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10363989-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal pain, ovarian cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P___ transfer from ___ with acute onset pain in her vagina like she is being stabbed and lower back pain beginning earlier this morning. Reports the lower back pain was constant all day. The vaginal pain was initially intermittent for the first hour but is now constant. No vaginal discharge. She reports the back pain and vaginal pain are different pains. No h/o STIs. Reports had 3 cysts and tumor removed from right ovary ___ years ago done at ___ and reports similar pain during her presentation ___ years ago. IUD placed 2 months ago by ___ MD. ___ fever last night to 101 and feeling feverish all day. Denies chills, N/V, CP, SOB. Denies diarrhea. Reports two episodes of urinary incontinence last week but nothing recently and no fecal incontinence. Reports feeling of "orgasm" around bladder region when she urinates. Patient presented to ___ where she was found to have WBC 14.9 with no left shift, UA was unremarkable. She had a wet prep that showed a few clue cells. CT and U/S showed left hemorrhagic ovarian cyst 4.5 cm, normal flow to ovary. She was then given IV ceftriaxone, pain meds and transferred to ___ ED. Patient reports that she still has vaginal pain and left lower back pain ranging from ___. <PAST MEDICAL HISTORY> POB: - G1 SVD, uncomplicated, term, ___ - 1 x TAB @ 15wk PGYN: - reports remote history of abnormal Pap with no history of LEEP or cervical procedures - history of ovarian cysts and "ovarian tumor" s/p removal laparoscopically, reports history of endometriosis, reports benign path PMH: - endometriosis - cervical dysplasia - h/o cysts PSH: - laparoscopic ovarian cystectomies - knee surgery - denies anesthesia complications <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, mildly tender in the LLQ, +guarding, nondistended Ext: no TTP <PERTINENT RESULTS> LABS: ==== ___ 12: 55PM BLOOD WBC-9.0 RBC-3.91 Hgb-11.5 Hct-35.8 MCV-92 MCH-29.4 MCHC-32.1 RDW-13.2 RDWSD-44.4 Plt ___ ___ 01: 30PM BLOOD WBC-12.7* RBC-4.22 Hgb-12.4 Hct-38.4 MCV-91 MCH-29.4 MCHC-32.3 RDW-13.0 RDWSD-43.8 Plt ___ ___ 07: 00PM BLOOD WBC-13.0* RBC-3.98 Hgb-12.0 Hct-36.6 MCV-92 MCH-30.2 MCHC-32.8 RDW-13.2 RDWSD-44.9 Plt ___ ___ 03: 45AM BLOOD WBC-14.1* RBC-3.92 Hgb-11.4 Hct-36.4 MCV-93 MCH-29.1 MCHC-31.3* RDW-13.4 RDWSD-45.5 Plt ___ ___ 12: 55PM BLOOD Neuts-60.2 ___ Monos-8.2 Eos-2.8 Baso-0.3 Im ___ AbsNeut-5.40 AbsLymp-2.53 AbsMono-0.74 AbsEos-0.25 AbsBaso-0.03 ___ 01: 30PM BLOOD Neuts-70.3 ___ Monos-5.9 Eos-1.8 Baso-0.2 Im ___ AbsNeut-8.89* AbsLymp-2.72 AbsMono-0.75 AbsEos-0.23 AbsBaso-0.03 ___ 07: 00PM BLOOD Neuts-73.5* ___ Monos-4.9* Eos-1.8 Baso-0.2 Im ___ AbsNeut-9.54* AbsLymp-2.49 AbsMono-0.64 AbsEos-0.24 AbsBaso-0.03 ___ 03: 45AM BLOOD Neuts-62.9 ___ Monos-6.3 Eos-2.4 Baso-0.4 Im ___ AbsNeut-8.86* AbsLymp-3.88* AbsMono-0.89* AbsEos-0.34 AbsBaso-0.05 ___ 05: 26PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05: 26PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR ___ 05: 26PM URINE RBC-3* WBC-4 Bacteri-FEW Yeast-NONE Epi-6 ___ 05: 26PM URINE Mucous-RARE IMAGING: ======= ___ PUS FINDINGS: Both transabdominal and transvaginal ultrasound were performed. An anteverted uterus is present. That measures 7.6 x 4.0 x 5.3 cm measures 7 mm and is normal. An IUD is present within the uterine cavity in a satisfactory position. Right ovary is not seen either transabdominally or transvaginally. The left ovary shows a hemorrhagic cyst which currently measures 50 x 39 x 37 mm. This is essentially these same size that it was on the prior ultrasound of ___ where it measured 3.4 x 3.7 x 5.3. The ovarian tissue adjacent to this cyst does not appear to be edematous and does show arterial and venous flow. There is no free fluid within the cul-de-sac. IMPRESSION: No significant change since the prior ultrasound. Hemorrhagic left ovarian cyst. No ultrasonic evidence for torsion this is not totally excluded <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for observation of your pain likely due to hemorrhagic cyst. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. You were diagnosed with a urinary tract infection. Please complete the full course of antibiotics as instructed. You were also diagnosed with bacterial vaginosis. Please complete the full course of antibiotics as instructed. 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. * You may eat a regular diet. * You may walk up and down stairs. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service for observation of vaginal and LLQ pain due to L hemorrhagic cyst. Please see the operative report for full details. Upon admission, pt was made NPO/IVF with tylenol for pain control. She was also started on ciprofloxacin for UTI (per UCX results from ___ and flagyl for BV (from clue cells noted on wet prep at ___. She received serial abdominal exams overnight which were stable. On the morning of HD#2, she noted resolution of her pain and was advanced to a regular diet. A few hours later, she noted some nausea and recurrence of her LLQ pain, reproduced on physical exam. A CBC was drawn which showed stable leukocytosis at 12.7 from 13.0 without bandemia. Her hct was also stable from 36.6 to 38.4. She was given IV dilaudid and made NPO/IVF. Given unchanged pain and exam a few hours later, a pelvic exam was repeated that showed increased pain along the L adnexa. A repeat PUS was performed which showed an unchanged L hemorrhagic cyst, preserved flow to the L ovary, and no free fluid. Pt was advanced to a regular diet and transitioned to PO dilaudid. On HD#3, pt's pain improved slightly. Repeat CBC with diff showed resolution of leukocytosis at 9.0 and stable hct of 35.8. She c/o some dizziness with ambulation though had negative orthostatic vitals and though to be due to narcotic use. Pt tolerated a regular diet throughout the day and was able to ambulate and void without issues. By HD#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 and torsion precautions. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*14 Tablet Refills:*0 3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills:*0 4. Ibuprofen 600 mg PO Q6H RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0 5. MetroNIDAZOLE 500 mg PO/NG BID RX *metronidazole 500 mg 1 tablet(s) by mouth every 12 hours Disp #*12 Tablet Refills:*0 6. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left hemorrhagic cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10366433-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> amitriptyline <ATTENDING> ___ <CHIEF COMPLAINT> cesarean delivery <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean section <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm, incision c/d/i Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 11: 14AM BLOOD WBC-9.4 RBC-4.10 Hgb-12.8 Hct-37.3 MCV-91 MCH-31.2 MCHC-34.3 RDW-12.7 RDWSD-41.9 Plt ___ ___ 11: 14AM BLOOD Creat-0.7 ___ 11: 14AM BLOOD ALT-17 AST-27 ___ 11: 14AM BLOOD UricAcd-6.3* ___ 11: 14AM URINE Hours-RANDOM Creat-40 TotProt-11 Prot/Cr-0.3* <DISCHARGE INSTRUCTIONS> refer to ___ rounder instructions and Rn teaching booklet
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On ___, Ms. ___ underwent a primary low transverse cesarean section for fetal intolerance to labor. She was transferred to the postpartum floor in stable condition. Her pain was managed with oral tylenol, ibuprofen and oxycodone. For her history of type 1 diabetes, she was managed on lantus and sliding scale regimen based on carb ratio. Her fingersticks remained normal in the postpartum period. For her preeclampsia, labs were within normal limits. She had elevated blood pressures of 160s/80-90s on PPD#4 and was started on labetalol 200 BID. Her BP remained in the mild range 140-150s/60s on PPD#5. 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 postpartum outpatient follow-up scheduled. Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth BID PRN Disp #*30 Capsule Refills:*1 2. Ibuprofen 600 mg PO Q6H:PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hrs PRN Disp #*30 Tablet Refills:*1 3. Labetalol 200 mg PO BID RX *labetalol 100 mg 2 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs PRN Disp #*20 Tablet Refills:*0 5. Sarna Lotion 1 Appl TP BID:PRN Rash RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to area of irritation BID PRN Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Cesarean section, liveborn, female Type 1 DM mild pre eclampsia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10366982-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> gabapentin <ATTENDING> ___. <CHIEF COMPLAINT> postmenopausal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingo-oophorectomy, periaortic lymphnode dissection, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G8P7 with pink spotting for past year and recently had a 2 days prior developed abdominal pain with "gush of vaginal bleeding." Soaked through panty liner and underwear. At that time patient presented to the ED where she had a pelvic. Denies any further heavy bleeding but continues to have vaginal spotting. She has intermittent abdominal pain. Denies constipation, diarrhea, unintended weight loss, nausea, vomiting, bloating. She underwent a PUS, ___ which revealed. The uterus is retroverted and measures 8.5 x 4.5 x 6.8 cm. The endometrial cavity is markedly expanded by blood products and the endometrium is thickened with irregular thickening and nodular regions with internal vascularity. There is a 0.8 x 0.8 x 1.2 cm fundal fibroid as well as a 1.5 x 1.6 x 1.5 cm posterior myometrial fibroid. Large complex cystic lesion with thickened septations containing blood flow in the right and adnexa measuring 5.4 x 2.8 x 4.0 cm. The left ovary was not visualized. There is no pelvic free fluid. EMB was then performed ___ which revealed Endometrial adenocarcinoma, endometrioid type, GIGO grade 3 of 3. Ct Scan of torso was ordered and showed no evidence of metastatic disease in the abdomen or pelvis. Parametrial extension of the mass. CT Scan of torso was negative for malignancy. <PAST MEDICAL HISTORY> PMHx: - Atrial fibrillation- reports brief episode of afib in past, but has been in normal rhythm with no issues, takes only aspirin - Hypertension - Glaucoma - Osteoarthritis - Sciatica - Bulging disc - Bone spurs right foot - Diverticulosis PSHx: - Spine fusion - Lsc tubal ligation - Bilateral knee replacements GYN Hx: LMP age ___ x q30 x 5 days - Denies history of menorrhagia, fibroids, ovarian cysts - G8P7- SVD x7, SAB x1 - No HRT use - No h/o abnl pap smear <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Mother died of cancer age ___- unsure type - Father- multiple strokes- died age ___ - No siblings - Denies known history of breast, ovarian uterine, 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> ___ 05: 42PM BLOOD WBC-30.7*# RBC-4.98 Hgb-14.4 Hct-42.4 MCV-85 MCH-28.8 MCHC-33.9 RDW-13.5 Plt ___ ___ 06: 25AM BLOOD WBC-24.6* RBC-4.54 Hgb-13.4 Hct-38.4 MCV-85 MCH-29.6 MCHC-35.0 RDW-13.5 Plt ___ ___ 03: 50AM BLOOD WBC-14.4* RBC-3.92* Hgb-11.5* Hct-32.9* MCV-84 MCH-29.4 MCHC-35.0 RDW-13.7 Plt ___ ___ 09: 10AM BLOOD WBC-12.7* RBC-4.10* Hgb-12.5 Hct-34.6* MCV-84 MCH-30.5 MCHC-36.2* RDW-13.5 Plt ___ ___ 06: 20AM BLOOD WBC-11.4* RBC-4.06* Hgb-12.1 Hct-34.6* MCV-85 MCH-29.8 MCHC-34.9 RDW-13.8 Plt ___ ___ 06: 45AM BLOOD WBC-8.8 RBC-3.94* Hgb-11.5* Hct-33.5* MCV-85 MCH-29.2 MCHC-34.3 RDW-13.8 Plt ___ ___ 07: 40AM BLOOD WBC-9.7 RBC-4.43 Hgb-13.0 Hct-37.4 MCV-85 MCH-29.3 MCHC-34.6 RDW-14.0 Plt ___ ___ 06: 25AM BLOOD Neuts-88.8* Lymphs-5.2* Monos-5.8 Eos-0.1 Baso-0.1 ___ 03: 50AM BLOOD Neuts-83.3* Lymphs-11.3* Monos-4.9 Eos-0.2 Baso-0.2 ___ 05: 42PM BLOOD Glucose-169* UreaN-17 Creat-1.0 Na-138 K-3.8 Cl-103 HCO3-23 AnGap-16 ___ 06: 25AM BLOOD Glucose-178* UreaN-17 Creat-0.9 Na-139 K-4.4 Cl-101 HCO3-26 AnGap-16 ___ 03: 50AM BLOOD Glucose-134* UreaN-16 Creat-0.7 Na-141 K-4.0 Cl-106 HCO3-30 AnGap-9 ___ 09: 10AM BLOOD Glucose-105* UreaN-16 Creat-0.7 Na-138 K-4.2 Cl-98 HCO3-30 AnGap-14 ___ 06: 20AM BLOOD Glucose-118* UreaN-14 Creat-0.7 Na-140 K-4.1 Cl-101 HCO3-27 AnGap-16 ___ 06: 45AM BLOOD Glucose-115* UreaN-10 Creat-0.7 Na-140 K-4.3 Cl-102 HCO3-29 AnGap-13 ___ 07: 40AM BLOOD Glucose-112* UreaN-10 Creat-0.6 Na-140 K-3.9 Cl-100 HCO3-31 AnGap-13 ___ 01: 36AM URINE Color-Yellow Appear-Clear Sp ___ ___ 01: 36AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 01: 36AM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 Urine Cx - negative C. Diff antigen - negative <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Aspirin 325 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 3. Aspirin 325 mg PO DAILY 4. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 5. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain do not drive or drink alcohol while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 6. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> grade 3 endometrial adenocarcinoma **final pathology pending** <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. * If you have staples, they will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
