICATIONS ON ADMISSION> Percocet (oxyCODONE-acetaminophen) 7.5 mg - 325 mg Amphetamine-Dextroamphetamine XR 50 mg PO DAILY Amphetamine-Dextroamphetamine 10 mg PO TID Hydrochlorothiazide 12.5 mg/Lisinopril 10 mg PO DAILY Lubiprostone 8 mcg PO BID Zolpidem Tartrate 10 mg PO QHS: PRN insomnia <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H Do not exceed 4000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID Do not take if you experience loose stools. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Tablet Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Please take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 4. Percocet (oxyCODONE-acetaminophen) 7.5 mg oral Q6H: PRN severe pain Do not exceed more than 4000 mg acetaminophen in 24 hours RX *oxycodone-acetaminophen [Percocet] 7.5 mg-325 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills: *0 5. Amphetamine-Dextroamphetamine XR 50 mg PO DAILY 6. Amphetamine-Dextroamphetamine 10 mg PO TID 7. Hydrochlorothiazide 12.5 mg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. Lubiprostone 8 mcg PO BID 10. Zolpidem Tartrate 10 mg PO QHS: PRN insomnia <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic uterine prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking 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. Please be aware that your Percocet has acetaminophen, so tally your total daily doses accordingly. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing 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 intravenous morphine and Toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to oral ibuprofen and Percocet. 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.
| 1,641
| 198
|
10329850-DS-20
|
<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> ___ 6 days PP from IOL for Pre-E and uncomplicated SVD. Reports HA and home with lightheadenss and some blurred vision "floaters", BPs at home last night and today 140/100 with home cuff. Pt has hx of Migraine HA, this feels different, but does feel the same as the HA she had during pregnancy that was worked up in the ED with neg MRI and neuro consult. Pt tried taking Ibuprofen yesterday and today without any relief. <PAST MEDICAL HISTORY> OBHx: -G1 ___ IOL 37 weeks gHTN vs. Pre-E (no Mag or antihypertensives per pt report - delivery in LA) -G2 current GynHx: infertility, denies abnormal paps, STI PMH: migraine HA PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VS: T 98.4, HR 87, BP 147/90, 128/87, 129/89, 139/95, 138/81, 104/60, 125/86, 140/95 -Gen: NAD -Abd: soft, NT <PERTINENT RESULTS> ___ 08: 30PM CREAT-0.5 ___ 08: 30PM ALT(SGPT)-68* AST(SGOT)-31 ___ 08: 30PM WBC-12.5* RBC-4.04 HGB-13.1 HCT-39.4 MCV-98 MCH-32.4* MCHC-33.2 RDW-12.4 RDWSD-44.6 ___ 08: 30PM PLT COUNT-299 ___ 02: 01PM CREAT-0.5 ___ 02: 01PM estGFR-Using this ___ 02: 01PM ALT(SGPT)-72* ___ 02: 01PM URIC ACID-6.8* ___ 02: 01PM WBC-11.7* RBC-4.16 HGB-13.2 HCT-40.0 MCV-96 MCH-31.7 MCHC-33.0 RDW-12.4 RDWSD-44.1 ___ 02: 01PM PLT COUNT-305# <MEDICATIONS ON ADMISSION> colace 100mg BID prn for constipation <DISCHARGE MEDICATIONS> 1. Ibuprofen 400-600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Postpartum pre-eclampsia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please review discharge instructions. Call immediately if seizure, recurrent headache unrelieved with Tyleonol/supportive measures, visual changes, pain on your right side, chest pain or shortness of breath.
|
Ms. ___ is a ___ who was readmitted on postpartum day 6 due to persistent headaches. She was an induction of labor due to pre-eclampsia. Labs upon readmission demonstrated a mild transaminitis. She was started on magnesium and the infusion was continued for 24hours. Her headache improved with magnesium and ultimately resolved with the additional aids of fioricet and compazine. Her blood pressures remained normotensive. She was discharged in stable condition
| 768
| 99
|
10334369-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> aspirin / ibuprofen <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 28w6d presents with a "bubbling sensation" that she further describes as intermittent sharp abdominal pain since 5am this morning. Patient reports having intermittent sharp pains in her mid abdomen and her abdomen since 5am. She states that the pain does not radiate between the two locations or to anywhere else. She also reports mild menstrual like cramping and occasional, non-painful abdominal tightening. She has tried drinking water but otherwise has not done anything for the pain. She denies any aggravating or alleviating factors. She reports some mild heartburn and occasional nausea but no emesis or change in appetite. She has rhinorrhea which she attributes to seasonal allergies but denies any other URI symptoms incl sore throat, congestion or cough. She denies fevers, chills, CP, SOB, other abdominal/back pain, abdominal trauma, recent intercourse, vaginal bleeding, leaking fluid, decreased fetal movement, abnormal vaginal discharge, dysuria, diarrhea, constipation. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP - Labs: O+/Ab neg/RI/RPRnr/HbsAg-/HIV-/GBS unk - Screening: per ___ records elev risk ___ tri screen for T21, no further follow-up done - FFS: wnl, posterior placenta - GLT neg, 81 - Issues: - late TOC from ___ at 22wks - poor maternal weight gain: pre-pregnancy BMI 19, only 1 lb wt gain between 22 and 26wk; instructed to drink ensure BID which she endorses doing - h/o DV: per ___ records h/o DV with FOB in ___, patient currently reports feeling safe and denies any current issues. PObHx: G1 - current PGynHx: No history of LEEP or other cervical procedure. Denies h/o abnormal paps, STIs, fibroids, cysts PMHx: G6PD PSHx: tonsillectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Vital signs 98.2 88 113/72 General: NAD. Comfortable Cardiac: RRR Pulm: CTA Abdomen: soft, no fundal tenderness, CTX palpable Ext: nontender, no erythema, no edema SSE: Normal external anatomy, cervical os visually 1-2cm, no blood in vaginal vault, normal physiologic discharge SVE: ___ at ___ NST: 145/mod var/+acc/-decels -- AGA TOCO: Q10-15min TAUS: vtx, MVP 6.0cm, FHR 150bpm, EFW 1244g, posterior fundal placenta <PERTINENT RESULTS> ___ WBC-12.6 RBC-3.88 Hgb-11.1 Hct-34.9 MCV-90 Plt-287 ___ Neuts-65.5 ___ Monos-7.4 Eos-0.9 Baso-0.4 Im ___ AbsNeut-8.25 AbsLymp-3.17 AbsMono-0.93 AbsEos-0.11 AbsBaso-0.05 ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD ___ URINE RBC-2 WBC-11 Bacteri-FEW Yeast-NONE Epi-2 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP. SMEAR FOR BACTERIAL VAGINOSIS (Final ___: POSITIVE: GRAM STAIN CONSISTENT WITH BACTERIAL VAGINOSIS YEAST VAGINITIS CULTURE (Final ___: YEAST. RARE GROWTH. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis NEISSERIA GONORRHOEAE, NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae URINE CULTURE (Final ___: NO GROWTH. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Preterm labor, now stopped <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the hospital for dilation of your cervix. We initially thought you had signs of labor, however this stopped and you had no further change in your cervix. We thus felt it was safe for you to go home. While you were here, you received an vaccine called Tdap that we think all pregnant women should receive. In addition, we initially treated you for a UTI, but the final test came back negative so you do not need to take antibiotics. Please call about any of the concerning signs listed below.
|
___ G1P0 admitted at 28w6d with preterm contractions and concern for preterm labor. On admission, she was afebrile and without any evidence of infection or abruption. Fetal testing was reassuring. She was only contracting every ___ minutes, but was noted to be 2-3cm dilated. Given her gestational age and concern for preterm labor, she was tocolyzed with Nifedipine and started on magnesium for neuroprotection. She received a course of betamethasone for fetal lung maturity and the NICU was consulted. The magnesium was discontinued when her repeat cervical exam was stable and delivery was not imminent. She was initially started on Keflex for a suspected UTI, however, this was continued when her urine culture returned negative. The Nifedipine was discontinued when she was betamethasone complete (___). She was observed off tocolysis and remained clinically stable without any evidence of ongoing labor. Her cervical exam was again unchanged prior to discharge. She was discharged home and will have close outpatient followup.
| 1,233
| 228
|
10334369-DS-16
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> aspirin / ibuprofen <ATTENDING> ___. <CHIEF COMPLAINT> abdominal cramping <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1 at ___ with cramping since ___ this AM. Also c/o increased vaginal discharge with odor. No itching. No leaking, bleeding. No other abdominal pain or fever. +FM. Of note, she was admitted to ___ from ___ to ___ for preterm contractions/pre-term labor. She received a course of nifedipine for tocolysis and she was made betamethasone complete on ___. Of note, she was found to have yeast and BV at the time of admission, but was not treated. Her SVE was ___ prior to discharge. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w with 12 week u/s (records from ___) - Labs: O+/Ab neg/RI/RPRnr/HbsAg-/HIV-/GBS neg (___) - Screening: per ___ records elev risk ___ tri screen for T21 (1 in 120), no further follow-up done - FFS: wnl, posterior placenta, girl - GLT neg, 81 - U/S: ___, r/o PTL 1244g - Issues: - late TOC from ___ at 22wks, ___ confirmed to be ___ based on ___ records; ___ previously stated as ___, which was confirmed to be incorrect after review of records - poor maternal weight gain: pre-pregnancy BMI 19, only 1 lb wt gain between 22 and 26wk; instructed to drink ensure BID which she endorses doing - h/o DV: per ___ records h/o DV with FOB in ___, patient currently reports feeling safe and denies any current issues. PObHx: G1 - current PGynHx: No history of LEEP or other cervical procedure. Denies h/o abnormal paps, STIs, fibroids, cysts PMHx: G6PD PSHx: tonsillectomy, dental surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Admission exam: Vital signs 98.2 108/67 100 General: NAD. Comfortable Cardiac: RRR Pulm: CTA Abdomen: soft, no fundal tenderness Ext: nontender, no erythema, no edema, palpable ctxs SSE: Normal external anatomy, cervical os visually 1-2cm, no blood in vaginal vault, copious cervical mucus, faintly pos nitrazine, neg ferns, neg pooling SVE: ___ Discharge exam: VSS Gen NAD CV RRR P no resp distress Abd soft, non tender, fundus firm below the umbilicus Ext WWP <PERTINENT RESULTS> ___ 11: 52PM WBC-14.3* RBC-3.66* HGB-10.5* HCT-32.4* MCV-89 MCH-28.7 MCHC-32.4 RDW-13.6 RDWSD-44.0 ___ 11: 52PM NEUTS-72.8* LYMPHS-17.4* MONOS-8.0 EOS-1.1 BASOS-0.3 IM ___ AbsNeut-10.39* AbsLymp-2.49 AbsMono-1.14* AbsEos-0.16 AbsBaso-0.04 ___ 11: 52PM PLT COUNT-298 ___ 11: 40AM WBC-15.7* RBC-3.78* HGB-10.8* HCT-33.9* MCV-90 MCH-28.6 MCHC-31.9* RDW-13.6 RDWSD-44.1 ___ 11: 40AM NEUTS-76.5* LYMPHS-13.4* MONOS-8.3 EOS-0.9* BASOS-0.3 IM ___ AbsNeut-12.04* AbsLymp-2.11 AbsMono-1.31* AbsEos-0.14 AbsBaso-0.04 ___ 11: 40AM PLT COUNT-256 ___ 09: 49AM URINE HOURS-RANDOM ___ 09: 49AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG marijuana-NEG ___ 09: 37AM OTHER BODY FLUID FETALFN-POSITIVE * ___ 07: 54AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 07: 54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG ___ 07: 54AM URINE RBC-1 WBC-71* BACTERIA-FEW YEAST-NONE EPI-12 ___ 07: 54AM URINE MUCOUS-RARE <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. 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: *0 2. Acetaminophen (Liquid) 650 mg PO Q6H: PRN pain Do not exceed more than 4,000mg in 24 hours RX *acetaminophen 500 mg/5 mL 1 by mouth q6h prn Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal delivery bacterial vaginosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms ___, Congratulations on your new addition to your family! Please refer to your discharge packet and the instructions below: Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
|
___ G1 with arrested PTL, vaginitis, with ultimate progression of preterm labor and vaginal delivery. . *) arrested PTL -> preterm labor -> SVD - SVE ___ x2 ___ ___ - tocolysis deferred - Utox neg - UA equivocal . *) Vaginitis - cx proven BV and yeast on ___, symptomatic - flagyl 500mg BID x7 days (started ___ and fluconazole 150mg x1 - rpt BV/yeast cx positive for BV The patient ultimately progressed into labor and delivered vaginally. Her post partum course was uncomplicated and she received routine post partum care. She was discharged home in stable condition with plan for follow up care and clear return precautions.
| 1,484
| 154
|
10337004-DS-19
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Preterm labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> -none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old G3P0 @ 33 weeks 5 days who presents to OB Triage after an episode of vaginal bleeding. Patient reports that she went to the bathroom and after wiping experienced some bright red blood on the toilet paper. She denies any fever, chills, abdominal pain, dysuria. No LOF. +AFM x 2. Patient denies any recent intercourse. <PAST MEDICAL HISTORY> GynHx: Patient has a history of uterine fibroids seen on US which have not been problematic. No abnormal pap smears or STI's. PMH: Hx of depression PSH: Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> At the time of admission: NAD, Comfortable CV: RRR Pulm: CTAB Abd: Gravid, NT, no guarding, no rebound SSE: Appears ~2 cm dilated SVE: ___ by Dr. ___ A: 145/mod/+accel/no decel B: 150/mod/+accel/no decel Toco: Q2-5 min TAUS: vtx/vtx BPP ___ x 2 Twin A: DVP 2.46 cm Twin B: DVP 2.39 cm <PERTINENT RESULTS> ___ 04: 24PM WBC-12.1* RBC-3.91* HGB-9.8* HCT-30.0* MCV-77*# MCH-25.0* MCHC-32.5 RDW-14.5 ___ 04: 24PM PLT COUNT-297 ___ 04: 24PM ___ PTT-25.6 ___ ___ 04: 24PM ___ ___ 04: 24PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04: 24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG <MEDICATIONS ON ADMISSION> Prenatal vitamins <DISCHARGE MEDICATIONS> 1. breast pump Sig: One (1) as determined by mom as needed for prematurity for as determined by mom months. Disp: *1 * Refills: *1* 2. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 4 weeks. Disp: *50 Tablet(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p vaginal delivery of twin boys <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> follow routine post-partum instructions
|
The patient was admitted with preterm labor at 33 weeks 5 days. Her cervical exam was ___. She was admitted for magnesium tocolysis and received betamethasone. Her magnesium was discontinued after she was betamethasone complete. She continued to contract intermittently and her cervix slowly dilated to ___. However she never progressed to active labor so she was managed expectantly on the antepartum floor. She was eventually augmented with pitocin and had an uncomplicated vaginal delivery of twins. Per postpartum course was uncomplicated and she was discharged home in good condition.
| 698
| 125
|
10337004-DS-20
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> D&C <HISTORY OF PRESENT ILLNESS> ___ G1P2 2 weeks s/p vaginal delivery of twins on ___ with uncomplicated postpartum course presents as OSH tx from ___ with new onset bleeding. Pt soaked one pad at noon on ___, then bleeding subsided until 11pm that night when she started passing heavy clots, soaking ___ pads per hour. Pt then presented to ___ where VS were 139/82 ___ and O2sat 100%. Hct at the time (0200 ___ was 31.1, PIV placed and fluids started. She was transferred directly to ___ triage, where she continued to have significant vaginal bleeding. At this time, pt denies SOB/dizziness and just c/o sleepiness. <PAST MEDICAL HISTORY> OBHx: G1P2 twins delivered vaginally on ___, uncomplicated. GynHx: Patient has a history of uterine fibroids seen on US which have not been problematic. No abnormal pap smears or STI's. PMH: Hx of depression PSH: Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> VS 97.9, 99 -> 85, 121/84, 18, 100%RA NAD, sleepy Abdomen soft, ND, uterus firm and low, tender to deep palpation. SSE with at least 200cc clots, unable to clear with ring forceps and numerous scopettes. <PERTINENT RESULTS> ___ 01: 23PM WBC-16.6*# RBC-2.57*# HGB-6.7*# HCT-20.3*# MCV-79* MCH-26.0* MCHC-32.9 RDW-16.6* ___ 01: 23PM ___ <MEDICATIONS ON ADMISSION> Ibuprofen, PNV, colace <DISCHARGE MEDICATIONS> 1. Ferrous Gluconate 324 mg (38 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> retained products of conception, status post dilation and curettage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> monitor bleeding
|
Patient was readmited from an outside hospital ___ transfer after presenting with delayed postpartum hemorrhage two weeks following vaginal delivery of twins on ___. Urgent D&C was performed due to a hematocrit decrease from 31.1 to 22.6 in 2 hours and observed large blood loss on examination in Gyn Triage. Her vital signs remained stable. Please see operative report for details of D&C. She was transfused one unit of packed red blood cells intraoperatively and then another two units postoperatively, and her hematocrit stabilized at 24.4. She was continued on oral methergin postoperatively for two days with observed decrease in vaginal bleeding. She was asymptomatic from anemia through the remainder of her hospital course and did not require further transfusions. During her hospital course, she had a fever to 101.2 and was give IV antibiotics until she remained afebrile for 24 hours. She was discharged on hospital day 4 with no active vaginal bleeding and having remained afebrile for the remainder of her stay. She was given instructions to follow up with her OB/Gyn as an outpatient in one week.
| 645
| 242
|
10339620-DS-13
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Zithromax <ATTENDING> ___. <CHIEF COMPLAINT> Fevers, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound guided pelvic drainage <HISTORY OF PRESENT ILLNESS> ___ yo G0 with history of severe endometriosis, chronic pelvic pain, history of recurrent ___, and infertility presents with worsening pelvic pain and fever. s/p oocyte retrieval ___. Patient states that oocyte retrieval was uncomplicated. No embryos available for transfer. Began menses on ___ when baseline pain worsened over last several days. Usually cramping improves after onset of menses. Now pain more constant, worse on R side. Fevers started this am though has been requiring perc or tylenol #3 for cramping so not sure if this masked fever. Some chills today. No foul smelling vaginal discharge. +nausea, no emesis. Intermittent constipation/ diarrhea (no diff from baseline). Seasonal allergy symptoms but no cough, sore throat. No dysuria, hesitency, freq. No sick contacts. <PAST MEDICAL HISTORY> OBhx: G0 GYNhx: LMP ___ Severe endometriosis (stage 4)-- recent lsc ___ with LOA, resection of endometrioma. on perc OR tylenol #3 for pain. Infertility-- Has been through several IVF cycles. Most recently 2 oocytes retrieved, non fertilized. ___ years ago developed infected endometriosis after egg retrieval @ outside institution with supsequent E Coli bacteremia requiring prolonged IV abx. H/o ___ ___ ago)-- treated with IV--> PO abs H/o abn paps, bx wnl, unsure of date of last pap PMH: endometriosis, chronic pelvic pain PSH: LSC with resection of endometrioma and LOA in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> mom with severe endo, sisters with painful menses. no FH ovarian, uterine, cervix CA. <PHYSICAL EXAM> Exam on admission by Dr. ___: 101.2 108 ___ 100% NAD, lying in bed, +chills RRR CTAB Abd soft, ND, Diffuse TTP worse in lower quadrants R>L, +voluntary guarding, no rebound SSE: small amt of blood in vault. nl cervix. nl vagina BME: exquisitely TTP over uterus/ adnexa. uterus AV, immobile. <PERTINENT RESULTS> ___ WBC-4.1 RBC-3.12* Hgb-9.3* Hct-28.0* MCV-90 MCH-29.9 MCHC-33.4 RDW-13.0 Plt ___ ___ WBC-6.0# RBC-3.10* Hgb-9.2* Hct-27.7* MCV-89 MCH-29.5 MCHC-33.0 RDW-12.3 Plt ___ ___ WBC-12.5* RBC-3.20* Hgb-9.7* Hct-28.4* MCV-89 MCH-30.3 MCHC-34.1 RDW-12.3 Plt ___ ___ WBC-12.1* RBC-3.04* Hgb-9.1* Hct-26.9* MCV-89 MCH-30.1 MCHC-34.0 RDW-12.2 Plt ___ ___ WBC-9.9 RBC-3.31* Hgb-9.9* Hct-29.4* MCV-89 MCH-30.1 MCHC-33.9 RDW-12.7 Plt ___ ___ WBC-10.0 RBC-3.37* Hgb-10.0* Hct-29.4* MCV-87 MCH-29.7 MCHC-34.1 RDW-12.3 Plt ___ ___ WBC-10.2 RBC-3.87* Hgb-11.3* Hct-33.9* MCV-88 MCH-29.2 MCHC-33.3 RDW-12.2 Plt ___ ___ Neuts-66.2 ___ Monos-6.7 Eos-4.7* Baso-0.5 ___ Neuts-73.3* ___ Monos-5.0 Eos-1.9 Baso-0.4 ___ Neuts-82.1* Lymphs-10.9* Monos-6.5 Eos-0.3 Baso-0.1 ___ Neuts-84.1* Lymphs-7.6* Monos-8.0 Eos-0.2 Baso-0.1 ___ Neuts-78* Bands-6* Lymphs-9* Monos-7 Eos-0 Baso-0 ___ Myelos-0 ___ Neuts-88.6* Lymphs-5.8* Monos-4.5 Eos-0.7 Baso-0.4 ___ ___ PTT-30.6 ___ ___ UreaN-3* Creat-0.6 ___ Glucose-115* UreaN-8 Creat-0.6 Na-137 K-3.8 Cl-101 HCO3-26 AnGap-14 ___ ___ ___ HCG-<5 ___ ALT-13 AST-18 AlkPhos-51 ___ Lactate-1.0 CT Abd/pelvix ___: Right adnexal cystic mass, most likely tubo-ovarian abscess, measuring 7.2 x 5.9 x 5.4 cm. While the appendix is not definitively identified, this complex collection is not thought to represent a perforated appendicitis. Hypodense indeterminate lesion in right lobe of the liver. A liver ultrasound can be performed on a nonemergent basis for further characterization Pelvic u/s ___: Complex right adnexal fluid collection consistent with a tubo-ovarian abscess. This is amenable to transvaginal ultrasound-guided drainage. <MEDICATIONS ON ADMISSION> perc or tylenol #3, motrin, prozac 10qd, coq10, DHEA, melatonin <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* 3. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp: *14 Tablet(s)* Refills: *0* 4. ondansetron HCl 4 mg Tablet Sig: ___ Tablets PO Q8H (every 8 hours) as needed for nausea. Disp: *50 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Pelvic abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 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 * You may eat a regular diet To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. You will need to have the drain flushed at least twice daily. A visiting nurse service will assist you with this process. The fluid collection will be re-assessed with Dr. ___ in the office on ___. You will also need to have your blood drawn at that time to assess the eosinophil count. Please take the antibiotics through ___.
|
Ms. ___ was admitted to the GYN service for management of likely post-procedure tubo-ovarian abscess. She was started on IV ciprofloxacin and Flagyl and continued to spike fevers as high as 103. Infectious disease was consulted and agreed with the antibiotic plan. Overnight on hospital day 2 she was triggered for BP 80/50 with dizziness. At that time she was not tachycardic and her labs were stable. Her BP improved with a 1.5L bolus of IVF. On ___ she underwent successful ultrasound guided drainage of the abscess and had a drain left in place. After the procedure the patient started to improve clinically. On hospital day 3 she defervesced and her WBC started improving. By hospital day 5 she remained afebrile x48 hours and she was switched to oral antibiotics (ciprofloxacin). She was discharged home with oral antibiotics, pelvic transvaginal drain in place and follow-up plans to assess for removal of drain in two days.
| 1,805
| 219
|
10340554-DS-2
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodinated Contrast Media - IV Dye <ATTENDING> ___. <CHIEF COMPLAINT> <CHIEF COMPLAINT> fever, abd pain after Bx Reason for MICU transfer: hypotension <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ 1. Exploratory laparotomy. 2. Evacuation of infected contents of cystic pancreatic lesion with contents sent for cytology and microbiology. 3. Open biopsy of the wall of cystic pancreatic lesion. 4. Resection of large intra-abdominal mass, with en bloc distal pancreatectomy and splenectomy. 5. Placement of gold fiducials for possible CyberKnife ___ Primary classical cesarean section <HISTORY OF PRESENT ILLNESS> ___ G2P1 ___ s/p EUS-guided Bx on ___ presents with fever, malaise, and abdominal pain for 3 days. The patient was experiencing an uncomplicated pregnancy until ___, at which time a routine ultrasound revealed a cystic abdominal mass of unknown origin. The patient had noted persistent mild epigastric discomfort for the last ___ years without significant workup; this had been attributed to gas and possibly gastritis. During her pregnancy she has reported continued intermittent stabbing abdominal pain/fullness for 5 months, some associated nausea. She has been able to eat and drink normally, no weight loss, normal pregnancy per her report to this point. She has had normal bowel function with occasional constipation. Outpatient labs ___ notable for albumin 2.8 and Ca 8.3, CMP otherwise normal, lipase 101, amylase 69. CBC ___ > 10.9 / 32.0 < 202 with diff 76% N, 0.8% bands, 14% L, 5% M, 3% E. The mass was biopsied on ___ by ERCP-guided approach. She was discharged home with Augmentin BID x 5 days, plan for surgical follow-up once results are available this week. Since she woke from ERCP, she had more severe epigastric abdominal pain radiating to the back, similar in location and quality to her prior abdominal pain, but more severe. She felt nauseous (no vomiting), fatigue, diaphoresis and chills with fevers 101-102 at home, and generalized malaise. She did not initially take any medications, as she was unsure what would be safe in the context of her pregnancy. She started Tylenol on ___ with some relief, but continued fever as this wore off. She was not able to eat much solid food, but continued to drink normally until ___ at which time her fluid intake decreased. She presented to ___ last night, ___, given persistent fever. She was treated with 1L NS, morphine 4mg IV x1, and Tylenol ___ PO x1. Given her ongoing workup here, she was transferred to ___. On arrival to the ___, she was noted to be tachycardic to the 120s with BP 84/70, fever 101. She received Flagyl 500mg IV, fentanyl 25 mcg for pain x 2. On transfer to the ___ triage unit, she received another 1.5L LR and per ERCP fellow was given Unasyn. By mid-morning her HR improved to 100, BP 100s/60s. She continued to feel mildly lightheaded and fatigued with continued abdominal pain. Testing revealed WBC 15, INR 1.7, lipase normal at 20, lactate normal at 1.1, K 3.0, and bland UA. Blood and urine cultures sent. Given her lack of improvement, Ob requested transfer to ICU for SIRS/sepsis care. At this time the management of her cystic abdominal mass is pending biopsy results. She is due to meet with Surgical Oncology (Dr ___ later this week as biopsy results are available. Given she is currently 24 weeks, surgical options are challenging as is early delivery. Ob believes the preferred surgical plan is to wait another ___ weeks, then perform an ex-lap if necessary. However, as she may require earlier surgical intervention, NICU and MFM have been consulted and are following the patient. At the time of the transfer, the patient is complaining of persistent epigastric abdominal pain radiating to the back, lightheadedness on sitting or standing, malaise, fatigue. She denies feeling subjective fever/chills. She has no N/V. She reports some constipation with last BM yesterday (___) with small hard stool, no BM for ___ days prior. Denies CP, SOB, palpitations. Some vaginal ?mucus", no vaginal bleeding. No hematochezia or hematuria. Mild dysuria with dark yellow urine. Review of systems: (+) Per HPI. Also: She also noted some tingling in her right arm (now resolved), right knee pain (persistent during pregnancy). (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. <PAST MEDICAL HISTORY> Iron deficiency anemia positive PPD, partial course of treatment in ___ Passive suicidal ideations LUQ abdominal mass undergoing workup no surgical history G1 - ___, SVD at 37 weeks, induced for preeclampsia G2 - ___ ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM Vitals: Tm 101, Tc 98.0, BP 121/77, HR 115, RR 20, O2 sat 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, OP clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, pregnant, tender in epigastrium, bowel sounds present, mild rebound tenderness without guarding, unable to assess organomegaly ___ pregnancy Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM VSS General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-tender, LUQ and pfannensteil incisions c/d/i <PERTINENT RESULTS> ADMISSION LABS ___ 02: 00AM ___ PTT-28.3 ___ ___ 02: 00AM PLT COUNT-174 ___ 02: 00AM NEUTS-81.5* LYMPHS-10.4* MONOS-7.2 EOS-0.8 BASOS-0.2 ___ 02: 00AM WBC-15.1* RBC-3.36* HGB-10.1* HCT-30.7* MCV-91 MCH-30.1 MCHC-33.0 RDW-14.5 ___ 02: 00AM ALBUMIN-3.3* ___ 02: 00AM LIPASE-20 ___ 02: 00AM ALT(SGPT)-14 AST(SGOT)-14 ALK PHOS-58 TOT BILI-0.3 ___ 02: 00AM GLUCOSE-95 UREA N-11 CREAT-0.5 SODIUM-135 POTASSIUM-3.0* CHLORIDE-103 TOTAL CO2-20* ANION GAP-15 ___ 02: 14AM LACTATE-1.1 ___ 06: 06AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 06: 06AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD ___ 06: 06AM URINE RBC-2 WBC-7* BACTERIA-NONE YEAST-NONE EPI-4 ___ 06: 06AM URINE MUCOUS-FEW ___ Echinococcus IgG: Negative ___ Strongyloides IgG: Pending PERTINENT INTERIM LABS ___ 11: 55PM BLOOD ___ DISCHARGE LABS MICRO Blood cultures ___: Negative Urine culture ___: 10K - 100K yeast Blood culture ___: Negative Urine culture ___: 10K - 100K yeast Blood culture ___: Pending Peritoneal fluid ___: No PMNs, no microorgs, cultures negative (preliminary) Cystic fluid ___: 1+ PMNs, no microorgs, cultures negative (preliminary) CYTOLOGY Abdominal mass FNA ___ Negative for malignant cells. Histiocytes, consistent with cyst contents, and few glandular cells. Abdominal mass (left upper quadrant), cyst fluid ___: Negative for malignant cells. Neutrophils, histiocytes and few benign-appearing glandular cells. PATHOLOGY Pancreas ___ IMAGING CXR PA/lateral ___. Subtle left basal lobe opacity most likely represents a summation of shadows, however oblique views could be considered for further evaluation. 2. Mild cardiomegaly likely related to low lung volumes. 3. Mass effect in the upper abdomen with medial displacement of the gastric bubble B/L ___ ___ No evidence of deep venous thrombosis in the bilateral lower extremity veins. CXR ___ The large area of new opacification at the base of the left lung obscures the diaphragmatic pleural interface. Because of patient rotation I cannot tell how much leftward mediastinal shift there is. This is presumably left lower lobe collapse. Suggest careful followup with properly positioned chest radiographs, conventional if possible. Moderate cardiomegaly is exaggerated by lower lung volumes, perhaps increased mildly as well. There is no pulmonary edema. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY 2. Loratadine 10 mg PO DAILY 3. Prochlorperazine 10 mg PO HS: PRN sleep/nausea <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID Take to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 2. Acetaminophen 1000 mg PO Q6H: PRN pain Do not exceed 4000 mg of acetaminophen in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 3. HYDROmorphone (Dilaudid) ___ mg PO Q3H: PRN pain Do not drive. RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 4. 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 5. Loratadine 10 mg PO DAILY 6. double electric breast pump Please provide patient with hospital grade double electric breast pump for maternal-infant separation. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Retroperitoneal mass s/p resection PPROM Cord Prolapse s/p emergent classical CS <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 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.