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Ms. ___ was admitted to the gynecologic oncology service after undergoing total abdominal hysterectomy, bilateral salpingo-oophorectomy, periaortic lymphnode dissection, cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with dilaudid PCA and tylenol. Her diet was slowly advanced however on post-operative day 3 she began having nausea and emesis. A KUB performed that day revealed loops of small and lg bowel mildly dilated consistent with an ileus so she was backed down to NPO. Once her nausea improved and she was passing flatus her diet was again slowly advanced without difficulty and she was transitioned to oxycodone and tylenol for pain. On post-operative day #4, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She was evaluated by physical therapy during her admission who found that she did not have any acute needs and would be safe for discharge to home. On post-operative day 2 she spontaneously desatted to 88% on RA and was tachycardic both of which improved with O2 administrastion. Her lung exam was concerning for possible pneumonia or pulmonary edema so a chest x-ray was obtained with findings consistent with atalectasis. Incentive spirometry was encouraged and she was weaned to room air the following day with no further issues. By post-operative day 6, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10367545-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> left facial numbness, undesired pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilation and evacuation <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> ___ 01: 00AM URINE HOURS-RANDOM ___ 01: 00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS* cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 01: 00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01: 00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 09: 30PM GLUCOSE-92 UREA N-<3* CREAT-0.4 SODIUM-137 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-20* ANION GAP-17 ___ 09: 30PM estGFR-Using this ___ 09: 30PM CK(CPK)-40 ___ 09: 30PM cTropnT-<0.01 ___ 09: 30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 09: 30PM WBC-10.5* RBC-3.60* HGB-11.9 HCT-32.0* MCV-89 MCH-33.1* MCHC-37.2* RDW-12.5 RDWSD-40.6 ___ 09: 30PM NEUTS-81.2* LYMPHS-15.0* MONOS-3.4* EOS-0.0* BASOS-0.1 IM ___ AbsNeut-8.52* AbsLymp-1.57 AbsMono-0.36 AbsEos-0.00* AbsBaso-0.01 ___ 09: 30PM PLT COUNT-160 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p D&E <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the gynecology service prior to your procedure due to the need for evaluation of left facial numbness. 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. * No strenuous activity until your post-op appointment. * You may eat a regular diet. * You may walk up and down stairs. * Nothing in the vagina for 2 weeks To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___ Ms. ___ was admitted from the Emergency Department for left facial numbness prior to her scheduled Dilation and Evacuation procedure. She was seen by neurology who recommended outpatient follow-up. She continued to improve clinically during her admission and her vital signs were stable. On ___ she underwent dilation and evacuation as scheduled. Please see operative report for complete details. Her post-operative course was uncomplicated and she was discharged to home from the post-anesthesia care unit in stable condition with follow-up scheduled.
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10367896-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim / Penicillins / dicloxacillin <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> HPI: Ms. ___ is a ___ yo G___ at 28 weeks 4 days transferred from ___ with contractions and cervical change concerning for preterm labor. The patient reports initially feeling contractions regularly this morning, and increased in intensity. When she presented to ___, her initial SVE was fingertip; she later was found to be 1 cm dilated. UA there was negative. Hct 31.9 and WBC 10.7. LFTs and Cr within normal. First dose of betamethasone administered at 1300. She received vancomycin for GBS prophylaxis, a 6gm bolus of magnesium for fetal neuroprotection followed by a 1g/hr infusion. On evaluation here, she reports ongoing contractions that are painful and regular every few minutes. Denies LOF, vaginal bleeding. Active fetal movement for both twins. She desires a repeat cesarean delivery regardless of twin gestational age and presentation. ROS: Denies fevers/chills or recent illness. Denies HA, vision changes, RUQ/epigastric pain. Denies chest pain, shortness or breath, palpitations. Denies abd pain. Denies recent falls or abd trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. <PAST MEDICAL HISTORY> PNC: - ___ ___ by 6 wk Ultrasound - Labs Rh pos/Abs neg/Rub ___ /Treponema NR/HBsAg neg/Hep C neg/HIV neg/GBS pending - Varicella immune by history - Declined Tdap and flu - Screening: declined - FFS: wnl for both twins - GLT 98 - U/S ___: A 982 g (51%ile), B 1083g (60%ile), 9% discordance - Issues *) Di-di twins: - Spontaneous pregnancy - Historically twin A is presenting (female) and twin B is non-presenting (boy) - Normal concordant growths - Normal serum preeclampsia labs; no records of baseline urine protein assessment - On ASA prophylaxis daily OBHx: ___ - Primary cesarean delivery for breech, term - 5 vaginal deliveries (all VBAC), uncomplicated, at term - Largest baby 8lb 10 oz - No NICU stays for infants; no complications GynHx: - denies abnormal Pap or cervical procedures - denies fibroids, endometriosis, ovarian cysts - denies STIs, including HSV PMH: - Obesity, BMI 38 - Documented history of asthma, patient denies - No history of DM, HTN PSH: - WTE - Cesarean delivery x 1 for breech Meds: - PNV - Iron supplement - ASA 81 mg daily - Miralax PRN - Tums PRN All: - Sulfa drugs: anaphylaxis - Patient was initially concerned about an allergy to penicillins, as she took a pencillin around the same time as her sulfa allergy. However, the patient likely received cefazolin prior to this allergy at the time of her cesarean delivery without incident. No other known consumption of penicillins SocHx: Lives at home with her husband and six children. She is a ___ for them and does not work outside the home. She rarely drank alcohol before becoming pregnant as she was "breastfeeding my whole life," and denies any alcohol, substance, or tobacco use. <PHYSICAL EXAM> On day of admission: ___ 15: 40BP: 131/69 (84) ___ ___: 98 ___ 15: 45BP: 133/72 (85) ___ ___: 101 Afebrile Gen: A&O, comfortable CV: RRR, no m/r/g Pulm: nl work of breathing Abd: soft, gravid, nontender Ext: no calf tenderness SVE: 1-2/25/-3/firm/post, membranes palpably intact SSE: deferred On day of discharge: 24 HR Data (last updated ___ @ 310) Temp: 98.6 (Tm 98.7), BP: 103/62 (103-120/60-68), HR: 86 (86-93), RR: 18 (___), O2 sat: 97% (97-99), O2 delivery: ra, FHR: a140-150 b140-150 General: NAD Respiratory: No evidence of respiratory distress Abdomen: soft, non-tender Extremities: bilateral lower extremities, nontender and nonedematous <PERTINENT RESULTS> ___ 04: 15PM BLOOD WBC-14.4* RBC-3.64* Hgb-10.2* Hct-31.4* MCV-86 MCH-28.0 MCHC-32.5 RDW-14.2 RDWSD-44.0 Plt ___ ___ 04: 15PM BLOOD Neuts-90.1* Lymphs-7.3* Monos-1.7* Eos-0.1* Baso-0.1 Im ___ AbsNeut-12.92* AbsLymp-1.05* AbsMono-0.25 AbsEos-0.01* AbsBaso-0.02 ___ 04: 15PM BLOOD Plt ___ ___ 04: 00PM URINE Color-Straw Appear-Clear Sp ___ ___ 04: 00PM URINE Blood-MOD* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR* ___ 04: 00PM URINE RBC-<1 WBC-1 Bacteri-FEW* Yeast-NONE Epi-3 ___ 04: 00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 03: 30PM OTHER BODY FLUID CT-NEG NG-NEG ___ 3: 30 pm SWAB Source: Vaginal. **FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: Indeterminate. Altered vaginal flora that does not meet criteria for diagnosis of bacterial vaginosis. If signs and/or symptoms persist, repeat testing may be warranted. Interpretive criteria have only been established for pre-menopausal women and post-menopausal women on hormone replacement therapy. As low estrogen levels alter vaginal flora, results should be interpreted with caution in post-menopausal women. Refer to the on line laboratory manual. Note, neither lactobacilli nor Gardnerella/Bacteroides/Mobiluncus morphotypes observed. The absence of these morphotypes likely represents normal flora in post-menopausal women. ___ 3: 30 pm ANORECTAL/VAGINAL Source: Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: Negative for Group B beta streptococci. ___ 4: 19 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. <MEDICATIONS ON ADMISSION> - PNV - Iron supplement - ASA 81 mg daily - Miralax PRN - Tums PRN <DISCHARGE MEDICATIONS> - PNV - Iron supplement - ASA 81 mg daily - Miralax PRN - Tums PRN <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Preterm contractions <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital for preterm contractions. You were given betamethasone, a steroid which helps the baby's lungs among other benefits. Your contractions and cervical exam remained stable and you are now safe to be discharged home. Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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The patient was admitted for evaluation of preterm labor. At ___, her cervical exam remained stable at 1-___/-3/firm/post over multiple exams (last on ___. There was no evidence of chorioamnionitis or abruption. She received Magnesium for fetal neuroprotection and cefazolin for GBS prophylaxis. This was discontinued once her cervical exam was deemed to be stable and there was no ongoing concern for progression of preterm labor. She received a course of betmethasone, and received indomethacin tocolysis until betamethasone complete on ___. On ___, she remained in stable condition and was discharged home. Fetal testing was reassuring.