|
Ms. ___ is a ___ G2P1 female admitted on ___ @ ___ GA with large LUQ abdominal cyst concerning for mucinous neoplasm. She presented on ___ with fever, malaise, and abdominal pain s/p EUS Bx ___. She was admitted to the FICU given SIRS. She was evaluated by Surgical Oncology and excision was recommended. She underwent enbloc resection of mass with distal pancreatectomy and splenectomy on ___. She was readmitted to the FICU after her surgery was complete. The following represents her FICU course: # Fever/abdominal pain s/p EUS: Concern for post-procedural infection, specifically superinfection of cystic mass. She initially met SIRS criteria. EUS Bx grew scant strep viridans. Further cultures pending; echinococcus antibody negative and strongyloides antibodies pending. She was evaluated by Infectious Disease, who recommended ceftriaxone (day 1: ___ and metronidazole (day 1: ___. She had already been on some antibiotics, including Unasyn (___) Augmentin (___) one dose Flagyl (___), and Unasyn (___). Cystic structure was surgically removed as described below. ID recommended continuing antibiotics until POD #5. She was treated with hydromorphone PRN pain. She received IVF as well as acetaminophen and ondansetron. # Abdominal mass: Initially found abdominal mass on regular obstetric ultrasound ___. EUS Bx ___ showed histiocytes, although given imaging appearance concerning for mucinous neoplasm she went to OR ___ for resection of abdominal mass. Cytology from surgical specimen again showed histiocytes. On ___ she underwent exploratory laparotomy, evacuation of infected contents of cystic pancreatic lesion, open biopsy of the wall of cystic pancreatic lesion, resection of large intra-abdominal mass, with en blocdistal pancreatectomy and splenectomy, and placement of gold fiducials for possible CyberKnife. EBL was 1700cc. She received 4u pRBCs, 10L LR, 250cc albumin (for BP ___. She was on Neo during the case, changed to Levophed thereafter, pressors came off a few hours after moving to ___. She remained intubated overnight, extubated early the next morning. UOP 650cc, positive for day, Hct 41 -> 37-33 in setting of massive resuscitation. # Pregnancy: Patient was at 23w4d ___ ___ at the time of admission. She was continued on a prenatal vitamin. Post-extubation she had uterine cramping and was dilated 1 cm. She was started on indomethacin in efforts to prevent preterm labor. She was followed by MFM and NICU during hospitalization and transferred to OB after post-op stabilization in the ICU. # Tachycardia: Likely due to pain, anxiety, hypovolemia, sepsis. There was no O2 requirement ___ edema to suggest VTE, though pt was at risk of blood clot given pregnant state. LENIs were negative for DVT. She was treated with anxiolytics, pain control, antibiotics and fluid resuscitation. She was on heparin SC for DVT ppx. Tachycardia was markedly improved post-operatively when she transferred back to the medical ICU. # INR elevation: INR 1.7 on presentation, may be ___ pregnancy, possibly with contribution by pancreatic/abdominal mass v. malnutrition. DIC was considered but fibrinogen was elevated. There was no evidence of active bleeding. Coags were monitored daily. # Sore throat: With nasal congestion. Patient has seasonal allergies and had not taken loratadine in several days. She also noted some sore throat since EUS. Likely irritation due to allergies and EUS. She was treated with cepacol, nasal saline, and loratadine. # Anemia: Initially source was unclear, possibly related to pregnancy with increased plasma volume, with no overt signs of bleeding. Hct remained mostly stable prior to surgery. She was placed on an iron supplement. During surgery, estimated blood loss was 1700cc. She received 4u pRBCs, 10L LR, 250cc albumin (for BP ___. Hct 41 -> 37-33 in setting of massive resuscitation. Hct was subsequently stable. The patient was stabilized and transferred from the FICU to the Antepartum Service on ___. On ___ she had preterm premature rupture of membranes. Latency antibiotics were started. Given that she was already on IV ceftriaxone and metronizadole, decision was made to continue these and add azithromycin. After 48 hours of IV medications, she was transitioned to PO amoxicillin. She was healing well from her surgery and was stable until ___ at which time Ms. ___ had a cord prolapse on the floor and had a stat classical cesarean section under general anesthesia. Post operatively she had a TAP block and was transitioned to a PCA, IV tylenol and toradol for pain control. She was transitioned to a regular diet. Social work was following Ms. ___ for support given her complicated course. On ___ she had a temperature to 100.7 and received IV gent/clinda for endometritis. Her surgical staples from her abdominal surgery were removed as was her JP drain on ___. Her Pfannensteil incision staples were removed prior to discharge on ___. She recovered well and was discharged home on post partum day #5. She received PPV, Hib, meningitis vaccinations for being s/p splenectomy prior to discharge.
| 2,829
| 1,230
|
10340554-DS-3
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Iodinated Contrast Media - IV Dye <ATTENDING> ___. <CHIEF COMPLAINT> fever, wound erythema and drainage <MAJOR SURGICAL OR INVASIVE PROCEDURE> wound opening <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ s/p STAT c-section for a cord prolapse at 25 weeks after she underwent PPROM few days after undergoing an ex-lap, resection of a mucinous cystic neoplasm of the pancreas, distal pancreatectomy and splenectomy. She was discharged to home per routine on ___ s/p c-section and presented to ED with 2 days of increasing drainage from her subcostal incision, fevers at home to a max of 100.4, increasing erythema around her phanestiel incision and new onset serous draining from the right side of her incision. She otherwise denies purulent drainage from her phanestiel. Upon eval by ED resident, they noted foul smelling wound at her subcostal incision with no clear evidence of drainage. She has been evaluated by the surgical team and she underwent CT of her abdomen/pelvis. She had significant ___ incisional pain despite narcotics, no pain at subcostal incision site. +Dysuria and abnormal urination. Notably, urine culture from ___ returned with Pseudomonas. <PAST MEDICAL HISTORY> Iron deficiency anemia positive PPD, partial course of treatment in ___ Passive suicidal ideations LUQ abdominal mass undergoing workup no surgical history G1 - ___, SVD at 37 weeks, induced for preeclampsia G2 - ___ ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Admission Exam: Vitals: 97.5 74 125/99 16 100% RA No acute distress RRR no m/r/g CTAB ABD S/non-distended. Phanestiel incision site appears erythematous and indurated. On the right of incision, there is serous drainage visualized. Steristrip was removed on the side and wound explored with qtip. There was dark red old serous drainage expressed from the wound. No purulent material. Fascia is intact. New steristrips were placed over the incision. Multiple gauze placed over steris to apply pressure. Ext nt/ne Discharge Exam: VSS General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-tender, subcostal incision with dehiscence at Y-portion of incision, tissue pink and well-healing, packed. Pfannensteil incision opened with healthy tissue, hemostatic and no e/o infection, packed. No erythema or drainage. <PERTINENT RESULTS> Labs: ___ 04: 15AM BLOOD WBC-17.4* RBC-3.67* Hgb-10.9* Hct-34.9* MCV-95 MCH-29.6 MCHC-31.1 RDW-14.7 Plt ___ ___ 06: 25AM BLOOD WBC-16.1* RBC-3.50* Hgb-10.7* Hct-32.3* MCV-92 MCH-30.4 MCHC-33.0 RDW-14.5 Plt ___ ___ 06: 50AM BLOOD WBC-12.3* RBC-3.58* Hgb-10.4* Hct-34.0* MCV-95 MCH-29.0 MCHC-30.5* RDW-15.0 Plt ___ ___ 06: 30AM BLOOD WBC-11.9* RBC-3.76* Hgb-10.5* Hct-35.4* MCV-94 MCH-28.0 MCHC-29.8* RDW-14.7 Plt ___ ___ 04: 15AM BLOOD Neuts-71.6* Lymphs-16.9* Monos-7.3 Eos-3.6 Baso-0.6 ___ 06: 25AM BLOOD Neuts-74.2* Lymphs-13.3* Monos-9.1 Eos-3.2 Baso-0.4 ___ 06: 50AM BLOOD Neuts-58.5 ___ Monos-9.2 Eos-4.9* Baso-0.8 ___ 06: 30AM BLOOD Neuts-58.8 ___ Monos-8.5 Eos-5.1* Baso-0.9 ___ 04: 15AM BLOOD ___ PTT-29.5 ___ ___ 11: 45AM BLOOD ___ PTT-29.9 ___ ___ 06: 30AM BLOOD Glucose-84 UreaN-16 Creat-0.4 Na-140 K-4.5 Cl-110* HCO3-21* AnGap-14 ___ 06: 25AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-139 K-4.6 Cl-100 HCO3-29 AnGap-15 ___ 06: 30AM BLOOD Phos-3.0 Mg-1.8 ___ 06: 25AM BLOOD Calcium-9.6 Phos-4.6*# Mg-1.9 ___ 02: 12AM BLOOD Genta-1.1* Vanco-4.5* ___ 04: 15AM URINE Color-Straw Appear-Clear Sp ___ ___ 04: 15AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 04: 15AM URINE RBC-0 WBC-9* Bacteri-FEW Yeast-NONE Epi-0 ___ 04: 15AM URINE CastHy-1* ___ 04: 15AM URINE Mucous-OCC Microbiology: ___ 2: 34 pm SWAB Source: ___ wound. **FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: NO GROWTH. Blood cultures negative x 2. Imaging: CT Abd/Pelvis ___ IMPRESSION: 1. In the region of the lower abdominal wall incision site there is a small 2.9 x 1.4 x 2.4 cm fluid collection with a small locule of air, which raises concern for possible abscess. At the right upper abdomen incision site there is some thickening of the underlying rectus abdominus muscle and a small hypodense collection within the rectus abdominal muscle which measures 3 x 0.5 x 1 cm, and may represent a post-operative seroma vs small abscess. A third collection in the anterior abdominal wall measures 1 x 1 x 1.5 cm with a tiny locule of air, and may represent a post-operative seroma, but again superimposed infection cannot be excluded. 2. In line with the c-section scar within the uterus there are two small hypodense fluid collections along the inferior uterus for which the differential includes post-operative seroma where superinfection cannot be excluded, liquefied hematoma or possibly degenerating fibroids. <MEDICATIONS ON ADMISSION> Loratadine, sleeping aid, dilaudid, tylenol <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4000 mg of acetaminophen in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. HYDROmorphone (Dilaudid) ___ mg PO Q3H: PRN pain Do not drive on this medication. RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 4. 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 5. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 10 Days RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> urinary tract infection wound dehiscence wound infection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with a wound infection and a urinary tract infection. You were treated with IV antibiotics for both of these infections. Your c-section wound was opened. Both wounds were packed and evaluated by a wound care specialist. You are now safe for discharge home. Please follow the general 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. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks from your delivery. * 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 have been instructed on the care of your wounds. The plan is for daily dressing changes. * For the top wound, your husband will be doing the dressing changes. As instructed, he is to wash his hands and put on gloves. Remove the prior dressing. Spray the wound with the wound cleanser. Dry the area. Apply the gel to the base of the wound. Apply a small amount of saline to a 2x2 gauze. Place moistened gauze in wound. Place dry guaze above this. Apply tape over dry gauze. * For the c-section wound, you will be coming to the ___ on ___ for daily dressing changes with Dr. ___. Please call ___ for any questions or problems. 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 ___.
|
Ms. ___ was readmitted to the hospital on ___ ___ s/p stat classical cesarean delivery for cord prolapse at 25 weeks and ___ s/p laparotomy, distal pancreatectomy and splenectomy for large infected pancreatic mucinous cystic neoplasm with high-grade dysplasia, no carcinoma, with wound infection and urinary tract infection. She initially presented to the emergency department where CT of the abdomen and pelvis was performed. In the emergency department she underwent wound exploration of both incisions. The ___ incision was opened completely, irrigated, and packed. There was clear overlying erythema consistent with cellulitis. The subcostal wound was evaluated by the surgical team with a 2.5cm defect and minimal purulent drainage noted. This was also irrigated and packed. The patient was then transferred to the ___ for further treatment. She received IV gentamicin and vancomycin for her wound infection. These antibiotics were transitioned to PO Bactrim on ___. She underwent twice daily dressing changes of her Pfannensteil incision. General surgery followed and evaluated her subcostal wound on a regular basis. Her pain was controlled with PO dilaudid, tylenol, and ibuprofen. She was able to tolerate a regular diet, was ambulatory, and was able to void spontaneously. She was noted to have pseudomonas UTI, which was treated adequately with the above IV gentamicin. She remained afebrile with incisions healing well throughout her stay. She underwent wound care consultation on ___. At this time, Pfannensteil dressing was changed and there was significant bleeding from the wound. There was a small arterial vessel that was bleeding, which was controlled with silver nitrate. Surgifoam was placed. Hemostatsis was obtained. Wound was repacked with wet to dry dressings. Patient was stable and desired discharge. Decision was made for patient to be discharged and to return to ___ for wound evaluation on ___. On ___, patient was stable for discharge home. She was tolerating a regular diet, ambulatory, and voiding spontaneously. Both wounds were packed with wet-to-dry dressings. Husband was instructed in care of subcostal wound. Patient was scheduled for follow-up with ___ on ___ for wound evaluation and further dressing changes. Plan to continue PO Bactrim for 10 day course.
| 2,477
| 494
|
10343782-DS-21
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Percocet <ATTENDING> ___ <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Panniculectomy. 2. Placement of an incisional VAC. 3. Exploratory laparotomy 4. right salpingo oophorectomy 5. Myomectomy 4. Lysis of adhesions <HISTORY OF PRESENT ILLNESS> ___ morbidly obese woman with a history of thyroid cancer and atrial fibrillation who recently underwent a colonoscopy by Dr. ___ here at ___ ___. The patient notes that on ___ she had a colonoscopy and a few days after that she developed severe right-sided pelvic and abdominal pain. This basically passed over the course of two days, but she saw Dr. ___ in followup for this. It was not associated with fever, vomiting, change in bowel habits. A CT scan was obtained on ___. This revealed a 15 cm right adnexal lesion, which appeared to have "increased in size in comparison to a ___ MRI dated ___ and findings most consistent with ? fibroid versus ovarian fibroma. The mass is inseparable on imaging studies from the sigmoid colon and cecum. Also noted was a calcified thrombosed aneurysm of the GDA and likely second aneurysm within the left upper abdomen. She is here for discussion of treatment options. ___ has had additional imaging studies and brings with her today a MRI from ___ Imaging. She has been followed by Dr. ___ this problem in the past and has basically been observed during this time period. ___ has been reluctant to undergo surgery for this mass in the past. The patient was seen for follow up visit on ___. She returned after having had a MRI to evaluate her pelvic mass at an outside institution. She had a repeat of her MRI performed once again at ___ Imaging and this revealed, as expected, a slight enlargement of the large 15-17 cm right adnexal mass. It is unclear once again whether this is a fibroid or a tumor of the ovary. She also had noted on her CT scan an abnormality to the blood supply within the celiac axis. She has undergone an MRA and this reveals significant stenosis of the proximal celiac artery. There are also dilated anterior and posterior pancreaticoduodenal arteries with aneurysmal dilations and collaterals in the root of the mesentery adjacent the SMA. A renal lesion was also identified and was advised for evaluation in six months for a pre and post contrast renal MRI. Also noted was a 3-mm cystic lesion in the pancreatic body. This could also be followed in six months. The patient was recommended to have a preoperative evaluation. The patient had several follow up visits between ___ and ___. She returned on ___ for a followup evaluation. In the interim time period, the patient had elected to proceed with surgery but unfortunately fell and had a urinary tract infection as well as pneumonia. She was admitted here to the hospital. We had to delay her surgery. Post-hospitalization followup chest x-rays have been done. Her most recent was on ___ and this reveals little change from her prior chest x-ray, which shows "improved but not complete resolution of a right middle lobe pneumonia," followup is recommended. <PAST MEDICAL HISTORY> The patient has a history of fib, morbid obesity, and thyroid cancer, which appears to be under control and without evidence of recurrence. She denies history of hypertension, mitral valve prolapse, asthma, or thromboembolic disorder. She is up-to-date with respect to mammography and colonoscopy. PAST SURGICAL HISTORY: She had an appendectomy in ___, ovarian cystectomy and fibroidectomy also in ___. This was evidently a partial thyroidectomy. OB/GYN HISTORY: Her last menstrual cycle was ___ years ago. She denies postmenopausal bleeding. She denies any history of fibroids, cysts, pelvic infections or abnormal Pap smears. On further review, we discussed the fact that the pelvic masses may in fact be a fibroid. She has had this for "for a number of years." She reports she has never been pregnant. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports a cousin both had breast cancer. She denies any family history of thromboembolic disorder. REVIEW OF SYSTEMS: She denies fever, weight change, or weakness. HEENT: Denies headache, visual or hearing changes, epistaxis, dysphasia. Cardiovascular: Denies chest pain, palpitations, or orthopnea. Respirations: Denies cough, dyspnea, or hemoptysis. GI: Denies abdominal pain, anorexia, nausea, vomiting. She denies constipation, diarrhea or melena. GU: Denies dysuria or frequency. She denies hematuria or abnormal vaginal bleeding. Neuro: Denies syncope, paresthesia, or muscle weakness. Hematologic: Denies fatigue, petechia, or spontaneous bleeding. <PHYSICAL EXAM> PHYSICAL EXAMINATION: GENERAL: The patient appears in no apparent distress. She appears her stated age. HEENT: Normocephalic, atraumatic. Oral mucosa without evidence of thrush or mucositis. Eyes, sclerae are anicteric. NECK: Supple. No masses, no palpable thyromegaly identified: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy, however, her exam is limited due to adiposity. CHEST: Lungs clear bilaterally. HEART: Regular rate and rhythm. I do not appreciate a murmur today. BACK: No spinal or CVAT tenderness. ABDOMEN: Soft, nontender, no apparent distention. A large vertical midline incision is noted to extend from the umbilicus down. The pannus is without any evidence of edema or irregularity. EXTREMITIES: There is no clubbing or cyanosis. There is edema of bilaterally, 1+ to 2+ of the lower extremities. The inner thigh show evidence of a previous operation, which the patient relates was resection of fatty tissue. PELVIC: Normal external genitalia. The inner labia minora is normal. Urethral meatus is normal. The speculum is placed and a normal cervix is identified. Bimanual exam reveals a fairly mobile uterus. The pelvic mass on the right side is very difficult to palpate due to the patient's morbid obesity. I do not palpate any mass on the the left side. There is a fullness appreciated on the right side only. A rectal exam reveals good sphincter tone without mass or lesion. <PERTINENT RESULTS> ___ 04: 43AM BLOOD WBC-10.2 RBC-3.48* Hgb-10.3* Hct-31.1* MCV-89 MCH-29.5 MCHC-33.1 RDW-15.2 Plt ___ ___ 09: 05AM BLOOD WBC-8.4 RBC-3.18* Hgb-9.6* Hct-28.6* MCV-90 MCH-30.1 MCHC-33.5 RDW-14.8 Plt ___ ___ 09: 07AM BLOOD WBC-5.6 RBC-3.46* Hgb-10.3* Hct-30.1* MCV-87 MCH-29.8 MCHC-34.2 RDW-14.7 Plt ___ ___ 04: 43AM BLOOD Glucose-119* UreaN-24* Creat-0.7 Na-144 K-4.3 Cl-108 HCO3-26 AnGap-14 ___ 05: 41AM BLOOD Glucose-129* UreaN-21* Creat-0.7 Na-137 K-4.1 Cl-104 HCO3-26 AnGap-11 ___ 06: 22AM BLOOD Glucose-138* UreaN-17 Creat-0.6 Na-141 K-3.7 Cl-104 HCO3-28 AnGap-13 ___ 05: 23AM BLOOD CK(CPK)-53 ___ 05: 23AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 04: 43AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.0 ___ 09: 07AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9 ___ 06: 22AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9 ___ 3: 41 am URINE Source: Catheter. URINE CULTURE (Final ___: NO GROWTH. ___ 12: 29 am MRSA SCREEN NASAL SWAB. MRSA SCREEN (Final ___: No MRSA isolated. ___ Bilateral Lower extremity dopplers FINDINGS: Focused exam for evaluation for DVT was performed. The study was moderately limited by body habitus. The bilateral common femoral, superficial femoral and popliteal veins demonstrate normal compressibility. Proximal flow, waveforms and augmentation were normal. IMPRESSION: Moderately limited exam without evidence of lower extremity DVT. ___ CXR REASON FOR EXAM: ___ woman with shortness of breath. Rule out pneumonia versus volume overload. Since ___, right internal jugular catheter still ends in the upper to mid SVC. Mild cardiomegaly is unchanged. Mild vascular congestion is new. Small left pleural effusion slightly increased. Basilar opacities are unchanged, likely atelectasis. Lingular opacities are new, could be atelectasis, should be followed. ___ ECHO The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). 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 ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Mild mitral regurgitation. Dilated ascending aorta. <MEDICATIONS ON ADMISSION> Crestor, Cymbalta, vitamin D, flecainide, Lasix, Synthroid, metoprolol, Ditropan, Ambien, aspirin, loratadine, pseudoephedrine. <DISCHARGE MEDICATIONS> 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp: *10 Tablet, Delayed Release (E.C.)(s)* Refills: *0* 2. Senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day) as needed for constipation. Disp: *20 Tablet(s)* Refills: *0* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp: *40 Tablet(s)* Refills: *0* 4. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: ___ Disk with Devices Inhalation BID (2 times a day). 6. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 9. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take if you are taking narcotics to precent constipation. Disp: *40 Capsule(s)* Refills: *0* 14. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp: *30 Capsule(s)* Refills: *0* 16. Albuterol 90 mcg/Actuation Aerosol Sig: ___ Puffs Inhalation Q4H (every 4 hours) as needed. 17. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 18. Dilaudid 2 mg Tablet Sig: ___ pill Tablet PO every ___ hours as needed for pain. Disp: *15 Tablet(s)* Refills: *0* 19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* 20. Commode Bedside commode Disp: ONE Refills: NONE <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ Diagnosis: Right ovarian fibroma and uterine fibroid. Excessive abdominal laxity, abdominal pannus. <DISCHARGE CONDITION> good <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.
|
Ms. ___ is a ___ year old with multiple comorbidities who underwent an exploratory laparotomy, right salpingo oophorectomy, myomectomy, adhesiolysis for a large ovarian fibroma. She also underwent a panniculectomy by plastics given abdominal wall laxity. Please see the operative report for further details. Patient was admitted to the gyn-oncology service. Post operative course is outlined below. *) Neuro: - Pain control was initially managed with an epidural, which was removed on POD # 3. - Patient experienced intermittent periods of confusion which were attributed to narcotic use. The neurological exam was unremarkable. CBC, electrolyte panel, UA and urine cultures were done, which were normal. Patient's confusion was much improved with decreased narcotics. - Pain control was achieved with Tylenol and minimal doses of Dilaudid *) Pulmonary - Patient was admitted to the ___ ICU on POD # 0 for monitoring of ventilatory status. She was initially retaining CO2 and was placed on BIPAP overnight but was weaned off to nasal canula by POD # 1. - The patient maintained an oxygen requirement overnight until POD # 4 - The patient had several episodes of desaturation and tachypnea with activity, which was felt to be partially secondary to severe deconditioning and volume overload. Chest XRay on ___ suggested mild volume overload. The patient underwent diuresis with Lasix. She ambulated with physical therapy and had significant improvement in her respiratory status. - Given concern for potential DVT, the patient underwent ___ on ___, which were negative - She is discharged with oxygen saturations in the 94-98% RA *) Cardiovascular: - Patient has a history of Atrtial fibrillation. She was monitored on telemetry on POD # ___ without any events. She continued her home doses of flecainaide and metoprolol - Patient has a history of congestive heart failure and continued her home dose of Lasix. Given the intermittent desaturations as described above, a medicine consultation was obtained. The patient under recommendation of the medicine team underwent a transthoracic echocardiogram on ___ which revealed a mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Mild mitral regurgitation. Dilated ascending aorta. Overall the findings were similar to prior studies on ___. - Patient's antihypertensive medications were titrated and Lisinopril was restarted. *) Gastrointestinal - The patient's diet was slowly advanced to regular diet by POD # 2. *) Renal/GU: - The patient had transient oliguria on POD # 2, which resolved spontaneously. - The patient's foley catheter was kept in place until the patient was ambulatory. - The foley catheter was removed on POD # 6. *) Wound care: - Patient had a prophylactic wound vac placed by plastics, which was removed on POD # 3. - The patient had JP drains x 3 and was receiving prophylactic Kefzol IV while the drains were in place. One JP was removed prior to discharge. - The patient will follow up with plastics for JP drain removal. She will continue PO Keflex for prophylaxis until then. *) Endocrine: - Patient has hypothyroidism. She continued her home dose of Synthroid. *) Prophylaxis - The patient received Protonix and subcutaneous heparin as well as pneumoboots as prophylactic measures during her hospitalization - The patient was also asked to have aggressive incentive spirometry The patient was discharged home with home ___ on POD # 9 in stable condition.
| 3,301
| 770
|
10344594-DS-3
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Dilantin Kapseal / Triamterene / Dyrenium <ATTENDING> ___ <CHIEF COMPLAINT> vaginal bulge <MAJOR SURGICAL OR INVASIVE PROCEDURE> colpocleisis and cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ woman who presents with vaginal bulge and pressure symptoms since last visit. She notes no significant urinary incontinence. She does get up once to urinate at night. She has occasional constipation. She does have some difficulty emptying her bladder. She is not sexually active. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Significant for peripheral venous stasis, colitis ? Crohn's versus diverticulitis, stroke with residual expressive aphasia, osteoporosis with compression fractures. Past Surgical History: TAH-BSO for benign disease, vein stripping and aneurysm clipping in ___. Past OB History: Two prior vaginal deliveries, two living children. Drug <ALLERGIES> Dilantin, triamterene, hydrochlorothiazide caused constipation. Review of Systems: Positive for vision changes, shortness of breath, rash, psoriasis, low back pain, vaginal bulge and pressure, but negative for other systems on a 14-system review. <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> Significant for mother who died of Hodgkin's disease and first cousin with breast cancer. <PHYSICAL EXAM> Vital signs: weight 118, height 59 inches, blood pressure 140/100, HR 66. General: Well developed, well groomed, normal weight. Psych: Oriented x3. Affect is normal, expressive aphasia, slurred speech, daughter at visit. Skin is warm and dry. Pulmonary: Normal respiratory effort. Abdomen: Soft, nontender. No masses, guarding, or rebound. No hepatosplenomegaly noted. Lymph Nodes: No inguinal lymphadenopathy. Cardiovascular: Pulse normal rate and rhythm. No pedal edema or varicosities. Skin: Venous stasis changes in the lower extremities. Genitourinary: External genitalia normal except for atrophic changes. Vaginal mucosa atrophic with stage III cystocele and vaginal vault prolapse. It was difficult to perform a POP-Q due to the patient was not very cooperative and was unable to relax; however, the most dependent portion of the vagina, which was the anterior vaginal wall came out at least 3 cm, it was not greater. The patient was also unable to generate a Valsalva or cough. Speculum exam revealed atrophic vaginal mucosa, no lesions. Vaginal vault is also coming down to release the opening. The bimanual exam revealed no pelvic masses and was well tolerated. The uterus, cervix, and adnexa were surgically absent. Anus and Perineum: No masses or tenderness. Supine empty stress test was negative, although the patient was not able to generate a good Valsalva or cough. Postvoid residual volume obtained via catheterization was 140 mL of clear urine. The patient was unable to void prior to be come despite trying. She had last voided at home prior to coming to the office. <MEDICATIONS ON ADMISSION> furosemide 10mg daily, as needed for swelling alendronate 70mg, weekly <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN pain RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *2 2. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *1 4. Alendronate, once weekly 5. Lasix 10mg as needed <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> vaginal vault prolapse <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> Ms. ___, You were hospitalized after undergoing a procedure called colpocleisis, which was a surgical treatment performed to close your vagina so that the internal organs no longer fall into your vagina. This procedure involved closing the walls of the vagina to prevent prolapse you were previously experiencing. You should follow the instructions below: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing colpocleisis and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with dilaudid and toradol On post-operative day 1, she passed a voiding trial, per urogyn protocol, and thus her foley was discontinued. Her diet was advanced without difficulty and she was transitioned to oxycodone and acetaminophen. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating with a walker, and pain was controlled with oral medications. Given family and nursing concern for ability of patient to perform activities of daily living at home, she was set up with visiting nurse services, with plan for home safety evaluation. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,284
| 190
|
10344639-DS-16
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / meropenem <ATTENDING> ___. <CHIEF COMPLAINT> fever, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ultrasound guided drainage of abscess <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ postmenopausal woman who presented as a transfer from ___ for concern for Left ___ discovered on CT scan. She reported that on ___, she started having chills, malaise, body aches. She checked her temperature at the time and found it to be 104.5. She had taken tylenol at the time thinking she had a viral illness, which resolved the fever. However, she started to have vaginal discharge and developed bilateral lower abdominal pain and recurrence of a fever to 102. She presented to ___ where she was afebrile with stable vitals but had a leukocytosis of 16. She had a pelvic exam, which was notable for yellowish discharge, +CMT. She had a CT scan, which was concerning for a 3cm ___. Given these findings, she was started on Gent/Clinda and transferred to ___ ED. Upon presentation, patient endorsed nausea but no emesis. She denied diarrhea. She continued to have lower abdominal pain. She was afebrile with stable vitals. <PAST MEDICAL HISTORY> OB Hx: 1 SVD at term, no complications 2 TAB's with D&C's GYN Hx: Postmenopausal since age ___, 1 episode of postmenopausal bleeding s/p neg em bx Denies any recent instrumentation Denies history of abnormal Paps Remote hx of trichomonas and exposure to Gonorrhea which was treated with negative subsequent STI screening. Hx of salpingitis resulting in removal of IUD in the ___ On review of record, patient has documented hx of a left hydrosalpinx, which was still seen on imaging in ___ measuring 3.8cm. Exposures: Reports that she and husband use sex toys during intercourse, which she inserts into her vagina and they also have anal sex Med Hx: - Elevated cholesterol - ? stroke vs. TIA, no deficits - Shingles Surg Hx: - Breast biopsy, which was negative - D&C's <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Upon Admission Physical Examination Vitals: 98.4 92 110/66 16 97% GEN: No acute distress HEART: RRR no m/r/g LUNGS: CTAB ABDOMEN: +BS, soft, non-distended, moderate tenderness to palpation in b/l lower abdomen L>R without rebound or guarding. No CVAT. PELVIC: Normal appearing external genitalia. On insertion of speculum, cervix was visualized with yellowish non-purulent discharge coming from the os. GC/CT cultures obtained. On bimanual examination, there is notably CMT on deviation of the cervix towards the patient's right. No uterine or right adnexal tenderness is appreciated. There is moderate TTP in left adnexa. EXT NT/NE. Upon Discharge physical exam: 98.5 126/82 78 16 78/RA Gen: NAD, A&O x 3 CV: RRR, no r/m/g Pulm: CTAB Abd: soft, NT, ND, mild discomfort in lower abdominal quadrants though no r/g/d Ext: moving all 4 extremities <PERTINENT RESULTS> Pelvic US ___ HISTORY: Pelvic pain, fevers. CT with concern for tubo-ovarian abscess. COMPARISON: CT abdomen pelvis ___, pelvic ultrasound ___. TECHNIQUE: Grayscale Doppler ultrasound images of the pelvis were taking, first using a transabdominal approach, then a transvaginal approach for better delineation of the uterus and adnexa. FINDINGS: The uterus is retroverted and measures 5.6 x 3.2 x 8 x 4.4 cm. The endometrium is regular and measures 2 mm. The right ovary is unremarkable. A small amount of complex free fluid is seen adjacent to the right ovary. There is a left hydrosalpinx, which is now contains complex fluid and thick walled. The hydrosalpinx was seen in ___ ultrasound, but complexity is new since the prior study. This corresponding to the abnormality seen on the recent CT. The left ovary is not visualized. IMPRESSION: New complexity of the known left hydrosalpinx. Given the clinical presentation, this may represent a tubo-ovarian abscess. Followup to imaging resolution is recommended. <MEDICATIONS ON ADMISSION> - Lovastatin 20mg daily - Baby ASA daily - Vitamin D and B12 supplements <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 3. Levofloxacin 500 mg PO Q24H RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills: *0 4. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> tubo-ovarian abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * Nothing in the vagina (no tampons, no douching, no sex) until follow-up appointment * 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 * 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service. She was continued on IV gentamicin and clindamycin. A pelvic ultrasound confirmed a diagnosis of likely tubo-ovarian abscess. On ___, she underwent ultrasound guided drainage. Post-procedure, she developed fever and chills. Her antibiotics were switched to meropenem and vancomycin and repeat cultures were sent. Her blood cultures showed did not have any growth by hospital day 3, and her ___ cultures showed S. pneumoniae. She developed a rash that and her meorpenem was d/c as she had a history of penicillin allergies. She was then transitioned to oral levo/flagyl. Her WBC improved from 14 (pre-drainage) to 11. She defervesced the evening after her drainage and remained afebrile for the remainder of her hospital stay. Her abdominal tenderness subsided, and the patient was able to resume her normal daily activities including tolerating a regular diet, ambulating independently, voiding spontaneously, with minimal pain controlled with ibuprofen/acetaminophen. On ___, the patient was in stable condition for discharge. She was discharged home with levofloxacin, sensitive to the abscess culture, and metronidazole for a 14 day regimen. She will follow-up with the residency practice as scheduled.