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10367896-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim / Penicillins / dicloxacillin <ATTENDING> ___. <CHIEF COMPLAINT> Preterm labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat low transverse cesarean delivery <PHYSICAL EXAM> On discharge: ___ 2216 Temp: 97.4 PO BP: 108/74 HR: 84 RR: 18 O2 sat: 98% O2 delivery: RA Pain Score: ___ ___ 1827 Temp: 98.1 PO BP: 129/74 HR: 71 RR: 16 O2 sat: 97% Gen: appears comfortable, NAD Abd: ND, NT; FF at U Inc: well approximated without oozing or erythema, dried blood on steris, no new blood or active bleeding Ext: no calf tenderness, 1+ BLE edema <PERTINENT RESULTS> ___ 06: 02PM BLOOD WBC-12.5* RBC-3.91 Hgb-10.5* Hct-32.4* MCV-83 MCH-26.9 MCHC-32.4 RDW-14.6 RDWSD-43.8 Plt ___ <MEDICATIONS ON ADMISSION> - PNV - Iron supplement - ASA 81 mg daily - Miralax PRN - Tums PRN <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 34 week gestation, twins, malpresentation, history of cesarean delivery, preterm labor <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 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.
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Ms. ___ is a ___ yo G9P6 who was transferred from ___ ___ on ___ with contractions concerning for preterm labor. Her contractions became progressively stronger and more painful and she was noted to dilate her cervix to 5cm. An ultrasound revealed breech presentation of the presenting twin. As a result, the decision was made to proceed to the operating room for cesarean delivery. Patient thus underwent an uncomplicated repeat low transverse cesarean section. Please see operative note for details. Her post operative course was uncomplicated. By post operative day 4, patient reached all her post operative milestones. She was thus discharged to home in stable condition.
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10369667-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> elevated blood pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery <HISTORY OF PRESENT ILLNESS> ___ yo G1P1 at 32+0 WGA who was found to have elevated BP in the office today and was sent to OB triage for PIH eval. Denies h/a, vision changes, RUQ pain or epigastric pain. Denies vaginal bleeding, contractions and leaking of fluid vaginally. +FM. <PAST MEDICAL HISTORY> OB Hx: G1P0 Gyn Hx: h/o benign breast cyst removed R breast PMH: ulcerative colitis Surg Hx: breast bx <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: Gen: NAD VS: T 98.1 BP 156/96, 163/89, ___, 162/97, 160/87 HR 59 RR 18 CV: rrr w/o m/g/r Chest: CTA B Abd: gravid, soft, nontender Back: - CVAT Ext: -edema B SVE: deferred SSE: deferred EFM: 140 ___, mod variability, +accels, no decels, reactive. Toco: no contractions TAUS today: breech, + fetal cardiac motion seen, BPP ___ (-2 breatheing), AFI 13.2 On discharge: VS wnl, afebrile General: NAD, comfortable CV: RRR, no m/r/g Lungs: CTAB Abdomen: soft, NTND, fundus firm below umbilicus Ext: no edema, no tenderness <PERTINENT RESULTS> ___ 12: 09PM BLOOD WBC-11.9* RBC-4.32 Hgb-13.1 Hct-38.4 MCV-89 MCH-30.3 MCHC-34.2 RDW-13.9 Plt ___ ___ 12: 09PM BLOOD Creat-0.6 ___ 12: 09PM BLOOD ALT-19 AST-29 TotBili-0.3 ___ 12: 09PM BLOOD UricAcd-5.2 ___ 12: 09PM BLOOD BILE ACIDS- CHOLIC ACID 5.3 H 3.1 OR LESS umol/L DEOXYCHOLIC ACID 1.5 7.3 OR LESS umol/L CHENODEOXYCHOLIC ACID 3.6 9.9 OR LESS umol/L TOTAL BILE ACIDS 10.4 4.5-19.2 umol/L ___ 12: 05PM URINE Color-Straw Appear-Clear Sp ___ ___ 12: 05PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 04: 30PM URINE pH-6 Hours-24 Volume-2950 Creat-40 TotProt-9 Prot/Cr-0.2 ___ 12: 05PM URINE Hours-RANDOM Creat-35 TotProt-10 Prot/Cr-0.3* ___ 04: 30PM URINE 24Creat-1180 24Prot-266 Pathology: ___ placenta, 277 g, less than ___ percentile for gestational age of 32 weeks (A-F): - Unremarkable fetal membranes and cord. - Chorionic villi with increased syncytial knots. <MEDICATIONS ON ADMISSION> PNV, mercaptopurine 50mg qd, Canasa 1000mg PR, Lialda 1.2gm delayed release 3 tabs daily. <DISCHARGE MEDICATIONS> 1. Breast pump Hospital grade breast pump for maternal infant separation 2. NIFEdipine CR 30 mg PO DAILY RX *nifedipine [Procardia XL] 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *1 3. Mesalamine (Rectal) 1000 mg PR QHS UC 4. Mercaptopurine 50 mg PO DAILY UC 5. ___ *NF* (mesalamine) 3 TAB ORAL DAILY UC 6. Lia___ *NF* (mesalamine) 3 TAB ORAL DAILY UC 7. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*45 Tablet Refills: *0 8. 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: *0 9. Codeine Sulfate ___ mg PO Q6H: PRN pain RX *codeine sulfate 30 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean delivery gestational hypertension liveborn infant <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see printed instructions
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This patient is a ___, G1, P0, who presented for evaluation with elevated blood pressure on ___, and was admitted to the ___ service for monitoring and a 24-hour urine collection. A 24-hour urine protein was negative in terms of preeclampsia evaluation; however, she was diagnosed with PPROM on the morning of ___. There was no bleeding to suggest abruption. Latency antibiotics were started. In the early morning of ___, the patient developed painful contractions q.5 minutes and was examined and found to be 4 cm dilated, in spontaneous labor. Fetal status was reassuring; however, breech presentation was known. The decision was made to proceed with a primary cesarean section for delivery secondary to breech presentation and spontaneous labor. Primary cesarean section was performed on ___. Please see operative report for full details. Her post-partum course was complicated by elevated blood pressures to 180s/80-90s. She was started on nifedipine 30 mg CR on ___. Her blood pressures improved. Her post-partum course was otherwise uncomplicated, and she was discharged home on ___ with outpatient follow up scheduled.
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10370220-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> PEC eval <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G7P2 at 36w3d presents from the office. On ___ she had a blood pressure that was 140/80 (rpt 138/88) and it prompted a PEC eval including a 24 hr urine. On ___ the 24 hr urine returned 449 mg and her blood pressures were 130-140/80s. She denies any HA, visual changes or RUQ pain. She reports active fetal movement and denies LOF or VB. No previous h/o PEC. Patient had 2 BP's at 140 , both first BP's on arrival to the clinic with repeat BP in the 130/80's. The positive 24 hour urine was accompanied by hematuria. ROS: + mild right flank pain : pain is constant and dull but with minutes of sharp severe pain that radiates to the groin and resolves spontaneously - dysuria, frank hematuria, chest pain, shortness of breath <PAST MEDICAL HISTORY> PNC: Dating: ___ ___ by first tri u/s labs: O+/anti-/HBSAg-/RPRNR/RI/HIV-/HCV-/GBS unknown (collected) screening: T21 risk 1: 188, 1: 414 after Sequential, normal FFS, declines amnio Issues: - previous TAB at ~18 wga for T18 POB: - SVD ___ uncomplicated 5#14oz - VAVD for NRFHT at 41 wks Apgars ___ 7#6. c/b meningitis postpartum - SAB x 2 - TAB x 2 PGYN: distant h/o GC and CT at age ___, treated negative in this pregnancy PMH: anemia PSH: TAB x 2, D&C for SAB x 1, open appy <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> (on admission) BP 111/70, 116/69, 129/69, 125/73 98.2, 100, 16 NAD Abd soft NT gravid FHT 140 / mod var / + accels / no decels toco: irritability, occasional ctx (on discharge) normotensive, stable vital signs Gen: NAD, AxO Abd: soft, gravid, NT Ext: calves nontender FHT: reactive NST Toco: no contractions <PERTINENT RESULTS> ___ 08: 24PM BLOOD WBC-12.0* RBC-3.59* Hgb-9.9* Hct-29.3* MCV-82 MCH-27.5 MCHC-33.7 RDW-14.4 Plt ___ ___ 08: 24PM BLOOD UreaN-12 Creat-0.6 ___ 08: 24PM BLOOD ALT-11 AST-18 ___ 08: 24PM BLOOD UricAcd-4.9 ___ 04: 38PM URINE Color-Yellow Appear-Clear Sp ___ ___ 08: 24PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04: 38PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG ___ 08: 24PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG ___ 04: 38PM URINE RBC-8* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 08: 24PM URINE RBC-14* WBC-2 Bacteri-FEW Yeast-NONE Epi-5 ___ 08: 24PM URINE CastHy-1* ___ 08: 24PM URINE Hours-RANDOM Creat-166 TotProt-148 Prot/Cr-0.9* ___ 8: 24 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ___ 10: 47 pm ANORECTAL/VAGINAL CULTURE Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP. Please contact the Microbiology Laboratory (___) immediately if sensitivities to clindamycin and erythromycin are required on this patient's isolate. ___ OB US: EFW 3236g (70%ile), ___ BPP with AFI 14.5, cephalic ___ RENAL ULTRASOUND: The right kidney measures 10.9 cm, and the left kidney measures 10.6 cm. There is mild hydronephrosis on the right. Minimal pelviectasis is present on the left. No renal stones or masses. Grossly normal color flow bilaterally. No free fluid. There is a single live intrauterine pregnancy with heart rate of 153 BPM. IMPRESSION: Fairly mild hydronephrosis of the right kidney; minimal pelviectasis on the left; these are findings which can be seen in pregnancy. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Acetaminophen 650 mg PO Q6H: PRN Pain 3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H: PRN pain not relieved by acetaminophen RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every six (6) hours Disp #*5 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Proteinuria Hematuria r/o pre-eclampsia <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for monitoring of your blood pressures because they were elevated in the office. Your blood pressures have been normal, and your labs do not support a diagnosis of pre-eclampsia. There is blood in your urine, but a renal ultrasound did not show any evidence of a kidney stone at this time. You should follow-up with ___ for a blood pressure check on ___. Call if you develop headache, vision changes, upper abdominal pain, difficulty breathing, fever/chills, contractions, leaking fluid, vaginal bleeding, decreased fetal movement, or any other concerning symtpoms. If you continue to have blood and protein in your urine after you deliver your baby, you may need to follow-up with a nephrologist (kidney doctor). The ___ clinic number at ___ is ___.