| 1,457
| 286
|
10344968-DS-3
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> adenomyosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic-assisted total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy <PHYSICAL EXAM> Discharge physical exam Vitals: stable and within normal limits Gen: no acute distress; alert and oriented to person, place, and date CV: regular rate and rhythm; no murmurs, rubs, or gallops Resp: no acute respiratory distress, clear to auscultation bilaterally Abd: soft, appropriately tender, no rebound/guarding; incision clean, dry, intact Ext: no tenderness to palpation <PERTINENT RESULTS> Labs on Admission: ___ 11: 15AM BLOOD WBC-10.4* RBC-4.60 Hgb-13.6 Hct-39.9 MCV-87 MCH-29.6 MCHC-34.1 RDW-12.9 RDWSD-40.2 Plt ___ ___ 11: 15AM BLOOD Plt ___ <MEDICATIONS ON ADMISSION> ATORVASTATIN - atorvastatin 20 mg tablet. 1 tablet(s) by mouth at bedtime - (Prescribed by Other Provider) CYCLOBENZAPRINE - cyclobenzaprine 5 mg tablet. ___ tablet(s) by mouth at bedtime as needed for muscle spasm - (Not Taking as Prescribed) HYDROCHLOROTHIAZIDE - hydrochlorothiazide 12.5 mg tablet. 1 tablet(s) by mouth at bedtime - (Prescribed by Other Provider) (Not Taking as Prescribed)Entered by MA/Other Staff LISINOPRIL [PRINIVIL] - Prinivil 10 mg tablet. 1 tablet(s) by mouth at bedtime - (Prescribed by Other Provider) METFORMIN - Dosage uncertain - (Prescribed by Other Provider)Entered by MA/Other Staff NORETHINDRONE ACETATE - norethindrone acetate 5 mg tablet. 1 tablet(s) by mouth every day at same time as needed for up to three times a day OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth at bedtime - (Prescribed by Other Provider) SERTRALINE [ZOLOFT] - Zoloft 100 mg tablet. 1.5 tablet(s) by mouth at bedtime - (Prescribed by Other Provider) --------------- --------------- --------------- --------------- <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever do not exceed 4000mg in 24 hours 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity please take with food 3. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe do not drink or drive while taking this medication 4. Atorvastatin 20 mg PO QPM 5. Lisinopril 10 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Sertraline 150 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 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. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing RA-TLH and BS for adenomyosis. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and Toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, Tylenol, and ibuprofen. 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.
| 1,307
| 161
|
10346019-DS-10
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> oxybutynin / amoxicillin / Lamisil / ciprofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, right pelvic peritonectomy, extended appendectomy, right colectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___, gravida 2, para 2, with recent diagnosis of large pelvic mass and thickened appendix on CT scan obtained when she presented with severe abdominal pain. Her CT on ___ showed a large mixed solid and cystic pelvic mass measuring 16.3 x 12.7 x 16 cm likely ovarian in origin. The appendix was also noted to be thickened measuring 12 mm in diameter. There was also mild right hydronephrosis secondary to the mass no left-sided hydronephrosis and no adenopathy. In addition, she had elevated tumor markers of a CA-125 of 288, a CEA of 160, and a ___ of 48. Prior to her scheduled surgery, she presented to the ED on ___ with acute abdominal pain and was found to have a slightly enlarged pelvic mass and no other acute process. Given her acute discomfort minimally relieved with narcotic pain medicine, she was urgently admitted and added onto the OR schedule for ___. <PAST MEDICAL HISTORY> Past medical history: -Hypertension -DVT (2 prior DVTs, ___ in the setting of a urologic procedure, ___ in the setting of a 18 hour car trip, workup for a clotting disorder with a hematologist was negative per report) -ADHD Past surgical history: -___: TVT at ___ -___: NovaSure ablation Health maintenance: -Mammogram: ___ -Colonoscopy: ___, "precancerous cells" found per report, was due for repeat in ___ which has not been performed -Bone density: ___ Obstetric history: Gravida 2 para ___: SVD, toxemia -___: SVD, toxemia Gynecologic history: -Menopause: Roughly ___, had endometrial ablation in ___ and had spotting for approximately ___ years to follow -Menarche age ___, monthly menses with 7+ days of heavy flow -Denies history of abnormal Pap smears, last Pap fall ___ and normal -Not sexually active -History of OCP use ×10+ years, denies HRT use -Denies gynecologic infections -History of urinary incontinence status post TVT as above Medications Wellbutrin Lisinopril ___ Multivitamin <ALLERGIES> -Oxybutynin --> rash -Lamisil --> GI upset/diarrhea -Cipro --> GI upset/diarrhea -Amoxicillin --> rash <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with breast cancer in her ___, also history of melanoma. Brother with diabetes. <PHYSICAL EXAM> Discharge Exam: 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, normoactive bowel sounds ___: nontender, nonedematous <PERTINENT RESULTS> ___ PORTABLE ABDOMEN INDICATION: ___ year old woman with NGT placed for concern for post-op ileus with N/V// confirm NGT placement, eval for ileus vs sbo TECHNIQUE: Abdomen single view COMPARISON: ___ FINDINGS: Enteric tube tip is near gastroduodenal junction. Few mildly distended small bowel loops, suggest adynamic ileus. Mildly distended non dilated transverse colon. Surgical staples. Pelvic phleboliths. IMPRESSION: Few mildly dilated small bowel loops, suggest adynamic ileus. ___ ___ CHEST (PORTABLE AP) INDICATION: ___ year old woman with ileus, c/f placement of ngt, pulled back approximately 5cm.// c/f placement of NGT COMPARISON: Chest CT ___ FINDINGS: Portable AP upright view of the chest via. There is no focal consolidation, pleural effusion, or pneumothorax. NG tube terminates in the stomach. There is bibasilar atelectasis. Cardiomediastinal silhouette is within normal limits. IMPRESSION: NG tube terminates in the stomach. ___ ___ Cytology - finalized ___ SPECIMEN(S) SUBMITTED: PERITONEAL FLUID DIAGNOSIS: Peritoneal fluid: ATYPICAL. Reactive mesothelial cells and rare atypical cells that are immunoreactive for CK20 and CD7. CDX-2 is negative. Mucicarmine stain is negative. ___ ___ Pathology - finalized ___ 1) Fallopian tube and ovary, right salpingo-oophorectomy: - Metastatic mucinous adenocarcinoma involving ovary. See note. - Fallopian tube with chronic salpingitis and paratubal cysts. 2) Appendix: Mucinous adenocarcinoma, see synoptic report and see note. 3) Peritoneum, right pelvic sidewall: Fibroadipose tissue with acute and chronic inflammation, granulation tissue and focal mucin deposition. No carcinoma identified. 4)Uterus, cervix, left fallopian tube, ovary; total hysterectomy, left salpingooherectomy: - Endometrium with cystic atrophy. - Fallopian tube with chronic salpingitis and paratubal cysts. - Unremarkable left ovary and cervix. 5) "Posterior cul-de-sac peritoneum": Fibrous tissue with focal mucin deposition. No carcinoma identified. 6) Omentum, omentectomy: Adipose tissue, no malignancy identified. 7) Colon, right, partial colectomy: - Segment of ileum with serositis extending to proximal resection margin. See synoptic report. - Unremarkable segment of colon. - 7 out of 27 lymph nodes with metastatic adenocarcinoma (___). Note: Both appendiceal and right ovarian tumor are morphologically similar. A precurson lesion/ adenoma seen in appendix. The tumor is positive for CK20 , CDX-2 and negative for CK7 and PAX-8. *) Appendix: Resection Synopsis (Appendectomy with or without Right Hemicolectomy) Staging according to ___ Joint Committee on Cancer Staging Manual -- ___ Edition, ___ and College of ___ Pathologists Protocol for the Examination of Specimens from Patients with Carcinoma of the Appendix (___) Macroscopic Specimen Type: Appendix, Right Colon, Terminal Ileum, Total hysterectomy and bilateral salpingo oopherectomy and omentectomy Procedure: Appendectomy and right colectomy Length of appendix: 9.5 cm. Length of colonic segment: 16.1 cm Specimen Integrity: Intact Tumor Site: Appendix, not otherwise specified Tumor Size: Cannot be determined, Histologic Type: Mucinous adenocarcinoma (greater than 50% mucinous) Histologic Grade: Grade 2: Moderately differentiated Extent of Invasion TNM Descriptors: None Primary Tumor (pT): pT4a: Tumor penetrates the visceral peritoneum Regional Lymph Nodes (pN): pN2: Metastasis in 4 or more regional lymph nodes Lymph Nodes: Number of lymph nodes examined: 27. Number involved: 7 Distant Metastasis: PM1: Distant metastasis, site: right ovary Margins Proximal Margin: Negative for invasive carcinoma, Distal Margin: Negative for invasive carcinoma, Mesenteric Margin: Negative for invasive carcinoma, distance of tumor from closest margin: 1.2 mm. Lymphovascular Invasion: Present Satellite Peritumoral Nodules: Present, Number identified: 2 Perineural invasion: Present Additional Pathologic Findings: Representative Tumor Blocks: 2G, 2H, 2I <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. dextroamphetamine-amphetamine 60 mg oral DAILY 2. Lisinopril 40 mg PO DAILY 3. BuPROPion XL (Once Daily) 300 mg PO DAILY 4. Aspirin 325 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4g in 24 hours RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID Take this medication while on narcotics RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*28 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Reason for PRN duplicate override: indication Take medication with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drive or operate heavy machinery while on this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills: *0 6. Aspirin 325 mg PO DAILY - resume after finishing enoxaparin injections 7. BuPROPion XL (Once Daily) 300 mg PO DAILY 8. dextroamphetamine-amphetamine 60 mg oral DAILY 9. Lisinopril 40 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> pelvic mass <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. 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. * 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. * Your staples will be removed at your follow-up visit. 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. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
|
Ms. ___ was admitted to the gynecologic oncology service after undergoing an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and right colectomy. Please see the operative report for full details. Her postoperative course was complicated by an ileus vs partial SBO. Her diet was slowly advanced, however, she started to complain of nausea on postoperative day 3. She then had large-volume emesis on postoperative day 5. She was made NPO and managed conservatively with a NG tube placed. By postoperative day 9, she was passing flatus and had decreased NGT output. A clamp trial was done with minimal residuals and the NG tube was discontinued. She was subsequently advanced again to regular diet. Immediately postoperatively, her pain was controlled with dilaudid PCA and toradol. She was then transitioned to PO dilaudid and acetaminophen with good pain control. After she began independently ambulating, her foley catheter was discontinued and she voided spontaneously. By post-operative day ___, 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.
| 2,759
| 267
|
10348703-DS-19
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> leaking of fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> induction of labor vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ yo G1 P0 at 32w5d presents after feeling gush of fluid at home at approximately 0200 and continual leaking. She denies any contractions. Reports active fetal movement. No vaginal bleeding. No fevers, chills, nausea, vomiting, or dysuria. <PAST MEDICAL HISTORY> PRENATAL COURSE *) Dating: EDC: ___ by LMP and confirmed by early u/s per pt Per pt: IUI pregnancy, low risk era no prenatal records available OBSTETRIC HISTORY nullip GYNECOLOGIC HISTORY h/o abnl pap ___ years prior with colpo nl paps since no h/o LEEP, STIs or other procedures PAST MEDICAL HISTORY depression PAST SURGICAL HISTORY cosemtic surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 96.5, HR 83, RR 18, BP 111/80 GENERAL: NAD LUNGS: CTA bilaterally HEART: RRR ABDOMEN: soft, gravid, NT SSE: +pooling, +nitrazine, +ferning, os appears closed, no VB FHT: 130s/mod var/+A/no D TOCO: Q4-5min TAUS: VTX, BPP ___, AFI 7 <PERTINENT RESULTS> ___ WBC-8.3 RBC-3.92 Hgb-11.1 Hct-34.9 MCV-89 Plt-326 ___ Neuts-56.6 ___ Monos-6.6 Eos-1.7 Baso-0.4 ___ WBC-11.5 RBC-3.68 Hgb-11.0 Hct-32.2 MCV-88 Plt-365 ___ WBC-15.0 RBC-3.63 Hgb-10.3 Hct-31.8 MCV-88 Plt-388 ___ ___ PTT-26.6 ___ ___ URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG URINE CULTURE (Final ___: NO GROWTH R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Percocet ___ mg Tablet Sig: One (1) Tablet PO every ___ hours: as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. Motrin 600 mg Tablet Sig: One (1) Tablet PO every ___ hours: as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 3. breast pump Sig: One (1) as needed: hospital grade breast pumg - prematurity, maternal-baby seperation, poor latch. Disp: *1 device* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> PPROM - 33 weeks vaginal delivery <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> call for increased pain, bleeding or fever
|
___ yo G1P0 admitted at 32w5d with PPROM. . Ms ___ was admitted for expectant management of PPROM. She was afebrile and without evidence of infection or abruption. Her cervix was visually closed on speculum exam and she had irregular contractions. Fetal testing was reassuring. She received Ampicillin and Erythromycin for latency as well as a course of betamethasone for fetal lung maturity. The NICU was consulted. After close monitoring on labor and delivery, she was transferred to the antepartum floor. She underwent close fetal surveillance with twice daily NSTs and twice weekly BPPs. Of note, the fetal stomach appeared small on routine ultrasound. Her full fetal survey was reviewed and the fetal stomach appeared normal at that time. She remained clinically stable without evidence of chorioamnionitis or preterm labor until 34 weeks when she underwent induction of labor. She had an uncomplicated spontaneous vaginal delivery on ___. NICU staff was present for delivery and transferred the neonate immediately for prematurity. She remained afebrile and had an uncomplicated postpartum course. She was discharged home on PPD#2.
| 825
| 250
|
10350272-DS-17
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Labial abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> Incision and drainage of labial abscess <HISTORY OF PRESENT ILLNESS> ___ G8P4 with history of Hep C, Left below-the-knee amputation from motor vehicle accident, substance abuse on methadone presented with worsening pain from L labial abscess. Initially noticed pain and swelling at her BKA stump site and was prescribed clindamycin on ___. She then noticed swelling and redness in her left buttock and perineal area with fevers and chills. She presented to the ___ ED on ___ for these symptoms. Per PCP note and their review of ___ records, not available currently, she had "what appeared to be a self drained abscess just left of her vaginal area at the junction of her thigh and buttocks, there is significant surrounding cellulitis and there is some induration without much fluctuance. There was a plan for admission with IV antibiotics and consideration of surgical consultation for abscess evaluation and drainage. She requested pain medications. She then pulled her IV and eloped. She re-presented to ___ on ___ but left before being seen." She reported that on ___ the lesion near her vagina "burst and white puss started to come out. She was seen by her PCP one day prior to admission at which time she hypotensive and given concern for systemic infection she was sent to the ED for further evaluation. <PAST MEDICAL HISTORY> OBHx: G8P4 SVD x 4 TAB x 4 GYNHx: LMP 5 months ago, not currently sexually active Remote history of abnormal paps, unsure re: last pap H/o gonorrhea x 3, Trichamonas Denies history of fibroids H/o ovarian cyst as a teenager PMH: Hep C, Asthma, liver lesion seen on CT scan at ___ PAST SURGICAL HISTORY: LEFT BKA CHOLECYSTECTOMY <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Vital signs T 98.0PO BP 104 / 73 HR 69 RR 16 SpO2 98 RA General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended GU: left labial incision gauze dressing removed, no iodoform tail visible, area of induration extending medially approx 2cm without drainage, appearance of decubitus ulcer at lateral border of incision. nontender to palpation, minimal surrounding erythema. Smaller left buttock incision healing well with minimal underlying induration, no erythema or drainage. <PERTINENT RESULTS> ___ 08: 20AM BLOOD WBC-9.6 RBC-3.90 Hgb-12.1 Hct-36.6 MCV-94 MCH-31.0 MCHC-33.1 RDW-14.1 RDWSD-48.7* Plt ___ ___ 08: 20AM BLOOD Neuts-56.2 ___ Monos-10.1 Eos-2.4 Baso-1.0 Im ___ AbsNeut-5.40 AbsLymp-2.76 AbsMono-0.97* AbsEos-0.23 AbsBaso-0.10* ___ 07: 48PM BLOOD Glucose-70 UreaN-11 Creat-1.0 Na-143 K-4.6 Cl-103 HCO3-26 AnGap-14 ___ 02: 10PM BLOOD ALT-12 AST-12 ___ 01: 20PM BLOOD HIV Ab-NEG ___ 08: 02PM BLOOD Lactate-1.2 CT: IMPRESSION: 1. Soft tissue thickening and stranding of the labia majora with a left labial skin defect and adjacent 3.4 cm abscess. 2. No deep intrapelvic involvement is identified. 3. lymphadenopathy as described above, likely reactive. <MEDICATIONS ON ADMISSION> Albuterol Amytriptyline Amoxapine Benzonatate Clobetazol Fexofenadine Gabapentin Methadone <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ capsule(s) by mouth every six (6) hours Disp #*60 Capsule Refills: *0 2. Ibuprofen 400 mg PO Q8H: PRN Pain - Moderate RX *ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 3. Sulfameth/Trimethoprim DS 2 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by mouth twice a day Disp #*48 Tablet Refills: *0 4. Amitriptyline 75 mg PO QHS 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Cetirizine 10 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Gabapentin 800 mg PO TID 10. Methadone 20 mg PO BREAKFAST pain 11. Methadone 15 mg PO LUNCH pain 12. Methadone 15 mg PO DINNER 13. Multivitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ Diagnosis: Vulvar abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for evaluation of your abscess. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. 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 ___.