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On the evening of ___, Ms. ___ was admitted to the antepartum service from OB Triage for blood pressure monitoring and pre-eclampsia evaluation. *) PEC eval: Her serum pre-eclampsia labs were within normal limits, and a clean catch UA continued to show proteinuria with a protein:creatinine ratio of 0.9 ___s microscopic hematuria. During admission, she was completely normotensive (90s-120s/60-80s) without any symptoms of pre-eclampsia. Without any elevated BP's the diagnosis of preeclampsia is unlikely. An ultrasound showed that the fetus was well-grown in the 70th percentile, normal amniotic fluid index and ___ biophysical profile. *) Microscopic hematuria: A repeat straight cath urinanalysis continued to show microscopic hematuria. A urine culture was not definitively positive for urinary tract infection, with only ___ of lactobacillus. Given her right flank pain and hematuria, a renal ultrasound was obtained, which was negative for any evidence of obstruction or nephrolith. She was percocet for clinical nephrolithiasis and if she continues to have microscopic hematuria after delivery, she will follow-up with nephrology in the postpartum setting, as per discussion with the renal fellow. On the morning of ___, she was discharged with stable condition with close follow-up for BP and continued evaluation for preeclampsia.
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10370502-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Bilateral adnexal masses, fevers <MAJOR SURGICAL OR INVASIVE PROCEDURE> CT-guided drainage of bilateral tubo-ovarian abscesses <HISTORY OF PRESENT ILLNESS> ___ yo G0 transferred from ___ with bilateral adnexal masses and persistent fevers. Patient reports for approximately past two months has had fevers and abdominal pain. Reports high fevers at home starting beginning of ___. Initially no other symptoms other than fevers and body aches. Was evaluated by PCP and had "multiple blood tests" done. Reports continued to have almost daily fevers since that time. Has been taking ibuprofen amost daily for fevers. Reports started to develop diffuse lower abdominal pain associated with fevers several weeks prior. PCP ordered pelvic ultrasound which was done on ___ and revealed bilateral pelvic masses right 9.2x5.6x5cm and left sided 13.1x12x10.6cm. An MRI was performed on ___ and revealed a 10.3x8.7x7.8cm complex left adnexal mass, 4.5cm right adnexal mass. CT scan was done at ___ on ___ which showed bilateral adnexal masses with spetations and an air filled portion of right sided loculation adnexal masses measuring 15cm together. Patient transferred to ___ for further management given concern of air in mass and possible fistula with bowel. Patient reports decreased appetite for past two months, stools softer more frequent. Denies any nausea, vomiting, blood in stools. Reports periods normal. <PAST MEDICAL HISTORY> OB/GYN Hx: - G0 - LMP ___ - Reports periods q29-30days, x5days, reports cramping pain with periods - Denies any history of abnormal Pap - Denies any history of STI, pelvic infections - Denies any history of fibroids, ovarian cysts PMHx: - Denies - Denies HTN, asthma, clotting disorders PSHx: - Denies Medications: - ibuprofen PRN <ALLERGIES> - NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Denies any history of breast, colon, uterine or ovarian cancer - Denies any history of clotting disorders, HTN, asthma <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally, normal work of breathing Abd: soft, appropriately tender, nondistended, three lower abdominal drains without evidence of skin infection continuing to drain small amounts of yellow-colored material, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ CT-Interventional Procedure: Successful CT-guided placement of 2 ___ pigtail catheters into the right lower quadrant and left lower quadrant tubo-ovarian abscesses. Samples sent for microbiology evaluation. ___ Abscess culture: Mixed bacterial flora including pseudomonas aeruginosa (rare growth, pan-sensitive), bacteroides fragilis (moderate growth, + beta-lacatamase), prevotella (moderate growth, - beta-lactamase) ___ Blood culture: no growth ___ CT Pelvis: 1. Bilateral adnexal collections with pigtail catheters an appropriate position. 2. The left adnexal collection was aspirated to completion based on the images from the prior CT interventional procedure. However, in the intervening days, the collection has reaccumulated. 3. Possible fistula between the sigmoid colon in the left adnexal collection is identified. ___ Blood culture: no growth ___ CT-Interventional Procedure: 1. Successful CT guided exchange of left adnexal catheter. 2. Successful placement of additional right adnexal pigtail catheter as described above. 3. Limited preprocedure CT demonstrates enteric contrast within the left adnexal collection, confirming the presence of a fistula with the sigmoid colon. The left adnexal collection contains dense material, compatible with enteric contrast from the colonic fistula identified on the prior CT. ___: Duplex left upper extremity: Nonocclusive thrombus within the left basilic vein, surrounding the PICC ___: CT Abdomen/Pelvis: 1. 2 right-sided and 1 left-sided transabdominal drains within significantly smaller adnexal collections. 6 x 6.5 cm left adnexal collection, just inferior and anterior to the left pigtail drain and 4 x 4.1 cm right anterolateral collection anterolateral to the lower right-sided pelvic drain, in addition to a smaller 1.6 x 2 cm adjacent collection. These collections demonstrate T1 hyperintensity and T2 shading on the prior MRI, compatible with patient's known endometriomas. 2. Small right larger than left pleural effusions. <MEDICATIONS ON ADMISSION> ibuprofen prn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Ciprofloxacin HCl 750 mg PO/NG Q12H RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every 12 hours Disp #*20 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *1 4. Lorazepam ___ mg PO QHS: PRN insomnia Do not drive while using this medication. RX *lorazepam 1 mg 1 tablet by mouth at bedtime Disp #*5 Tablet Refills: *0 5. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills: *0 6. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain do not drive or drink alcohol, causes sedation RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ Diagnosis: bilateral tubo-ovarian abscesses left tubo-ovarian abscess with colonic fistula <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 bilateral adnexal masses, pain, and fever. You were found to have bilateral tubo-ovarian abscesses, one of which connected with your colon. Interventional radiology placed tubes into the abscesses to drain and these were later replaced with larger drains. You were given antibiotics which you will continue when you go home. You have recovered well after this procedure, and the team feels that you are safe to be discharged home close outpatient followup. 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 in 24 hrs. * No strenuous activity until cleared by your physician. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
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Ms. ___ was admitted to the gynecologic oncology service at the ___ after transfer from ___ on ___ for bilateral pelvic masses, fever, and pain. On hospital day #1, she underwent CT-guided drainage of bilateral collections with drainage of foul-smelling material and she was started on gentamycin and clindamycin for suspected tubo-ovarian abscesses bilaterally. On hospital day #3,she was transitioned to ceftriaxone and flagyl after consultation with Infectious Disease given gram stain and drain output concerning for feculent material. Infectious disease was consulted; the patient was started on IV ceftriaxone/flagyl then transitioned to meropenem. On hospital day #4, Ms. ___ had a fever to ___ and her antibiotics were then changed to meropenem. She underwent a repeat CT of her abdomen and pelvis which revealed re-accumulation of the abscesses bilaterally to their pre-drainage size as well as contrast extravasation from the sigmoid colon to the left tubo-ovarian abscess. Colorectal surgery was consulted and recommended repeat drain placement and conservative management. The patient then underwent CT-guided exchange of the previous 2 drains with larger drains and placement of a third drain by interventional radiology. Enteric contrast from her previous CT scan was aspirated from the left adnexal collection, confirming the presence of a colonic fistula. On hospital day #6, Ms. ___ received 2 units of packed red blood cells as well as vitamin K for a hematocrit of 20.6 and INR of 1.8. There was no evidence of bleeding and she had an appropriate rise in her hematocrit and improvement in her INR. On hospital day #9, Ms. ___ experienced numbness and tingling in her left upper extremity. Ultrasound revealed a non-occlusive basilic vein thrombosis around her PICC. The PICC was removed and she was continued on prophylactic lovenox. Repeat imaging on hospital day #10 showed interval improvement in drainage of bilateral adnexal collections without active drainage of enteric contrast into the collection. During her admission, Social Work was consulted for assessment and support in coping with this unexpected hospitalization and diagnosis. The patient was found to have adequate social support and coping mechanisms for self care and was given resources for further support as an outpatient. By hospital day #11, she was afebrile with stable vital signs, tolerating oral intake and ambulating independently. Her infectious disease doctors agreed with ___ to oral ciprofloxacin and flagyl and the gynecology oncology team, in conjunction with the colorectal surgery service, felt the patient was safe for discharge home with continued antibiotics and close outpatient followup. She was then discharged home in stable condition with home nursing services and close outpatient followup scheduled.
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10373619-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Plum / Peach / Apple / Pear / Nut Flavor / Mold/Yeast/Dust <ATTENDING> ___. <CHIEF COMPLAINT> Menorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy <HISTORY OF PRESENT ILLNESS> ___ yo G___ with a long-standing history of iron deficiency and anemia who was last seen in ___. She underwent a Mirena IUD placement in ___ but has continued to have symptomatic menorrhagia. Her last EMB in ___ was negative for malignancy. She also had a pelvic ultrasound in ___ which was notable for a slightly enlarged uterus and an IUD that appeared to be in a low position within the proximal aspect of the endometrial cavity. Since her last visit, ___ reports heavy cycles with intermenstrual bleeding. She has spotting on about 11 out of 20 days in between cycles. Her cycles last 7 days and she reports using 40 super absorbency tampons within that time. Reports slight abdominal cramping with periods. Denies CP/SOB/dizziness. Reports some fatigue. Last IV iron infusion was in ___. She notes that her fatigue has increased and she has affinity for ice chips again, wondering if her anemia has worsened. <PAST MEDICAL HISTORY> PAST OB/GYN HISTORY: DATE OF LAST PAP SMEAR: ___ PLACE: ___ RESULT: Negative Hx OF ABNORMAL PAP: Denies STDs: Denies *) ___ SVD 8#8 @ term, male *) ___ PTD 6# @ 34 wks, male *) ___ SVD 5#13 @ term, female *) ___ SVD Term female 6 # 4 oz, female 5# 10 oz *) SAB -->D&C *) TAB x 3 PAST MEDICAL HISTORY: *) Asthma *) GERD *) Obesity *) Depression *) Iron Deficiency Anemia PAST SURGICAL HISTORY: *) Left knee surgery x 3 (including total knee replacement) *) Right knee arthroscopy *) Laryngeal polyp removal *) History of stab wound to chest @ age ___, surgical repair lung *) D&C x 4 *) Tubal Ligation <SOCIAL HISTORY> ___ <FAMILY HISTORY> Breast cancer in maternal aunt dx in ___ Otherwise no other GYN cancers <PHYSICAL EXAM> ___ by Dr. ___: Vital Signs BP: 110/70. Weight: 255. BMI: 35.1. LMP: ___. GENERAL: NAD, appears well NEURO: A+O x 3 ABDOMEN: Soft, non-tender, non-distended, no masses appreciated, no guarding and no rebound SVE: Mirena IUD strings appreciated at cervical os. No CMT. Uterus anteverted, but size difficult to assess secondary to habitus. Uterus is non-tender. Adnexal without palpable masses and non-tender. Ext: Non-tender <PERTINENT RESULTS> None. <MEDICATIONS ON ADMISSION> FLUOXETINE - (Prescribed by Other Provider) - 40 mg Capsule - 1 Capsule(s) by mouth twice a day FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 sprays each nostril twice daily FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk with Device - 1 (One) puff orally twice a day IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 puffs inhaled four times a day LEVONORGESTREL [MIRENA] - 20 mcg/24 hour IUD - one once LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for insomnia/anxiety MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth daily TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *1* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 3. ipratropium-albuterol ___ mcg/Actuation Aerosol Sig: ___ Puffs Inhalation Q6H (every 6 hours) as needed for shortnes of breath: follow-up with PCP for more refills. Disp: *1 * Refills: *0* 4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 5. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: Do not exceed 4 g acetaminophen in one day. . Disp: *40 Tablet(s)* Refills: *0* 11. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). <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> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. **if no cervix p LSC hyst, nothing in vagina for 3 months * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the GYN service post-operatively. Please see operative note for full details. Post-operatively she was able to tolerate a regular diet, control her pain with oral pain medications, ambulate and void after removal of her foley catheter. She was discharged on post-operativ day 2 without complications with follow-up.
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10374489-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet / Vicodin <ATTENDING> ___. <CHIEF COMPLAINT> scheduled C-section <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary c-section <HISTORY OF PRESENT ILLNESS> The patient is a gravida 3, para 0 with a history of multiple sclerosis. The multiple sclerosis got worse during the pregnancy and she had a flare in the third trimester, with increased muscle weakness. Ultrasound also showed that the baby was a large baby, weighing over 4000 g, and therefore, in discussion with Maternal-Fetal Medicine and the patient, given the high chance the patient would have a C-section in any case because of decreased ability to push and the large size of the baby, a decision was made to do a primary cesarean section. PNC: -Labs: A pos/Ab neg/RI/RPRNR/HbSAg neg/GBS neg OB: G3P0, TAB x1, SAB x1. <PAST MEDICAL HISTORY> ___: -MS: onset since ___, with 5 relapses -Anxiety disorder: Precipitated her first MS relapse since ___ and was associated with stresses of a new job. Followed by cognitive neurology in the past at ___. - Lumbar back strain ___ PSH: -ear tubes placed when she was young (uncertain of age) for recurrent infections <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of MS, autoimmune diseases, or seizures. No history of other neurologic diseases. No familial history of stroke or clotting diseases. <PHYSICAL EXAM> Vitals: T: 96.5 P: 88-102 R: 16 BP: 122/60 SaO2: 100% RA General: Pleasant woman appears stated age lying in hospital bed in pre-op area prior to her c/s on L and D. Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT, gravid. Extremities: 2+ edema bilaterally, warm and well-perfused Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. <PERTINENT RESULTS> ___ 01: 16PM BLOOD WBC-9.1 RBC-3.95* Hgb-13.2 Hct-38.9 MCV-98 MCH-33.5* MCHC-34.1 RDW-13.0 Plt ___ ___ 01: 16PM BLOOD Creat-0.5 ___ 01: 16PM BLOOD ALT-28 AST-22 ___ 01: 16PM BLOOD UricAcd-7.8* <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. hospital grade breast pump Sig: One (1) as needed: multiple sclerosis,poor latch. Disp: *1 device* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain for 2 weeks. Disp: *40 Tablet(s)* Refills: *0* 3. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours for 2 weeks. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Multiple Sclerosis Macrosomia <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> call for increased pain, bleeding or fever
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Ms. ___ was admitted after undergoing scheduled primary LTCS. She was given stress dose of steroids for her hx of MS. ___ surgery was uncomplicated. Please see ___ note for complete details. Pt received routine postpartum care and was followed by the neurology consult team for her hx of MS. ___ consult also evaluated the pt due to gait disorder due to MS. ___ rest of ___ postpartum course was uncomplicated. She was discharged home on ___ in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and urinating without difficulty.
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10379678-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> presents from radiology for short cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ y/o G1 at ___ who presents to triage from radiology due to concern for short cervix. Upon review of film, 14mm-21mm noted today on TV U/S. Pt reports a 3 day H/O on/off again of scant vaginal spotting of light pink to brown. She denies dysuria, gross hematuria, or urinary urgency. She does however state that she has some occasional cramping but not consistent. No lof and pt reports fetal movement. <PAST MEDICAL HISTORY> PRENATAL COURSE *) Dating ___ ___ by sure LMP c/w 11wk U/S *) Labs: O pos/Ab /R-I/RPR-NR/HBsAg neg/HCV neg/HIV neg *) random glucose 76 *) FFS normal per pt ISSUES - smoker, few daily per pt (cut down from 1 ppd) - H/O marijuana use prior to pregnancy OBHx G1 GYNHx LMP ___ regular denies abn pap/STI's PMH benign SurgHx: knee <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: BP 105/59, HR 73, RR 18, T 97.7 po HEART: RRR S1S2 no murmurs LUNGS: CTA B ABD: gravid, soft, no rebound tenderness or guarding EXTREMITIES: no edema FHT: 130 by doppler TOCO: irritability noted, po hydration SSE: no blood noted in the vault or at the os, cervix appears long and closed and petechiae noted on the cervical surface GC/Chlamydia done Wet prep: negative <PERTINENT RESULTS> ___ WBC-10.1 RBC-3.51 Hgb-11.3 Hct-31.9 MCV-91 Plt-179 ___ Neuts-69.3 ___ Monos-6.1 Eos-1.0 Baso-0.4 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG URINE CULTURE (Final ___: NO GROWTH Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR NEISSERIA GONORRHOEAE, NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria Gonorrhoeae by PCR <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. progesterone micronized 100 mg Insert Sig: Two (2) Vaginal at bedtime. Disp: *60 inserts* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 22 weeks gestation short cervix <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> *continue modified bedrest and pelvic rest at home *stay well hydrated *please start vaginal progesterone as prescibed - please call Dr. ___ if you have any trouble filling this prescription *please keep your follow up appointments as scheduled
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___ y/o G1 admitted at 21w6d with short cervix. On arrival to triage, she had no further vaginal spotting. Her cervix appeared closed/long by speculum exam. She was afebrile and had no evidence of infection. Tocometer showed irritability. Given the history of spotting, cramping, and irritability, she was not a candidate for a cerclage until subclinical infection was ruled out. She was observed closely and was reassessed in the ATU on ___. Her cervical length was stable, measuring 21mm with no funneling. She was counseled regarding options and opted to start vaginal progesterone. She was discharged home in stable condition and will have close outpatient followup. . Given she was previable, she was monitored with spot checks only. She had a normal full fetal survey on the day of admission.
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10379678-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> short cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ G1 at ___ who was sent from the ATU for admission due to short cervix. Pt previously admitted at ___ gestation after incidental finding of short cervix. She was clinically stable and discharged home on bedrest and vaginal progesterone. Her cervical length has been followed and was stable at 21mm until today when it measured 11mm. MFM recommended admission for observation and betamethasone. Pt with no complaints. She denies any cramping, contractions, vaginal bleeding, or leaking of fluid. Denies fever/chills, dysuria. Active FM. <PAST MEDICAL HISTORY> PRENATAL COURSE *) Dating ___ ___ by sure LMP c/w 11wk U/S *) Labs: O+/Ab-,RI,RPRnr/HBsAg neg/HCV neg/HIV neg *) random glucose 76 *) FFS normal per pt ISSUES *) smoker, few daily (___) per pt (cut down from 1 ppd) *) H/O marijuana use prior to pregnancy *) short cervix: - 22wks - 24wks: CL 21mm - ___ 11mm OBHx G1 GYNHx LMP ___ regular denies abn pap, STI's, cervical procedures PMH benign SurgHx: - knee <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: BP 118/67, HR 83, RR 18, T 97.0 po HEART: RRR LUNGS: CTAB ABD: gravid, soft, nontender EXTREMITIES: no edema FHT: 130s, mod var, +accels, no decels TOCO: irritability SSE: deferred ATU today: vtx, MVP 5, EFW 905g(41%) <PERTINENT RESULTS> ___ WBC-12.9 RBC-3.91 Hgb-12.5 Hct-36.6 MCV-94 Plt-179 ___ Neuts-83.4 ___ Monos-3.5 Eos-0.9 Baso-0.4 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG <MEDICATIONS ON ADMISSION> PNV vaginal progesterone <DISCHARGE MEDICATIONS> 1. progesterone micronized 100 mg Capsule Sig: Two (2) Capsule PO qhs (). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - pregnancy - short cervix <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted with a short cervix; it was stable/improved on repeat ultrasound. Please call your doctor for the following: - fever, chills - frequent and/or painful contractions - leaking of fluid - vaginal bleeding - decreased fetal movement
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Ms. ___ is a ___ year old G1 admitted at ___ with short cervix. Given the significant shortening in her cervical length since her prior ultrasound, the decision was made to admit Ms. ___ for observation. She was afebrile and without any evidence of labor, infection, or abruption. She was not feeling any cramping or contractions. She had occasional runs of irritability on toco. Fetal testing was reassuring. She was given a course of betamethasone for fetal lung maturity (complete ___ and the NICU was consulted. . A repeat cervical length measured on ___ was stable, however, the fetal fibronectin was positive. She remained hospitalized until 28 weeks. At that time, her cervical length was repeated and found to be improved to 2.4 centimeters without funneling. Additionally her fetal fibronectin was negative at this time. . She was clinically stable and thus discharged home on ___ with precautions.
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10379678-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> leakage of fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> SVD <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 33w4d GA reported leakage of fluid since ___ this evening. Her underwear and pants were soaking wet, c/w spontaneous rupture of membranes. On ROS: Denies fever, chills, other abdominal pain, abdominal trauma, dysuria, other abnl vaginal discharge except LOF, vaginal bleeding, DFM. <PAST MEDICAL HISTORY> PRENATAL COURSE *) Dating ___ ___ by sure LMP c/w 11wk U/S *) Labs: O+/Ab-,RI,RPRnr/HBsAg neg/HCV neg/HIV neg/GBS unknown *) random glucose 76, 2 hr GTT neg (89, 102, 75) *) FFS normal except for short cervix ISSUES *) former smoker (quit in ___, smoked a few daily (___) per pt for the early part of pregnancy, cut down from 1 ppd) *) H/O marijuana use prior to pregnancy *) short cervix: - 22wks - 24wks: CL 21mm -> ___ CL 11mm ->admitted to ___ service from ___ to ___, BMZc -> ___ mm - most recent ___ BPP ___, AFI 17.4 OBHx G1 GYNHx LMP ___ regular denies hx of abnl pap, STI's, cervical procedures PMH: denied SurgHx: - knee sx <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Admission: Vital signs T98.6 BP 108/65 HR 90 RR 18 General: NAD Cardiac: RRR Pulm: CTA Abdomen: soft, no fundal tenderness Ext: no erythema, no edema SSE: Normal external anatomy, cervical external os visually dilated to 0.5 to 1 cm, no blood in vaginal vault. +Nitrazine, neg ferns, +pooling SVE: deferred NST: 125/mod var/pos accel/neg decel TOCO: irritability BPP: VTX, ___, AFI: 10.7 <PERTINENT RESULTS> ___ 08: 12PM BLOOD WBC-10.1 RBC-3.68* Hgb-11.8* Hct-33.4* MCV-91 MCH-32.2* MCHC-35.4* RDW-13.2 Plt ___ ___ 08: 57PM BLOOD ___ PTT-22.8 ___ ___ 08: 12PM BLOOD Plt ___ ___ 08: 57PM BLOOD ___ <MEDICATIONS ON ADMISSION> PNV, vaginal progesterone <DISCHARGE MEDICATIONS> 1. Breast Pump Sig: One (1) Hospital grade breast pump as needed as needed for feeding: Due to infant in NICU - thus SEPARATION. Disp: *1 pump* Refills: *0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *30 Capsule(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 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> Reviewed Nothing in vagina x 6 wks
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Ms. ___ was admitted with pre-term premature rupture of membranes. She was begun on latency antibiotics of Ampicillin to Amoxicillin and Erythromycin. She had no signs of infection or labor, and fetal assessment was reassuring. On hospital day 3 she reached 34 weeks gestational age and the decision was made to proceed with induction of labor for PPROM. She received cytotec and pitocin for her induction, which lasted 24 hours. On ___ she underwent spontaneous vaginal delivery of a live male, weight 1970g, Apgars 8 and 9. NICU was present for delivery due to prematurity. Additional cytotec and uterine massage were given for brief bleeding which slowed to normal limits, and she remained hemodynamically stable. Her postpartum course was uncomplicated, and she was discharged on postpartum day 2 in good condition: voiding, ambulating, tolerating a regular diet, and with her pain well-controlled on oral medications. SHe has follow up scheduled with Dr. ___.