|
Upon admission, CT demonstrated L labial abscess. She underwent bedside I&D on ___ abd was transitioned ___ clinda/flagyl (from ED) to IV vancomycin. Gram stain showed gram positive cocci and gram negative rods. On ___, her pain was well-controlled, and sensitivites returned showing staph sensitive to bactrim, so she was transitioned to PO bactrim and was discharged with close follow up. A plan was made with case management for ___ to see her once daily for dressing changes. Of note, during her stay, her history of Hepatitis C was discussed in light of a prior MRI showing an 8 mm liver lesion (___). The decision was made to defer further work up to the outpatient setting.
| 1,477
| 155
|
10352061-DS-16
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Flagyl / Isoniazid / Clindamycin / Codeine / Morphine <ATTENDING> ___ <CHIEF COMPLAINT> Scheduled Cesarean Section <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat Cesarean delivery blood transfusion <HISTORY OF PRESENT ILLNESS> ___ G3P2 @39+4 presented for elective repeat Cesarean delivery. No complaints. PNC: - ___ ___ by second trimester U/S - O+ / Ab- / RPRNR / RI / HBsAg- / GBS- - nl FFS, post placenta - menstrual dating discordant from U/S by >2wks @15wks, re-scan 1mo later concordant - severe sinusitis treated with abx and pain medications <PAST MEDICAL HISTORY> OB Hx: C/S x2 Gyn Hx: benign, treated for Chlamydia during first pregnancy Med Hx: postpartum depression, PPD+ s/p medications, GERD Surg Hx: C/S x2 as above, breast biopsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> VSS Gen NAD Chest CTAB Heart RRR Abd soft, gravid, NT EFW 7.5# Extr NT, tr edema <PERTINENT RESULTS> ___ 06: 36AM BLOOD WBC- 10.0 Hgb- 9.7* Hct- 29.5* Plt Ct- ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *60 Capsule(s)* Refills: *2* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for Pain. Disp: *30 Tablet(s)* Refills: *0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *2* 4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. Disp: *90 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> term pregnancy two prior Cesarean deliveries blood-loss anemia <DISCHARGE CONDITION> stable, good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per routine
|
The patient was taken to the operating room for her repeat cesarean delivery. The operation proceeded without complications, with an estimated blood loss of 700 cc and dense adhesions noted around the anterior uterus and bladder. Operative note from ___ in OMR. Post-operatively, a hematocrit was checked and was found to be 23.3, down from 29.5. The patient had tachycardia, as well as some dizziness with ambulation, and a work-up for a PE was done, with a negative CTA of the chest and an EKG showing sinus tachycardia with no other changes. Repeat hematocrit was 22.1 again on ___. Blood transfusion was recommended, and the patient agreed. Two units of packed RBCs were transfused on the evening of ___ without incident. The patient did well, with a post-transfusion hematocrit of 27.4. Her tachycardia and symptoms resolved, she felt less fatigued, and the remainder of her post-operative course was uneventful. She was discharged home in good condition on ___.
| 607
| 235
|
10352061-DS-17
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Flagyl / Isoniazid / Clindamycin / Codeine / Morphine <ATTENDING> ___ ___ Complaint: scheduled C-section <MAJOR SURGICAL OR INVASIVE PROCEDURE> Repeat lower transverse c-section and intra-operative Paragard IUD placement <HISTORY OF PRESENT ILLNESS> HPI: ___ G4P3 at 36w5d with placenta previa, h/o LTCS x 3, and placenta acreta seen on ultrasound. s/p MFM consult. Most recent ultrasound ___: EFW 2980, 51%; several areas of irregularity of the placental-myometrial interface consistent with placenta acreta (largest area 2.2cm). She has had no other complications during this pregnancy. No contractions, VB, LOF. + AFM. PNC: EDC: ___ Labs: O+/Ab-/RPRNR/RI/HBsAg-/HCV-/HIV-/GC-/CT-/Pap- U/S: FFS nl Testing: Declined aneuploidy screening, GTT nl Issues: placenta previa/acreta <PAST MEDICAL HISTORY> ObHx: ___, 39w4d, Rpt C/S, 3200g, c/b anemia/blood transfusion ___, 41w2d, Rpt C/S, 3395g ___, 42w0d, LTCS for arrest at 6cm/NRFHT GynHx: Remote h/o chlamydia. No abnl Paps. PMH: Frequent UTI's Migraine headaches Depression, history of pp depression (treated with SSRI) Hepatitis/liver disease: No. + PPD, CXR negative as child, s/p INH/Rifamin x ___ Question of a blood clot in neck vessels, hospitalized x 2 days with IV Heparin, then reimaging and no clot seen, anti-coagulation discontinued, no issues since. PSH: LTCS x ___ left breast lump removed, benign. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> PE: VS: BP: 124/68, Weight: 249.9 NAD RRR CTAB Abd soft, obese, gravid, NT Ext NTNE <PERTINENT RESULTS> ___ 07: 07AM BLOOD WBC-10.8 RBC-2.97* Hgb-8.5* Hct-25.9* MCV-87 MCH-28.8 MCHC-33.0 RDW-14.4 Plt ___ ___ 09: 00AM BLOOD WBC-17.8* RBC-3.26* Hgb-9.5* Hct-27.6* MCV-85 MCH-29.2 MCHC-34.4 RDW-14.5 Plt ___ ___ 07: 20AM BLOOD WBC-17.3* RBC-3.24* Hgb-9.2* Hct-27.8* MCV-86 MCH-28.5 MCHC-33.2 RDW-14.8 Plt ___ ___ 02: 27AM BLOOD WBC-11.0 RBC-2.75* Hgb-7.8* Hct-24.1* MCV-88 MCH-28.5 MCHC-32.4 RDW-14.2 Plt ___ ___ 05: 42PM BLOOD WBC-12.7* RBC-2.95* Hgb-8.3* Hct-25.6* MCV-87 MCH-28.3 MCHC-32.6 RDW-13.9 Plt ___ ___ 12: 26PM BLOOD WBC-12.4*# RBC-2.78*# Hgb-7.9*# Hct-23.8*# MCV-86 MCH-28.6 MCHC-33.3 RDW-13.9 Plt ___ ___ 07: 14AM BLOOD WBC-8.3 RBC-3.50* Hgb-10.2* Hct-30.0* MCV-86 MCH-29.1 MCHC-34.0 RDW-14.0 Plt ___ . ___ 07: 20AM BLOOD Neuts-87.8* Lymphs-6.7* Monos-5.3 Eos-0.1 Baso-0.1 ___ 07: 40PM BLOOD Neuts-87.6* Lymphs-6.0* Monos-6.0 Eos-0.2 Baso-0.2 ___ 02: 27AM BLOOD Neuts-84.5* Lymphs-10.0* Monos-5.3 Eos-0.2 Baso-0.1 ___ 12: 26PM BLOOD ___ PTT-27.3 ___ ___ 11: 46AM BLOOD ___ PTT-80.9* ___ ___ 12: 26PM BLOOD ___ ___ 11: 46AM BLOOD Fibrino-96* . ___ 07: 07AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-139 K-4.0 Cl-107 HCO3-25 AnGap-11 ___ 09: 45AM BLOOD Glucose-106* UreaN-5* Creat-0.5 Na-141 K-3.7 Cl-105 HCO3-25 AnGap-15 ___ 05: 46AM BLOOD Glucose-125* UreaN-3* Creat-0.6 Na-138 K-3.8 Cl-105 HCO3-25 AnGap-12 ___ 07: 07AM BLOOD Calcium-7.7* Phos-2.4*# Mg-2.5 ___ 09: 45AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.9 ___ 07: 40PM BLOOD D-Dimer-4205* . ___ EKG: sinus tachycardia . ___ CTA: 1. No evidence of central PE within context of suboptimal contrast bolus. 2. No evidence of acute aortic injury. 3. Bilateral small pleural effusions left greater than right with adjacent compressive atelectasis. 4. Stable 3-mm nodule in the left upper lobe. 5. Small amount of free abdominal air and free fluid consistent with patient's known C-section. 6. Unchanged anterior superior mediastinal soft tissue consistent with residual thymus. . ___ KUB: Frontal view of the abdomen demonstrates distention of colonic and small bowel segments with air. Surgical staples are in the midline. An IUD is present near the midline. Air is present in the stomach. These findings could be consistent with ileus. No air is seen in the rectum. <MEDICATIONS ON ADMISSION> PNV <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: take medication with food. . Disp: *60 Tablet(s)* Refills: *0* 3. Percocet ___ mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 4. breast pump Sig: One (1) unit prn. Disp: *1 unit* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> c-section delivery of baby girl <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Foley remain in place for 7 days after c-section (please see foley leg bag package) Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks No driving while taking percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
|
Ms. ___ underwent scheduled repeat LTCS and intraop Paragard IUD placement for previa and suspected accreta complicated by extensive adhesions from bladder to anterior uterus requiring significant dissection. Please see ___ note for complete details. Her post-operative course was characterized by the following issues: *)Foley - in terms of managing this patient because of how thin the bladder appeared intraop, decision was made to leave a Foley in place for 7 days to allow the bladder to adequately heal. *) Tachycardia/Transfusion - postop, pt was tachycardiac and her HR went as high as 140s to 150s on POD#1. Pt was evaluated with EKG, which showed sinus tachycardia. She then underwent CTA and V/Q scan, there was no evidence of PE. Labs were ordered, HCT nadired at 24.1. The decision was made to transfuse pt 2 units of PRBC. Pt's tachycardia improved after the transfusion and defervesced, thus the tachycardia was likely due to a combination of symptomatic anemia and fever. *) Fever - immediately after the surgery, pt was started on prophylactic antibiotic Kefzol given recent ParaGard IUD placement. Pt then spiked a fever, the antibiotic was changed to A/G. Pt continued to be febrile with A/G, the antibiotic was changed to Unasyn for broader coverage, which pt responded well. She was on Unasyn for 48 hrs afebrile. Her WBC trended down appropriately. *) Ileus - pt developed clinic symptoms that were consistent with ileus on POD#1, she was evaluated with a KUB on POD#2, which confirmed the diagnose. Pt was made NPO/IVF. Her electrolytes were repleted accordingly. Her symptoms then improved and her diet was slowly advanced to regular on POD#4. *) Dispo: Ms. ___ was discharged on post-operative day #5 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and foley in place.
| 1,928
| 452
|
10352603-DS-3
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abd pain, syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p egg retreival presenting as transfer from ___ ___. Pt undewent egg retreival on ___ at 0800. Per her report, procedure uncomplicated at 15 eggs retrieved. She recovered well and didn't feel any more discomfort that she remembered after her first retreival. All eggs were frozen, planning for FET. At home, she initially rested, then began feeling worsening abdominal discomfort as well as somewhat nauseated. She went to bathroom where she had episode of syncope. Thinks she may have had frontal head strike, but unsure. Unsure of exact duration of LOC, but from what her fiance told her it was "short." She was oriented on awakening, though felt weak. No preceding CP or SOB or palpitaions. She did notice bilateral shoulder pain. She then went to ___, where her work-up included a negative CTA and normal EKG. A CT abd/pelvis noted some intraperitoneal fluid and likely hematoma or hemorrhage. She was then transferred to ___ for further evaluation and managment. On arrival here, she reports continuded diffuse abdominal discomfort, constant and dull. She also notes bilateral shoulder pain. No nausea currently, though did have some nausea and emesis after receiving pain medications at ___. No GI or GU symptoms. Does note stomach feels "bloated." No vaginal bleeding. No fevers/chills. No lightheadedness/dizziness. <PAST MEDICAL HISTORY> OB Hx: G0 Gyn Hx: - unexplained infertility - endometriosis - denies abnormal pap - denies STIs PMH: - hypothyroidism - anxiety PSH: - egg retreival x 2 - LSC surgery for endo in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 04: 00PM WBC-8.1 RBC-3.57*# HGB-10.8*# HCT-31.1* MCV-87 MCH-30.3 MCHC-34.7 RDW-14.7 RDWSD-47.1* ___ 04: 00PM ___ PTT-26.8 ___ ___ 04: 00PM PLT COUNT-144* ___ 03: 20AM URINE HOURS-RANDOM ___ 03: 20AM URINE HOURS-RANDOM ___ 03: 20AM URINE UCG-POSITIVE ___ 03: 20AM URINE GR HOLD-HOLD ___ 03: 20AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03: 20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 03: 20AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 03: 20AM URINE MUCOUS-RARE ___ 01: 20AM GLUCOSE-113* UREA N-5* CREAT-0.5 SODIUM-136 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-20* ANION GAP-13 ___ 01: 20AM WBC-9.9 RBC-2.80* HGB-8.5* HCT-25.3* MCV-90 MCH-30.4 MCHC-33.6 RDW-12.9 RDWSD-42.8 ___ 01: 20AM NEUTS-81.8* LYMPHS-13.3* MONOS-4.2* EOS-0.1* BASOS-0.2 IM ___ AbsNeut-8.11* AbsLymp-1.32 AbsMono-0.42 AbsEos-0.01* AbsBaso-0.02 ___ 01: 20AM PLT COUNT-157 ___ 12: 00AM GLUCOSE-110* UREA N-6 CREAT-0.5 SODIUM-135 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-16* ANION GAP-17 ___ 12: 00AM estGFR-Using this ___ 12: 00AM WBC-UNABLE TO RBC-UNABLE TO HGB-UNABLE TO HCT-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO RDWSD-UNABLE TO ___ 12: 00AM PLT COUNT-UNABLE TO <MEDICATIONS ON ADMISSION> cabergoline 0.5 mg daily, levothryoxine 50 mcg daily, zoloft 25 mg daily <DISCHARGE MEDICATIONS> 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Sertraline 50 mg PO DAILY 3. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4g in one day RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 4. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain do not drive while taking this medication RX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours Disp #*30 Capsule Refills: *0 5. Lorazepam 0.5 mg PO Q4H: PRN sleep RX *lorazepam [Ativan] 0.5 mg ___ tablets by mouth every four hours Disp #*8 Tablet Refills: *0 6. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 7. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron HCl 4 mg ___ tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> large pelvic hematoma after egg retrieval secondary to a ruptured follicle <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. * 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service overnight for pain management and monitoring for a large pelvic hematoma secondary to egg retrieval. Her admission course was uncomplicated. She received two units of packed red blood cells, which helped to resolve some of her lightheadedness and dizziness symptoms. Her hematocrit did also stabilize after the two units of blood. Her pain was initially managed with IV dilaudid and IV tylenol. Once her hematocrit stabilized she was advanced to a regular diet and transitioned to oral pain medications. Her nausea was controlled by anti-emetics. Throughout her admission she did not demonstrate any signs of ovarian hyperstimulation syndrome. By hospital 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.
| 1,731
| 186
|
10354239-DS-4
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Preterm contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G6P2 presented at 25w6d with uncomfortable contractions. She reports that she has had months of contractions but on day of admit she started feeling some pressure with the contractions which were every 3 minutes, so she presented to ___. At ___, she was found to be contracting every ___ minutes uncomfortably and in tears. Her temp was 98.0 with normal BP and heart rate. She received one dose of nifedipine 10mg which cause her to feel "lousy" with chest discomfort and more painful contractions. She was then switched to magnesium 4g bolus to 2g/hr at 16: 45. She received betamethasone at 17: 00 and started penicillin for GBS prophylaxis. She had two SVEs that were both fingertip/2cm long. An FFN was negative. Her labs were CBC: 12.0 (74%N) > 30.8 < 218. UA neg nitrites, neg leuk esterase, 5 ketones. Chem 7 wnl, Cr 0.5. On arrival at ___, she continued to feel her contractions ___ every 8 minutes, which is less frequent that before. Denies fever/chills, recent illness, dysuria, cough, n/v/d, vaginal discharge, other abdominal pain, abdominal trauma, or vaginal bleeding. +AFM. <PAST MEDICAL HISTORY> PNC: *) Dating: ___: ___ *) Labs: A+/Ab-/RPRNR/RI/HbsAg-/HIV-/GBS pending at ___ *) Routine: - Genetics: declined - U/S: nl full fetal survey *) Issues - lsc CCY at 19wks - h/o PTD: CL 14wks 40mm, 18wk 36mm, 22wk 44mm, last CL on ___ was 37mm without any dynamic changes PObHx: G6P2 -G1: ___, SAB, 6wks -G2: ___, 36wks, 5#6, hospitalized at 25wks for magnesium for tocolysis then discharged home on bedrest -G3: ___, ectopic pregancy treated with methotrexate -G4: ___, 36wks, 6#5, hospitalized at ___ for tocolysis and discharged home on bedrest -G5: ___, TAB -G6 current PGynHx: Denies h/o abnormal pap smears or STIs, denies h/o LEEP or other cervical procedure PMHx: asthma (no hospitalization or intubation, takes albuterol PRN), migraines (formerly on amitriptyline) PSHx: lsc CCY ___ Meds: none <ALLERGIES> NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> PE: 98.7, 107/82, 103 General: NAD, does not appear uncomfortable during contractions Abdomen: soft, no fundal tenderness, contractions palpate moderate strength Ext: no edema, no calf tenderness SVE: FT/long/post at 19: 15 FHT: 120, mod var, +accels, no decels Toco: q4min -> spaced TAUS: ___ BPP, vertex, DVP 5.4cm EFW: 946g (~60%ile) <MEDICATIONS ON ADMISSION> Prenatal vitamins <DISCHARGE MEDICATIONS> Prenatal vitamins <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm contractions <DISCHARGE CONDITION> preterm contractions <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Modified bedrest at home until your next visit with Dr. ___.
|
She was admitted to the antepartu service for observation. Her contractions quieted so magnesium was discontinued. She received her second dose of betamethasone and had reassuring fetal testing. There were no other symptoms of preterm labor and she was discharged to home. She will follow-up with her primary OB in the next ___ days and she will need an appointment with Dr. ___ in ___ next week for follow-up.
| 896
| 88
|
10355653-DS-12
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> leakage of fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery <PHYSICAL EXAM> Physical Exam on Admission: AVSS Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness SVE: cervix 1cm/long effacement/high station/posterior position/medium consistency, SSE: +nitrazine, +clear fluid pooling, -VB Toco irregular and sporadic FHT HR 130 and 115/moderate variability/+accels/-decels (1 var @03: 32) Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm, incision c/d/i Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 09: 49PM PO2-19* PCO2-65* PH-7.14* TOTAL CO2-23 BASE XS--10 COMMENTS-CORD ___ ___ 09: 46PM PO2-9* PCO2-78* PH-7.09* TOTAL CO2-25 BASE XS--9 COMMENTS-CORD VEIN ___ 05: 58AM WBC-10.1* RBC-4.38 HGB-12.3 HCT-36.5 MCV-83 MCH-28.1 MCHC-33.7 RDW-12.6 RDWSD-38.4 ___ 05: 58AM PLT COUNT-282 <MEDICATIONS ON ADMISSION> --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription ALBUTEROL SULFATE [PROVENTIL HFA] - Proventil HFA 90 mcg/actuation aerosol inhaler. 2 puffs inhaled 2 x a day x 7 days POLYETHYLENE GLYCOL 3350 - polyethylene glycol 3350 17 gram oral powder packet. 1 packet powder(s) by mouth q 3 days as needed for constipation Medications - OTC DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day FERROUS SULFATE [FEOSOL] - Feosol 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth once a day LORATADINE-PSEUDOEPHEDRINE [LORATADINE-D] - Loratadine-D 5 mg-120 mg tablet,extended release 12 hr. tablet(s) by mouth once to twice a day only when needed - (OTC) PNV62-FA-OM3-DHA-EPA-FISH OIL [PRENATAL GUMMY] - Dosage uncertain - (OTC) --------------- --------------- --------------- --------------- <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal delivery of Twin 1 Cesarean delivery of Twin 2 Preterm premature rupture of membranes <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Routine postpartum instructions
|
On ___, Ms. ___ was transferred to the post-partum floor from labor and delivery status post a spontaneous vaginal delivery for twin A and a cesarean section for twin B. Her postpartum course was complicated by chronic hypertension, postpartum cough/shortness of breath, and diffuse abdominal pain. On post-partum day two, she developed a cough and shortness of breath. Given her previous history of pneumonia during this pregnancy a chest x-ray was done that showed no evidence of pneumonia and very small bilateral pleural effusions that did not explain the shortness of breath she was describing. Her symptoms were treated with albuterol PRN. Her respiratory symptoms were monitored throughout her stay and spontaneously resolved without incident. On postpartum day three, she developed diffuse abdominal pain that was concerning for hemoperitoneum. Her hematocrit was trended which remained stable with a nadir at 28.3 which was re-assuring for no hemoperitoneum or continued bleeding. Her abdominal pain spontaneously resolved. During her admission, her blood pressures remained well controlled without medications. By postpartum day 5, 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 outpatient postpartum follow-up scheduled.
| 921
| 279
|
10359200-DS-9
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> oligohydramnios <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal birth <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at ___ GA presents from ATU after being found to have AFI of 3.8cm. No LoF, VB, contractions. +AFM. <PAST MEDICAL HISTORY> PNC: ___ ___ by LMP O+/Ab-/RI/RPR NR/HBsAg-/GBS- nl GLT EFW ___: 2557g ___ percentile), BPP ___, AFI 8.6cm ___: BPP ___, AFI 3.8cm ObHx: nulliparous GynHx: colpo ___, nl f/u Paps PMH: hypothyroid PSH: none <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> HR 80, BP 131/66 NAD Abd: soft, gravid, NT Extr: no calf tenderness FHT: 130s, mod var, +A, no decels Toco: q3-5 minutes SVE: L/C/P <PERTINENT RESULTS> ___ 11: 48PM WBC-10.3 RBC-3.34* HGB-10.5* HCT-31.2* MCV-94 MCH-31.6 MCHC-33.8 RDW-12.2 ___ 11: 48PM PLT COUNT-220 ___ 04: 56PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04: 56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG <MEDICATIONS ON ADMISSION> PNV, iron, levothyroxine 50 mcg qd <DISCHARGE MEDICATIONS> 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *60 Tablet(s)* Refills: *2* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *1* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *60 Capsule(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal birth <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Pelvic rest
|
The patient was admitted to L&D. OCT was negative and induction was started with misoprostol. The patient became too uncomfortable to have a second tablet placed. Pitocin was started. After 12 hours, cervix changed from 1/long/-2 and soft to ___. Induction was abandoned and the patient was transfered to the antepartum service for the night. The following day, induction was resummed. The patient had an uncomplicated vaginal delivery of a 2345g female, apgars 9 and 9. Her postpartum course was uncomplicated. She was discharged home on PPD#2 in good condition.
| 653
| 137
|
10361833-DS-14
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal Pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G1___ with LMP ___ c/o lower abdominal pain x ~1wk. Began as intermittent crampy pain across the entire lower abd, 2d ago became knifelike and constant and the patient sought care at the ED at an OSH. Per the pt they did a number of blood tests, a pelvic exam and a transvaginal ultrasound but she wasn't aware of the results. Per the written referral form, the patient had a + Chlamydia test, although no official documentation was included at the time of transfer. The patient received pain control via a morphine PCA while at the OSH, from which she reports she obtained relief. She had a couple of episodes of vomiting while there, after receiving pain medication. The pt also reports watery yellow vaginal discharge without odor for longer than she has had this pain, uncertain duration. She has had one day of burning on urination. At the OSH, the patient was treated with Ceftriaxone and Doxycycline, and the physicians there noted no improvement. Imaging at the OSH raised concern or a tubo-ovarian abscess or ovarian torsion, thus the patient was transfered to ___. The patient has had unprotected intercourse recently. Does not know if any partners were + for STIs. <PAST MEDICAL HISTORY> OBHx - ___ TM SAB age ___, no D&C GynHx - irregular menses (doesn't keep track), denies h/o STIs, no known cysts or fibroids, has not had a Pap smear MedHx - occasional shortness of breath (never diagnosed with asthma) SurgHx - none <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> PE 99.1 110/70 74 18 NAD RRR CTAB Abd obese, soft, tender to palpation in lower quadrants, mid > R or L, no guarding or rebound Ext NT, NE SSE normal external genitalia, + tenderness on insertion of speculum; copious thin, yellow discharge partially obscuring cervix, cervix appeared normal and non-erythematous with no lesions; swab for GC/CT obtained BME tender on insertion of fingers, + voluntary guarding in lower abdomen, difficult to palpate uterus and adnexae secondary to voluntary guarding and body habitus; difficult to reliably discern overall discomfort from CMT, but apparent + CMT <PERTINENT RESULTS> Laboratory: ___ 11: 55PM BLOOD WBC-8.1 RBC-4.19* Hgb-11.8* Hct-34.8* MCV-83 MCH-28.3 MCHC-34.0 RDW-13.6 Plt ___ ___ 11: 55PM BLOOD Neuts-58.0 ___ Monos-4.5 Eos-2.1 Baso-0.2 ___ 11: 55PM BLOOD Glucose-88 UreaN-7 Creat-0.5 Na-141 K-4.0 Cl-107 HCO3-25 AnGap-13 ___ 11: 55PM BLOOD Calcium-8.6 Phos-4.3 Mg-1.8 ___ 11: 55PM BLOOD HCG-LESS THAN ___ 11: 55PM BLOOD CRP-10.6* ___ 11: 55PM BLOOD ESR-28* Imaging: ___ Pelvic U/S: IMPRESSION: 1. Findings suggestive of left pyosalpinx, measuring 6cm. 2. Small amount of free fluid. <MEDICATIONS ON ADMISSION> Albuterol PRN <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *45 Tablet(s)* Refills: *0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. Disp: *28 Tablet(s)* Refills: *0* 3. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 14 days. Disp: *28 Capsule(s)* Refills: *0* 4. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pyosalpinx Chlamydia infection <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 1. Take your antibiotics as prescribed. Flagyl 500mg twice per day for fourteen days and Doxycycline 100mg twice per day for fourteen days. Do not drink alcohol while taking these medications because it may make you feel nauseated. 2. Take Motrin and Percocet for pain. You will likely have some pain for several weeks. The pain should slowly improve. 3. Call your doctor with fever, worsening abdominal pain, nausea and vomiting, inability to tolerate food/liquids, or any concerns. 4. Make sure that your sexual partner is treated for this chlamydia infection.
|
Ms. ___ is a ___ P0 with lower abdominal pain, cervical motion tenderness, and + chlamydia test. TVUS consistent with a pyosalpinx measuring 6cm in length. Patient was treated with IV gentamicin and clindamycin for 36 hours and then transitioned to PO antibiotics. Her pain was initially controlled with SC dilaudid and then transitioned to PO percocet. Labs throughout this admission were unremarkable and the patient never had an elevated WBC count. She remained afebrile throughout this admission. Of note, upon admission, the patient appeared quite drowsy and withdrawn. Social work as well as internal medicine came to assess the patient. Both felt that social issues played a significant role in her interactions. On HD#2, the patient's family came to visit and she became much more engaging and responsive. The patient was discharged home on ___ in stable condition. She will take Flagyl 500mg BID and Doxycycline 100mg BID for 14 days total. The patient was counseled extensively regarding the risks of not adequately treating a pelvic infection. She states understanding. She will follow up in ___ clinic on ___.