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10380060-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim DS / Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> redness/pain at umbilical port site <MAJOR SURGICAL OR INVASIVE PROCEDURE> Aspiration and drainage of fluid from umbilical incision <HISTORY OF PRESENT ILLNESS> ___ POD24 from laparoscopic BSO, dx hysteroscopy, and D&C presenting with redness and pain at her umbilical incision site since ___. Reports feeling much improved last week, until ___ when she developed a 'stabbing' pain beginning at her umbilical port site. Over the past several days, redness around the area and her pain have been worsening. Pain at the incision site is worse with coughing but not straining for BM. Denies fevers but has had chills. No N/V, tolerating a regular diet. + flatus. <PAST MEDICAL HISTORY> GYN Hx: Denies h/o abnl Paps or STIs OB Hx: G2P0 PMH: invasive ductal carcinoma s/p chemo and on tamoxifen, hypothyroidism, contact dermatitis PSH: left lumpectomy Meds: synthroids, multivitamin, calcium, fish oil, cytomel, tamoxifen All: penicillin and bactrim (rash) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: hx breast cancer. <PHYSICAL EXAM> On day of discharge: afebrile, vital signs stable Gen: NAD Pulm: normal work of breathing Abd: soft, nondistended. erythema improved and within boundaries marked on admission. serosang drainage from wound. mild area of induration inferior to umbilicus, no fluctuance. <PERTINENT RESULTS> ___ 01: 24PM BLOOD WBC-12.0*# RBC-4.21 Hgb-11.7* Hct-33.9* MCV-81* MCH-27.7 MCHC-34.3 RDW-13.2 Plt ___ ___ 01: 24PM BLOOD Neuts-71.0* ___ Monos-5.4 Eos-0.4 Baso-0.2 ___ 06: 25AM BLOOD WBC-8.8 RBC-4.22 Hgb-11.7* Hct-34.4* MCV-82 MCH-27.8 MCHC-34.0 RDW-13.5 Plt ___ ___ 06: 25AM BLOOD Neuts-56.6 ___ Monos-8.3 Eos-1.5 Baso-0.5 ___ 01: 24PM BLOOD Glucose-87 UreaN-14 Creat-0.8 Na-136 K-4.1 Cl-100 HCO3-28 AnGap-12 . ___ 5: 52 pm ABSCESS Source: umbilical seroma. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH. CLINDAMYCIN MIC >= 1.0 MCG/ML. PROTEUS MIRABILIS. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (___) GROUP | PROTEUS MIRABILIS | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=1 S MEROPENEM------------- <=0.25 S PENICILLIN G----------<=0.06 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 0.25 S ANAEROBIC CULTURE (Final ___: Mixed bacteria are present, which may include anaerobes and/or facultative anaerobes. Bacterial growth was screened for the presence of B.fragilis, C.perfringenes, and C.septicum. None of these species was found. <MEDICATIONS ON ADMISSION> tamoxifen 20mg po daily levothyroxine 125 mcg po daily liothyronin 5mcg po daily <DISCHARGE MEDICATIONS> 1. Clindamycin 450 mg PO Q8H RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 8 hours Disp #*75 Capsule Refills: *0 2. Levothyroxine Sodium 125 mcg PO DAILY 3. Tamoxifen Citrate 20 mg PO DAILY 4. Liothyronine Sodium 5 mcg PO DAILY 5. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain do not drink alcohol or drive while taking RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Cellulitis, seroma <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 management of your skin infection. 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. * Complete the full course of antibiotics 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 shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after presenting with an umbilical incision cellulitis and seroma following a laparoscopic bilateral salpingo-oophrectomy, hysteroscopy and dilation and curettage on ___. . On the day of admission, she underwent incision and drainage of her wound seroma and was started on IV clindamycin. She was seen by wound care and underwent daily dressing changes. On hospital day 2,she was transitioned to oral clindamycin. The cellulitis continued to improve and she remained afebrile throughout her hospitalization. . By hospital day 3, her pain was controlled with oral medications and her cellulitis was improving. She was then discharged home in stable condition with home nursing to assist with daily dressing changes, and with outpatient follow-up scheduled.
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| 177
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10382945-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Captopril <ATTENDING> ___ ___ Complaint: Presents for scheduled operative procedure <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic recurrent incisional hernia repair with mesh, and extensive lysis of adhesions. Laparoscopic converted to open supracervical hysterectomy. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G2P2 followed for menorrhagia and fibroid uterus resulting in anemia. Management options were reviewed with her and she elected for laparoscopic hysterectomy. Risks and benefits of the procedure were reviewed. The procedure was planned in conjunction with a laparoscopic ventral incisional hernia repair with Dr. ___. <PAST MEDICAL HISTORY> PMHx: HTN, DM type 2, Anemia, Obesity, Arthritis PSHx: Tonsillectomy, C sections x 2, Gastric bypass, Hernia repair. <SOCIAL HISTORY> ___ ___ History: Non-contributory <PHYSICAL EXAM> PE: VS General: NAD Cardiac: RRR Pulm: CTA Abdomen: soft, obese Ext: NE, NT <PERTINENT RESULTS> ___ 07: 40AM BLOOD WBC-6.3 RBC-3.63* Hgb-8.4* Hct-27.7* MCV-77* MCH-23.1* MCHC-30.2* RDW-20.7* Plt ___ ___ 07: 10AM BLOOD WBC-8.2 RBC-3.42* Hgb-8.2* Hct-26.1* MCV-76* MCH-24.0* MCHC-31.5 RDW-21.2* Plt ___ ___ 06: 55AM BLOOD WBC-11.1* RBC-3.22* Hgb-7.7* Hct-25.0* MCV-78* MCH-24.0* MCHC-31.0 RDW-21.8* Plt ___ ___ 09: 15PM BLOOD WBC-13.5* RBC-3.37* Hgb-7.9* Hct-25.9* MCV-77* MCH-23.5* MCHC-30.6* RDW-21.3* Plt ___ ___ 03: 25PM BLOOD WBC-12.9* RBC-3.22* Hgb-7.7* Hct-24.8* MCV-77* MCH-24.0* MCHC-31.2 RDW-21.4* Plt ___ ___ 06: 37AM BLOOD WBC-11.9* RBC-3.15* Hgb-7.5* Hct-24.1* MCV-77* MCH-23.7* MCHC-30.9* RDW-21.6* Plt ___ ___ 07: 05AM BLOOD WBC-12.0* RBC-3.52* Hgb-8.3* Hct-27.5* MCV-78* MCH-23.7* MCHC-30.3* RDW-21.4* Plt ___ ___ 12: 38AM BLOOD WBC-13.7* RBC-4.02* Hgb-9.5* Hct-30.2* MCV-75* MCH-23.8* MCHC-31.6 RDW-20.9* Plt ___ ___ 07: 10AM BLOOD Neuts-72.2* ___ Monos-4.4 Eos-2.7 Baso-0.3 ___ 09: 15PM BLOOD Neuts-76.3* ___ Monos-4.0 Eos-1.4 Baso-0.2 ___ 07: 40AM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-137 K-3.7 Cl-102 HCO3-28 AnGap-11 ___ 07: 10AM BLOOD Glucose-87 UreaN-7 Creat-0.5 Na-139 K-3.5 Cl-102 HCO3-30 AnGap-11 ___ 06: 55AM BLOOD Glucose-91 UreaN-7 Creat-0.5 Na-139 K-3.1* Cl-102 HCO3-30 AnGap-10 ___ 06: 37AM BLOOD Glucose-89 UreaN-6 Creat-0.5 Na-138 K-3.1* Cl-101 HCO3-34* AnGap-6* ___ 07: 40AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.1 ___ 07: 10AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0 ___ 06: 55AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0 ___ 06: 37AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.0 ___ 10: 53PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR ___ 10: 53PM URINE RBC-1 WBC-10* Bacteri-NONE Yeast-NONE Epi-14 ___ 10: 53 pm URINE Site: CLEAN CATCH Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> Pravastatin 40mg', Levoxyl 150mcg daily', Atenolol 50mg daily', Metformin 850mg', PO Iron, Triamterene-HCTZ 37.5-25', Ezetimibe 10', Vit D ___ qweek, Epipen PRN anaphylaxis <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. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Dilaudid 2 mg Tablet Sig: ___ Tablets PO q3-4 hrs as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 6. acetaminophen 500 mg Capsule Sig: ___ Capsules PO every six (6) hours as needed for pain. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroids & menorrhagia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months *no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication
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Ms. ___ underwent the ___ described procedures. The laparoscopic hysterectomy was converted to an open procedure due to bleeding and poor visualization. Please see operative notes for details. On post-operative day 1 her Foley was dc'ed and she voided spontaneously. On POD#2, she had a fever to 101. Her physical exam did not demonstrate localizing signs. Her UA was unremarkable and WBC count 11. She was monitored carefully and did not have further fever and the one episode was attributed to atelectasis. Ms. ___ experienced slow return to bowel function. She did not pass flatus until POD#4, although she never became nauseous. This was managed by round the clock tylenol in order to decrease her narcotic requirement and a bowel regimen. She had return of bowel function on POD#5 and her diet was advanced. Her T2DM, hypertension, and hypothyroidism were managed with home medications. The remainder of her post-operative course was uneventful and she was discharged home on POD#6 ambulating, voiding, tolerating PO, and pain controlled with po meds.
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10382999-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Aspirin / Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> elevated blood pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo s/p SVD 5 days ago with elevated BP's at that time who had a visiting nurse today and an elevated BP noted. Patient with persistently elevated bp 160-170/90's after first dose of 10mg IV labetalol and 200mg PO labetalol. Given an additional 10mg IV labetalol. BP improved to 145/75 after second dose of IV labetalol. <PAST MEDICAL HISTORY> OBHx: SVD ___ with PIH labs that showed only gestational thrombocytopenia GYNHx: denies PMH: G6PD PSH: denies <PHYSICAL EXAM> Admission: VS: T 98.2 HR 78 BP 163/93, 160/98, 176/99, Gen: A&O, comfortable PULM: normal work of breathing Abd: soft, nontender Ext: no calf tenderness . Discharge: Gen: NAD Abd: soft, nontender <PERTINENT RESULTS> ___ 01: 05PM BLOOD WBC-7.2 RBC-2.98* Hgb-8.6* Hct-27.3* MCV-92 MCH-28.9 MCHC-31.5* RDW-11.7 RDWSD-39.2 Plt ___ ___ 01: 05PM BLOOD Creat-0.5 ___ 01: 05PM BLOOD ALT-25 AST-25 ___ 01: 05PM BLOOD UricAcd-5.9* ___ 01: 57PM URINE Hours-RANDOM Creat-89 TotProt-61 Prot/Cr-0.7* <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN HA or pain 2. Docusate Sodium 100 mg PO BID: PRN Constipation 3. Labetalol 200 mg PO BID Rx sent electronically, increased to 300 mg BID 4. Prochlorperazine 10 mg PO Q6H: PRN headache <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Post partum pre-eclampsia, severe by blood pressures <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for concern for post partum pre-eclampsia. Initially your blood pressures were high and you were given a medication called magnesium. You were started on a blood pressure medication called Labetalol and you will be discharged home on this medication. Please take as prescribed. Your blood pressures have improved and it is safe for you to go home today, with close follow up.
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Ms. ___ was readmitted for severe pre-eclampsia with severe range blood pressures. She received 10mg of IV labetalol twice initially. She received magnesium for 12 hours and was started on labetalol 200mg BID. Her blood pressures were well controlled and she was discharged with labetalol 200mg BID and outpatient follow up.
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10382999-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Aspirin / Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> Elevated blood pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> Magnesium, monitoring <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ yo pp day 8 from uncomplicated SVD who presents today with elevated BP's. She is s/p Mag after admission on ___ for same issue. She was discharged from hospital yesterday on PO labetalol 300 BID. She continues to have BPs in the 160s/100s today, as seen by visiting nurse. Patient also endorses severe headache that she has had for the past 3 days without palliation. Took Compazine this morning, but it did not seem to help. She also endorses some epigastric pain. Denies any chest pain, shortness of breath, vision changes, nausea, vomiting. No urinary or bowel issues. <PAST MEDICAL HISTORY> OBHx: SVD ___ with PIH labs that showed only gestational thrombocytopenia GYNHx: denies PMH: G6PD PSH: denies <PHYSICAL EXAM> Admission: VS: T 98.6 HR 62 BP ___ RR 18 O2Sat 100% Gen: A&O, comfortable, supine in bed CV: RRR PULM: normal work of breathing Abd: soft, nontender, +BS Pelvic: deferred Neuro: CN II-XII grossly in tact, no weakness or sensory deficits Ext: no calf tenderness . Discharge: Gen: NAD CV: RRR Abd: soft, nontender <PERTINENT RESULTS> ___ 02: 15PM BLOOD WBC-7.1 RBC-3.29* Hgb-9.2* Hct-30.4* MCV-92 MCH-28.0 MCHC-30.3* RDW-11.7 RDWSD-39.5 Plt ___ ___ 02: 17PM BLOOD ___ PTT-25.1 ___ ___ 02: 17PM BLOOD ___ ___ 02: 17PM BLOOD Creat-0.5 ___ 02: 17PM BLOOD ALT-30 AST-26 ___ 02: 17PM BLOOD UricAcd-5.0 <MEDICATIONS ON ADMISSION> pnv, labetalol 300mg BID, Compazine q6 prn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN Pain 2. Bisacodyl ___AILY: PRN Constipation 3. Docusate Sodium 100 mg PO BID: PRN Constipation 4. Milk of Magnesia 30 ml PO HS: PRN Constipation 5. NIFEdipine CR 30 mg PO DAILY RX *nifedipine 30 mg one tablet(s) by mouth q am Disp #*30 Tablet Refills: *3 6. Simethicone 80 mg PO QID: PRN Dyspepsia <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Elevated blood pressure <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Rest and relax. Take a short walk at least 4 times per day. Call if severe headache, visual change.
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Ms ___ is a ___ G1P1 8 days s/p spontaneous vaginal delivery now for her second readmission for postpartum preeclampsia. She was discharged on ___ with labetalol 300mg BID after her first readmission. While in triage, patient was given 20mg IV labetalol and 1mg dilaudid for headache. Her pressures dropped down to 140s-16-s/90s-100s. She also received 20mg Nifedipine and pressures dropped to 110s-130s/70-90s. PIH labs were normal. . Patient's symptoms improved after some rest and IV fluids and was admitted to postpartum to monitor blood pressures and establish blood pressure medication regimen. Nifedipine CR 30mg daily was started on ___ and the patient's blood pressures remained in the normotensive to mild range without symptoms. Patient was discharged on ___ with nifedipine CR 30mg daily and outpatient follow up.
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10383358-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> none <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P1001 at 32+3 weeks gestation with ___ ___. She presents to triage from the office after fingerstick of 234. Reports that over the past two days her fingersticks were: fastings 94, 90; post breakfast 199, 214; post lunch 120, 144; post dinner 108, 112; and states that usual BS FBS <100, breakfast high 234, lunch 112, and dinner 120. Pt reports being sent home from work last week due to hypoglycemia ___ 61) and symptomatic. <PAST MEDICAL HISTORY> PREANTAL COURSE (1)Dating ___ ___ by 11 wk u/s (2)Labs: O+/Ab-,RPRnr,RI,HBsAg-/GLT 202 (3)U/S: (___) FFS nl, ant placenta, no previa, left adnexal cyst (___) EFW 1484, 60%, placenta anterior, vtx ISSUES: *)GDM: GLT 202; pt monitors ___ intermittently -noncompliant with ___ PAST OBSTETRIC HISTORY G1 primary C/S at 39 wks secondary to presumed macrosomia, female, 7#12lbs. GDMA1 G2 current PAST MEDICAL HISTORY - unicornuate uterus - infertility PAST MEDICAL HISTORY benign PAST SURGICAL HISTORY denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother and maternal GM with T2DM no h/o thyroid problems or HTN in family <PHYSICAL EXAM> GENERAL: NAD VITALS: T 98.9 po, BP 117/78, HR 99, RR 18 HEART: RRR S1S2 no m/g/r LUNGS: CTA B ABDOMEN: gravid, soft, nontender, no CVAT EXTREMITIES: - edema B EFM: 155 ___, pos accels, no decels, Av, reactive TA U/S: BPP ___, AFI 15cm, vtx, placenta anterior, no previa, fetal cardiac motion seen. TOCO: no contractions noted SVE: deferred <PERTINENT RESULTS> ___ WBC-7.3 RBC-4.50 Hgb-12.1 Hct-36.1 MCV-80 Plt-237 ___ Glu-131 BUN-8 Cre-0.5 Na-135 K-3.9 Cl-105 HCO3-22 ___ Calcium-9.0 Phos-3.3 Mg-1.7 ___ %HbA1c-6.4 TSH-1.6 ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose->1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-1 pH-6.0 Leuks-NEG <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. One Touch Ultra 2 Kit Sig: One (1) Miscellaneous four times a day: Use as directed. Disp: *1 * Refills: *0* 2. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp: *100 * Refills: *2* 3. One Touch Ultra Test Strip Sig: One (1) In ___ four times a day. Disp: *100 * Refills: *2* 4. Humalog KwikPen 100 unit/mL Insulin Pen Sig: One (1) pen Subcutaneous As directed: 9u with breakfast, 3u with dinner. Disp: *1 pen* Refills: *2* 5. syringe needle for Humalog KwikPen Sig: One (1) twice a day. Disp: *60 needles* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 32+4 weeks gestation gestational diabetes <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor with any leaking of fluid, vaginal bleeding, regular or painful contractions or decreased fetal movement. Continue checking fingersticks as instructed.
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___ y/o G2P1 with GDM admitted at 32+3 wks gestation for glycemic control. . Mrs ___ had a fingerstick of 122 on arrival to triage. She had no complaints. Fetal testing was reassuring with a reactive NST. ___ was consulted and recommended admission and starting humalog with meals. Prior to transfer to the antepartum floor, she complained of lightheadedness and her fingerstick was 58. She was given juice and a sandwich with good result. . Her fingersticks were not optimal but improved, ranging from 83-157. Nutrition was consulted. Her hemoglobin A1C was 6.4%. Her insulin was titrated to achieve tighter control and upon discharge her regimen was humalog 9 units with breakfast and 3 units with dinner. She was counseled extensively about the risks associated with poorly controlled diabetes in pregnancy. She was given a new glucometer and all necessary supplies. She should have close outpatient follow up.