| 1,227
| 250
|
10361833-DS-15
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> transvaginal drainage of left fallopian tube <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year-old G2P0 who presents as a transfer from ___ for 1 week of pelvic pain, fever, and n/v concerning for ___. She reports that for the past week, she has had gradual worsening of pelvic pain, which she describes mostly as pressure "in my tubes" with occasional periods of sharp knife-like pain, similar to the pain she has had in the past when treated for PID. She denies any sudden acute exacerbation of pain. She has been taking naproxen with minimal relief. She has also had persistent nausea and vomiting for the past few days. Two days ago, she reports a fever to 104 at home as well as chills. She has had more watery vaginal discharge in the past week as well as vaginal spotting a few days ago. Her LMP was ___. Denies dysuria or hematuria. Had been constipated but took a powder (miralax?) and had a loose BM today. She has also been having nonproductive cough but denies any SOB/CP. She has been taking nyquil and theraflu for this. She presented to ___ today for evaluation. She was afebrile 98.4F. She had a negative CXR and a CT abd/pelvis which was negative (normal lung bases, liver, gallbladder, pancreas, spleen, adrenals, kidneys, small and large bowel, and appendix) except for dominant cystic lesions in pelvis, measuring 5.5cm on the left and 8.4cm on the right. She had GC/Ch and pelvic exam by Dr. ___ with scan vaginal discharge but moderate R > L adnexal tenderness and CMT. Labs were: 139 | 106 | 10 ---------------< 80 3.9 | 26 | 0.6 9.6 > 15.0 / 43.9 < 272 UCG neg, UA neg leuk/nitr They were unable to obtain an ultrasound because (per the pt) the ultrasound department had left for the night. Given the cystic pelvic masses and tenderness on exam, she received 500mg PO cipro, 500mg IV flagyl, and 1g ceftriaxone prior to transfer to ___. Currently, she continues to endorse the same bilateral pelvic pain which is improved with dilaudid. Has not had any emesis here. <PAST MEDICAL HISTORY> Obstetric History: G2P0, SAB x 2 Gynecologic History: - Menses generally monthly, lasting ___ days - h/o chlamydia and hospitalized for PID in ___ at ___, and reports having had transgluteal drains placed in her tubes at ___ - reports that her primary gynecologist has been recommending laparoscopic salpingectomy to her <PAST MEDICAL HISTORY> - asthma - depression/bipolar disorder - PTSD Past Surgical History: - tonsillectomy - ___ drains into TOAs <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On admission: Vitals in ED: 98.6 82 122/67 24 97% RA General: intermittently tearful obese Caucasian woman, NAD, AxO CV: RRR, no murmur Resp: CTAB, no crackles Abd: +BS, soft, obese, nondistended, tender to deep palpation in lower abdomen and mild RUQ tenderness, no rebound or guarding Pelvic: normal external genitalia without lesions, smooth vaginal walls without lesions, minimal physiologic discharge, cervix without lesions. On bimanual exam, which is limited by pt's body habitus, she has +CMT as well as tenderness in the bilateral adnexa (R > L). Unable to palpate any distinct adnexal masses although there is fullness bilaterally Ext: no calf tenderness On discharge: T98.2 HR 68 BP 115/75 RR 22 O2 96% RA General: NAD, comfortable, appears drowsy CV: RRR Lungs: CTAB Abdomen: Soft, nondistended, no rebound or guarding Extremities: No TTP, Bilateral ___ edema in all extremities, nonpitting <PERTINENT RESULTS> ___ 01: 20AM BLOOD WBC-12.6*# RBC-4.83 Hgb-14.4 Hct-43.3 MCV-90# MCH-29.7 MCHC-33.2 RDW-13.3 Plt ___ ___ 07: 30AM BLOOD WBC-8.2 RBC-4.22 Hgb-12.7 Hct-38.4 MCV-91 MCH-30.1 MCHC-33.1 RDW-13.4 Plt ___ ___ 01: 20AM BLOOD Neuts-88.3* Lymphs-10.2* Monos-0.6* Eos-0.8 Baso-0.2 ___ 07: 30AM BLOOD Neuts-56.5 ___ Monos-3.0 Eos-0.9 Baso-0.4 ___ 01: 20AM BLOOD ___ PTT-32.4 ___ ___ 01: 20AM BLOOD ESR-14 ___ 01: 20AM BLOOD Glucose-167* UreaN-12 Creat-0.5 Na-135 K-4.0 Cl-104 HCO3-18* AnGap-17 ___ 01: 20AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8 ___ 01: 20AM BLOOD HCG-<5 ___ 01: 20AM BLOOD CRP-10.8* ___ 07: 30AM BLOOD HIV Ab-NEGATIVE ___ 08: 58PM BLOOD Genta-0.3* ___ 01: 20AM BLOOD Lithium-LESS THAN Valproa-<3* ___ 07: 30AM BLOOD HCV Ab-PND ___ 01: 26AM BLOOD Lactate-3.3* ___ 03: 20AM URINE Color-Yellow Appear-Clear Sp ___ ___ 03: 20AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 03: 20AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 ___ 03: 20AM URINE UCG-NEGATIVE ___ 1: 20 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 1: 15 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 3: 42 am SWAB Source: Cervical. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. ___ 3: 42 am SWAB Source: Vaginal. SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Preliminary): ___ 5: 00 pm ABSCESS L ADNEXAL FLUID COLLECTION. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): RESULTS PENDING. ANAEROBIC CULTURE (Preliminary): Pelvic Ultrasound ___: 1. Bilateral dilated fallopian tubes with internal debris, which may represent blood or pus. Findings are suggestive of bilateral ___. 2. 4.9 cm right hemorrhagic ovarian cyst. Superinfection of the cyst cannot be excluded. 3. Normal left ovary. Right ovary only seen in one plane, but appears unremarkable. 4. Normal uterus and endometrium. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 100-200 mg PO QHS 2. Methylphenidate SR 40 mg PO QAM 3. HydrOXYzine 50 mg PO TID: PRN anxiety 4. Divalproex (EXTended Release) 250 mg PO QAM 5. Divalproex (EXTended Release) 1500 mg PO Q ___ <DISCHARGE MEDICATIONS> 1. HydrOXYzine 50 mg PO TID: PRN anxiety 2. Methylphenidate SR 40 mg PO QAM 3. Divalproex (EXTended Release) 250 mg PO QAM 4. Divalproex (EXTended Release) 1500 mg PO Q ___ 5. QUEtiapine Fumarate 100-200 mg PO QHS 6. Azithromycin 250 mg PO DAILY Take two pills first day, then one pill each day until prescription finished. RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*6 Tablet Refills: *0 7. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hematosalpinx (blood in tubes) hemorrhagic ovarian cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted for evaluation and treatment of abdominal pain and dilated fallopian tubes. You were given IV antibiotics in case the fluid in the tubes was due to an infection. The fluid in the left tube was drained by radiology and did not show evidence of infection. Your white blood cell count was normal after the drainage and you did not have a fever. After evaluation, it is thought that the pain you experienced was likely due to accumulation of blood in the fallopian tubes from a hemorrhagic cyst on your ovary. You do not need to take any more antibiotics for this problem. You also experienced a cough and wheezing and are being a given a prescription to take at home (azithromycin) to help with your upper respiratory infection. You should take use your inhaler as well to help with any wheezing. Please follow these instructions: *) take all medicines as prescribed *) Pelvic rest for two weeks after drain removal on ___ (Nothing in vagina: no sex, tampons, douching)
|
Ms. ___ was admitted to the gynecology service secondary to concern for pelvic inflammatory disease and possible tubo-ovarian abscess after being transferred from ___ ___ where she had presented with pelvic pain. In ___, she received 1 dose of ceftrixone, cipro and flagyl. On intial presentation to ___, she was afebrile. On physical examination she had adnexal tenderness as well as cervical motion tenderness. Lab evaluation releaved an elevated CRP and mild leukocytosis. Pelvic ultrasound revealed bilateral dilated fallopian tubes with internal debris consistent with fluid vs. pus as well as a 4.9 cm right hemorrhagic ovarian cyst. She was therefore admitted to the gynecology service for inpatient management. She received gentamicin and clindamycin for treatment of PID and possible tubo-ovarian abscess. She was made NPO for possible drainage. On ___ she underwent transvaginal ultrasound-guided placement of 8 ___ ___ catheter into complex left adnexal collection, which was thought to be likely a hematosalpinx as 15 cc of serosanguineous fluid was aspirated. Gonorrhea and chlamydia swabs were sent and negative. Yeast culture was negative, BV is still pending. Gram stain from the drained fluid was negative. Culture is still pending. A complete STI panel was sent and negative to date, although some results are pending. She remained afebrile. Her leukocytosis improved to 8.2 on hospital day #2. Given the minimal amount of serosanguinous drainage, the drain was discontinued. After review of her course, it was determined that her pelvic pain was likely secondary to a hemorrhagic ovarian cyst with an incidentally found left hematosalpinx, and less likely PID. On hospital day #2, she was afebrile and ambulatory. Pain was controlled and she tolerated a regular diet. She was discharged but prior to leaving, on the night of hospital day #2, she had an episode of pain, which was evaluated with a pelvic ultrasound and labs which were both stable. She had a reassuring exam and the pain resolved with NSAIDs. On hospital day #3, she continued afebrile and ambulatory with minimal pain. She tolerated a regular diet. She had experienced persistent wheezing and a productive cough throughout her hospitalization, and so was discharged home in stable condition with a prescription for azithromycin to treat a presumed bacterial upper respiratory infection. She plans to follow-up with her primary gynecologist Dr. ___.
| 2,494
| 542
|
10361880-DS-8
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> gestational hypertension T1DM <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 35w3d with h/o T1DM sent from routine OB visit for elevated blood pressures and headache. Today at routine OB visit was noted to have mild range BP. Patient also states that she wasn't feeling like her self. She had a ___ headache that is frontal in nature. She had spots in her vision prior to her appointment that resolved spontaneously. She denies ctx, VB, LOF. +FM. PNC: - ___ ___ by LMP - Labs A pos/Abs neg/Rub ___ NR/HBsAg neg/HIV neg/GBS pending - Screening: low risk Panorama - FFS: normal - GTT: deferred - U/S ___: 2887g, 62%, AC 87%; vertex, anterior placenta - Issues *) T1DM - followed by ___ - dx at age ___ - A1C 6.0 (___) - baseline 24hr urine 273 | ECHO normal (___) | EKG NSR ___ trimester) - mild NPDR *) s/p Infuenza A: dx ___, completed Tamiflu course *) gHTN - ruled in ___ (first mild range BP ___ in ED) <PAST MEDICAL HISTORY> OBHx: - G1: current GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: T1DM, heart murmur, migraines, anxiety PSH: hysteroscopy, trigger finger repair, knee surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> On admission: ___ 16: 35BP: 138/79 (94) ___ ___: 85 ___ 16: 37Temp.: 97.9°F ___ 16: 40BP: 140/74 (89) ___ ___: 78 ___ 16: 50BP: 140/74 (89) ___ ___: 77 ___ 17: 40BP: 125/77 (88) ___ ___: 77 Gen: A&O, comfortable Abd: soft, gravid, nontender Ext: no calf tenderness, +1 swelling SVE: deferred On discharge: Temp: 97.7 (Tm 97.7), BP: 118/77 (118-131/77-82), HR: 74 (74-81), RR: 20 (___), O2 sat: 98% (97-98), FHR: 150-160 (150-160) General: NAD Respiratory: No evidence of respiratory distress, LCTAB Abdomen: soft, non-tender Extremities: bilateral lower extremities, nontender and nonedematous <PERTINENT RESULTS> ___ 05: 20PM BLOOD WBC-8.9 RBC-3.75* Hgb-12.7 Hct-37.7 MCV-101* MCH-33.9* MCHC-33.7 RDW-13.1 RDWSD-48.1* Plt ___ ___ 05: 20PM BLOOD Neuts-67.7 ___ Monos-6.7 Eos-1.3 Baso-0.3 Im ___ AbsNeut-6.03 AbsLymp-2.12 AbsMono-0.60 AbsEos-0.12 AbsBaso-0.03 ___ 05: 20PM BLOOD UreaN-9 Creat-0.5 ___ 05: 20PM BLOOD ALT-8 AST-15 ___ 05: 20PM BLOOD UricAcd-3.5 <MEDICATIONS ON ADMISSION> PNV aspirin insulin <DISCHARGE MEDICATIONS> 1. Aspirin 81 mg PO DAILY 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> gestational hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the Antepartum service for close monitoring of your blood pressures and for testing to rule out pre-eclampsia. The 24hr urine test came back negative and reassuring; and your blood pressures have remained within a reassuring range. We do not feel that you have pre-eclampsia. You also experienced some contractions and light vaginal spotting after an exam. These symptoms have improved and we feel it is safe for you to go home. Please do not hesitate to call with any questions or concerns. Reasons to call your primary OBGYN provider ___: headache that does not go away with Tylenol, changes in your vision, new upper abdominal pain, new onset significant swelling of your extremities, painful regular contractions, vaginal bleeding, leaking fluid, or decreased fetal movement.
|
Ms. ___ is a ___ year old G1P0 with a history of T1DM who was admitted to the antepartum service on ___ for rule out preeclampsia. due to headache and elevated blood pressures. Her pregnancy-induced hypertension labs, urine protein:creatinine ratio, and 24-hour urine protein were all within normal limits. Her headache resolved overnight. On ___, she remained asymptomatic, without severe range blood pressures,, visual changes, chest pain, shortness of breath, or RUQ pain. She was given a diagnosis of gestational hypertension. Regarding her type 1 diabetes, patient was continued on her insulin pump. Of note, on ___, patient had noted some vaginal spotting with preterm contractions. On sterile speculum exam and sterile vaginal exam, her cervix was long/closed/posterior. She had some scant pinge tinge on the examination glove. NST was reactive. Given overall reassuring exam with no evidence of preterm labor or abruption, patient was encouraged toPO hydrate. She was Rh positive and thus no Rhogam was indicated. In the evening of ___, patient continued to have normal range BPs and no new symptoms. She was thus discharged to home with close follow up.
| 1,128
| 256
|
10361982-DS-20
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine <ATTENDING> ___ <CHIEF COMPLAINT> menorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G6 ___ LMP ___ with a history of abnormal uterine bleeding. She cycles approximately every 30 days and bleeding heavily for ___ weeks. During her heaviest bleeding period, she changes a pad/tampon every 15 minutes. She endorses dysmenorrhea, intra-menstrual bleeding and post-coital bleeding. She denies dyspareunia. She takes NSAIDs daily without total resolution of her uterine pain/dysmenorrhea. She has observed and underwent hormonal therapy in the form of OCPs and the Mirena IUD with no significant improvement in her bleeding and cramping symptoms. She notes that her uterine cramping can be ___ during the first 7 days of her menses. ___ u/s ==> uterus is anteverted and retroflexed and slightly enlarged, measuring 10.3 x 4.5 x 5.8 cm. No discrete mass is identified. The endometrium is homogenous and measures 6 mm. The ovaries are normal. There is no free fluid. On ___ she underwent an endometrial biopsy prior to her requested EUA, hysteroscopy, D&C and endometrial ablation. PATH==> secretory endometrium. Since that procedure, she has given the options for treatment more thought and now requests definitive therapy in the form of a total hysterectomy. Because of her age, she is concerned that the ablation could work for a few years and her menses would return. She does not want to spend anymore energy dealing with uterine cramping or AUB. <PAST MEDICAL HISTORY> Ob/Gyn hx: Menarche @ 12 -last pap ___ ==> normal hx of abnormal paps ==> ___ s/p laser therapy hx of genital warts heterosexual sexually active ==> s/p bilateral tubal ligation C/S x 3 Sab x 2 / hx of ectopic pregnancy (ruptured) MEDICAL HX: MENORRHAGIA ABNORMAL PAP SMEAR HYPOTHYROIDISM ADHD OPERATIVE HX: CESAREAN SECTION ___ CESAREAN SECTION ___ ADHESIOLYSIS ___ IUD PERFORATION OF UTERUS ___ ADHESIOLYSIS ___ CESAREAN SECTION ___ RUPTURED ECTOPIC PREGNANCY --> SALPINGECTOMY ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> N/A <MEDICATIONS ON ADMISSION> synthroid 50 mcg/day, venlafaxine ER 75 mg daily, Adderall 10mg twice daily <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO ONCE Duration: 1 Dose 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 [Colace] 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *1 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) ___ mg PO Q4H: PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Venlafaxine XR 75 mg PO DAILY 7. Adderall 10 mg twice daily <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 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 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service after undergoing total laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy for menorrhagia. 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. She developed some shortness of breath which was thought to be likely secondary to post-op pneumoperitoneum, as lungs were clear and vitals were stable. She was encouraged to utilize incentive spirometry, and her symptoms improved. Her diet was advanced, and she began transitioning to PO tylenol, ibuprofen, and oxycodone, though still required IV dilaudid for breakthrough pain. 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.
| 1,325
| 226
|
10361982-DS-21
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine <ATTENDING> ___ <CHIEF COMPLAINT> heavy vaginal bleeding after hysterectomy <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 6, para 3, with a history of abnormal bleeding that failed medical management and on ___, she underwent an exam under anesthesia, extensive lysis of adhesions, total laparoscopic hysterectomy with bilateral salpingectomies and cystoscopy. She was seen by me on ___ for her two-week postoperative check. At that time, her main complaint was abdominal bloatedness secondary to gas. We discussed dietary modification. At that time, she also had vaginal spotting to light bleeding and precautions were reviewed. The patient noted that she was in her usual state of health until yesterday morning when she started bleeding like a heavy period, passing "munchin" sized clots. She did not call yesterday because she was entertaining her family, although she did note that when she started bleeding more heavily, she did rest. The patient does have four small children at home and she was negotiating whether she could make it through the ___ events; however, she started passing more clots and presents today. Her preoperative hematocrit was 40.1. Today's hematocrit is 38.1. Patient denies any symptoms related to acute blood loss anemia. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 12. Last Pap was ___ and was normal. She does have a history of abnormal Paps. ___, she had laser therapy, history of genital warts. She is heterosexual, sexually active with her present husband. She has had three cesarean deliveries, two spontaneous losses, history of a ruptured ectopic pregnancy. Of note, in reference to her history of abnormal Paps, on ___ pathology showed secretory endometrium, adenomyosis, adenoma 1.0 cm, unremarkable cervix, bilateral fallopian tubes with paratubal cyst. PAST MEDICAL HISTORY: Significant for menorrhagia, history of abnormal Pap, hypothyroidism, ADHD. SURGICAL HISTORY: ___ EUA, total laparoscopic hysterectomy, bilateral salpingectomies, extensive lysis of adhesion, cystoscopy. ___, cesarean delivery. ___ cesarean delivery. ___ adhesiolysis. ___ IUD, perforation of uterus, also had adhesiolysis. ___, cesarean section. ___, ruptured ectopic pregnancy, salpingectomy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 01: 10PM WBC-8.7 RBC-4.75 HGB-12.6 HCT-38.1 MCV-80* MCH-26.5 MCHC-33.1 RDW-13.3 RDWSD-38.2 ___ 01: 10PM PLT COUNT-434* <MEDICATIONS ON ADMISSION> Synthroid 50mcg QD Venlafaxine ER 75mg QD Adderall 10mg BID <DISCHARGE MEDICATIONS> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Heavy vaginal bleeding after total laparoscopic hysterectomy <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 vaginal bleeding. Your bleeding has stopped and your blood count has remained stable. The team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. * Please follow up with ___ at the appointment listed below. * 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 ___.
|
On ___, Ms. ___ was admitted to the gynecology service for observation of heavy vaginal bleeding after total laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy on ___. Please see the operative report for full details. Upon examination in clinic on ___, there was no evidence of cuff dehiscence. A small vessel was cauterized. She had a PUS which revealed a normal vaginal cuff without evidence of a hematoma. Her hct was found to be 38, stable from preoperative hct of 40. Over the course of her stay, her bleeding gradually decreased, noting small clots. She remained hemodynamically stable throughout her hospitalization. She continued to tolerate a regular diet and was voiding without issues. Her pain was controlled with PO oxycodone, ibuprofen, and tylenol. For her history of hypothyroidism she was continued on Levothyroxine. For her history of ADHD, she was continued on Venlafaxine and Adderall. By hospital day 2, her bleeding had improved significantly and 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.
| 1,030
| 264
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.