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10384595-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> headache and lower abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ year old ___ s/p 8 week TAB/D+C on ___ who was seen in the ED for headache and lower abd pain. Regarding headache- patient has known intraranial AVM and was seen by neurosurgery and felt to be reassuring. Regarding lower abdominal pain, started today and is ___ and only present when she coughs. Given pain a pelvic ultrasound was performed in the ED which revealed possible retained products of conception so GYN was consulted. She reports minimal bleeding. Her D+C was on ___ in ___. <PAST MEDICAL HISTORY> POBH: - G4P3 - G1: LTCS, full term, arrest - G2: VBAC, premature labor, 4# - G3: rLTCS, full term PGYN: Denies hx STIs, abnormal Pap tests. PMH: - Recently diagnosed intracranial right frontal AVM, followed by neurology at ___ PSURGH: - D+C - C-section x2 Meds: keppra for seizure ppx, amoxicillin x1 wk since D+C All: NKDA <SOCIAL HISTORY> SH: husband present. Denies T/E/D. Denies hx abuse (asked when husband out of room) <PHYSICAL EXAM> PE upon admission 98.1 70 116/60 16 100% RA Gen: NAD CV: RRR Pulm: CTAB Abd: soft, mild suprapubic tenderness, no rebound or guarding Ext: nontender Back: no CVA tenderness Upon discharge VSS, AF Gen: NAD, A&O x 3 CV: RRR, S1 S2 Pulm: CTAB, no r/w/c Abd: soft, NT ND, no r/g/d Back: no CVA tenderness Ext: no c/c/e <PERTINENT RESULTS> ___ 06: 15PM URINE HOURS-RANDOM ___ 06: 15PM URINE HOURS-RANDOM ___ 06: 15PM URINE UCG-POSITIVE ___ 06: 15PM URINE GR HOLD-HOLD ___ 06: 15PM LACTATE-0.8 ___ 06: 15PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 06: 15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG ___ 06: 15PM URINE RBC-41* WBC-115* BACTERIA-FEW YEAST-NONE EPI-21 ___ 06: 15PM URINE MUCOUS-FEW ___ 04: 15PM GLUCOSE-81 UREA N-8 CREAT-0.6 SODIUM-139 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 ___ 04: 15PM estGFR-Using this ___ 04: 15PM HCG-855 ___ 04: 15PM WBC-5.4 RBC-4.03* HGB-12.3 HCT-36.8 MCV-91 MCH-30.5 MCHC-33.4 RDW-12.1 ___ 04: 15PM PLT COUNT-257 ___ 04: 15PM ___ PTT-37.5* ___ Final Report HISTORY: History of recent abortion on ___ now with suprapubic tenderness here to evaluate for retained products of conception. COMPARISON: No prior studies available. TECHNIQUE: Transabdominal and transvaginal ultrasound examinations of the pelvis were performed, the latter for better delineation of uterine /ovarian anatomy. Color and spectral Doppler analysis of the bilateral ovaries was also performed. FINDINGS: The uterus is enlarged, measuring 7.8 x 5.2 x 5.0 cm. The endometrium is thickened and heterogeneous at the fundus, measuring up to 14 mm in thickness. On Doppler analysis, there is abnormal vascularity in the endometrium with demonstrable flow on spectral Doppler. No dominant feeding or draining vessel is identified. Both ovaries are normal in size and appearance. There are demonstrable arterial and venous waveforms in the bilateral ovaries on Doppler evaluation. Trace free fluid is noted around the right adnexa. IMPRESSION: 1. Vascularized retained products of conception. 2. Normal-sized ovaries with symmetrical blood flow bilaterally. 3. Trace free fluid around the right adnexa is likely physiologic. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ <MEDICATIONS ON ADMISSION> Meds: keppra for seizure ppx, amoxicillin x1 wk since D+C <DISCHARGE MEDICATIONS> 1. LeVETiracetam 1000 mg PO BID 2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 Days RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> possible retained products of conception, 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 Gynecology service at ___ ___ with evidence of retained products of conception and urinary tract infection. You are stable for discharge and close followup. It is extremely important that you follow-up as scheduled, and follow the instructions below General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * Nothing in the vagina (no tampons, no douching, no sex) until followup. * You may eat a regular diet To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service from the emergency room for observation for retained products of conception after a termination. Please refer to the H&P for full details. The patient remained hemodynamically stable, with scant bleeding on her pad. Her uterine cramps were controlled with ibuprofen and acetaminophen. Her transvaginal ultrasound confirmed retained products of conception. The patient was thoroughly counselled on all of her options including expectant management, misoprostol or dilation and suction curretage. The patient opted for expectant management, which is reasonable as she is currently hemodynamically stable. The patient will f/u in 1 week with a TVUS to assess the amount of retained products. If there is still a significant amount present, we will re-evaluate her situation and possibly proceed with a D&C at that time. Otherwise, at the time of discharge, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10384894-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> spotting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 27w3d with rescue Shirodkar cerclage in place, here with pink spotting with wiping x1 associated with low back cramping, now resolved. Since she has been in triage, she has had no additional spotting. She is comfortable. Denies cramping/ctx, LOF. +FM. No fevers, other abdominal pain, N/V. Regular BM, last was yesterday. Denies constipation. No burning with urination or increased urinary frequency. No recent intercourse, nothing in vagina recently. Of note, was late registrant to care at 20 weeks. Was subsequently found to have short, dilated cervix at 21 weeks, for which a rescue Shirodkar cerclage was placed. Immediately after cerclage placement, the cervix was checked and found to be closed. <PAST MEDICAL HISTORY> PNC: - ___ ___ - Labs O+/Ab neg/Rub I/Var I/RPR nr/HBsAg neg/HIV neg/GBS neg (___) - LR NIPT - nl FFS with EIF - GLT 135 -> nl GTT - U/S: *) ___: 1016g, 51%; vtx, posterior placenta, CL 3.2cm with 1.9cm beyond cerclage - Issues: *) Short cervix s/p rescue Shirodkar cerclage on ___ at 21 weeks, was 1 cm dilated, 50% effaced; u/s on ___ demonstated CL 3.2cm, 1.9cm in length past cerclage *) HSV: +outbreak during pregnancy, cont acyclovir. *) chlamydia: treated ___, neg TOC on ___ *) ADD: stable on concerta OBHx: - G1 GynHx: - denies abnormal Pap, fibroids, Gyn surgery - h/o CT and GC PMH: HSV, h/o CT and GC PSH: cerclage <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) 97.9 99/62 81 16 Gen: A&O, comfortable Abd: soft, gravid, nontender Ext: no calf tenderness SSE: no herpetic lesions on vulva, no vaginal lesions, copious thick white discharge, cx appears long and closed, no blood in vault, cerclage stitch seen at 12 o'clock SVE: FT, long, mid without tension on cerclage Toco irritability FHT 140/moderate varability/+accels/-decels, reactive NST <PERTINENT RESULTS> ___ URINE Color-Yellow Appear-Hazy Sp ___ ___ URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4 pH-6.0 Leuks-LG ___ URINE RBC-6 WBC-43 Bacteri-FEW Yeast-NONE Epi-14 ___ OTHER BODY FLUID FetalFN-NEGATIVE URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA.>100,000 ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis NEISSERIA GONORRHOEAE, NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. MethylPHENIDATE (Ritalin) 12.5 mg PO BID 2. Prenatal Vitamins 1 TAB PO DAILY 3. Acyclovir 400 mg PO Q8H RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 27w5d short cervix vaginal bleeding <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for observation after an episode of vaginal spotting and preterm contractions. You had no further bleeding while you were here and there was no evidence of preterm labor. Fetal testing was reassuring. You received a course of betamethasone (steroids) for fetal lung maturity in case of a preterm delivery. Please avoid strenuous exercise and maintain pelvic rest (nothing in the vagina) at home
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___ G1 at with short cervix and rescue cerclage in place, admitted at 27w3d for observation after an episode of spotting. On admission, she was afebrile and without any evidence of infection. She had no further bleeding, but was felt to make a small change in her cervix to a fingertip/long (from closed). She appeared comfortable and had only irritability so she was not tocolyzed. She was admitted for observation. She received a course of betamethasone for fetal lung maturity (complete ___ and the NICU was consulted. She remained comfortable without any bleeding. Her cervix appeared visually closed on speculum exam prior to discharge. She was discharged home in stable condition and will have close outpatient follow up. Of note, she was started on acyclovir for HSV prophylaxis and she will continue this.
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10386865-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> elevated blood pressure, decreased fetal movement <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P0 at ___ WGA presents to triage from the office with bp 130/90 and less than usual fetal movements. Pt is being followed by cMFM for ___. On ___ BPP ___ (-2 for nonreactive NST), elevated BP, and IUGR <5% but inadequate fetal growth since ___ WGA. Patient denies CTX and VB. Patient denies HA/CP/N/V/vision changes/RUQ or epigastric pain. <PAST MEDICAL HISTORY> PNC: -___ of ___ by LMP ___ -Labs: A-/Ab-/RPRNR/RI/HepBSAg-/HIV-/GBS +, normal GLT -ERA low risk -FFS: normal FFS Recent US: ___: 1542g, <5% (160g wt gain in two week interval) OBHx -TAB ___ GYNHx -No h/o of abnormal Pap - No STD Hx PMHx: -anxiety -asthma -Opoiod abuse (Percocet) PSHx: - L inguinal hernia repair <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) BP 128/74, P 69, RR 18 NAD, lying comfortable in bed Soft, NT, gravid EFM: 140s, moderate variability, + accels, no decels TOCO: irritability BEDSIDE US: BPP ___, MVP 4cm Doppler: + EDF <PERTINENT RESULTS> ___ WBC-14.3 RBC-3.95 Hgb-13.3 Hct-37.6 MCV-95 Plt-216 ___ Creat-0.5 ALT-8 UricAcd-4.4 ___ URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2 pH-6.5 Leuks-LG ___ URINE RBC-9 WBC-14 Bacteri-MANY Yeast-NONE Epi-46 ___ URINE Hours-RANDOM Creat-158 TotProt-24 Prot/Cr-0.2 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG <MEDICATIONS ON ADMISSION> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 35w6d gestational hypertension <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital with elevated blood pressures and intrauterine growth restriction. Your blood pressures improved and you had no evidence of preeclampsia. In regards to the growth restriction, your fetal testing was otherwise reassuring. You will need to continue to have close testing (three times/week) and you should call your doctor immediately if there's any concern about your baby's movement.
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___ y/o G2P0 with IUGR admitted at 35w4d for preeclampsia evaluation. She had normal preeclampsia labs and a negative 24 hour urine collection. Her blood pressures improved significantly and were mostly in the normal range during this admission. . In regards to the IUGR, she underwent close fetal surveillance and had reassuring testing. Her BPPs were always ___ and she had normal fluid. Doppler studies revealed an elevated s/d ratio but no absent or reversed EDF. She was discharged home and will continue to have close outpatient followup. She has testing arranged in the ___ on ___. . Ms ___ was started on Keflex due to a suspected UTI. Unfortunately, a urine culture was not obtained prior to antibiotics due to the 24 hour urine collection. Of note, her urine toxicology screen was negative.
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10386880-DS-16
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<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> primary classical cesarean section <HISTORY OF PRESENT ILLNESS> ___ G2P0 at 23+5 weeks gestation who presents as a transfer from ___ with leaking of fluid since midnight. Denies any vaginal bleeding or contractions. Reports active fetal movement. States she was sleeping at the time of rupture, clear fluid. Denies fevers/chills, or any abnormal vaginal discharged. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ by LMP c/w ___ trimester U/S *)Labs: O+/Ab-,RPRnr,RI,HbsAg-,GC/CT-,HIV- *)Screening: FFS nl ISSUES: - rescue cerclage at 21wks after short cervix diagnosed on FFS 0BSTETRIC HISTORY TAB x 1 (8wks) no issues GYNECOLOGIC HISTORY denies STIs, abnormal paps, or fibroids PAST MEDICAL HISTORY hx EColi UTI during this pregnancy, neg TOC PAST SURGICAL HISTORY TAB x 1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) GENERAL: NAD VITALS: T 98.8, HR 111/58, HR 77 HEART: RRR ABDOMEN: soft, gravid, nontender EXTREMITIES: nontender bilaterally SSE: +pooling (grossly ruptured), no blood, cerclage in place cervix appears closed; Genprobe/BV/MRSA swabs collected SVE: deferred FHT: 160s, mod var, +accels, occ variable decels to 120 with SRTBL U/S: breech, EFW 569g, BPP ___ (-2 fluid) <PERTINENT RESULTS> ___ WBC-7.7 RBC-3.73 Hgb-10.4 Hct-32.0 MCV-86 Plt-236 ___ WBC-7.5 RBC-3.25 Hgb-9.2 Hct-27.7 MCV-85 Plt-262 ___ WBC-12.7 RBC-3.72 Hgb-10.5 Hct-32.5 MCV-87 Plt-267 ___ ___ PTT-27.4 ___ ___ ___ PTT-29.4 ___ ___ GLT-91 ___ 04: 46AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG SMEAR FOR BACTERIAL VAGINOSIS (Final ___: POSITIVE: GRAM STAIN CONSISTENT WITH BACTERIAL VAGINOSIS Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___ for Chlamydia trachomatis by PCR NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION(Final ___: NEG for N Gonorrhoeae by PCR URINE CULTURE (Final ___: NO GROWTH URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> colace prenatal vitamins <DISCHARGE MEDICATIONS> 1. breast pump Sig: One (1) unit PRN as needed for Breast Pumping: hospital grade, preterm infant in NICU. Disp: *1 unit* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for Pain: Do not drive while taking this medication. Disp: *40 Tablet(s)* Refills: *0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *90 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm premature rupture of membranes, delivered preterm delivery breech presentation, delivered <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> nothing in vagina, no tub bathing, no operating motor vehicle for 2 weeks. no heavy lifting for 6 weeks.
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___ G2P0 transferred from ___ with PPROM. . Ms ___ was admitted for expectant management. She was afebrile and without any evidence of infection or abruption. Fetal testing was overall reassuring. Ultrasound revealed a breech fetus with BPP ___ (-2 for fluid). She was not contracting and her cervix appeared closed on speculum exam. Her cerclage was left in place. She was counseled extensively regarding the implications of extreme prematurity. Ms ___ was transferred to the antepartum floor where she remained quite stable until 28 weeks gestation. She remained afebrile and without any contractions. She underwent close fetal monitoring with twice daily NSTs, twice weekly biophysical profiles, and growth scans every two weeks. The NICU was consulted. She received a course of betamethasone at 24 weeks (complete on ___. Fetal testing was reassuring, however, she had persistent anhydramnios. The fetal bladder and stomach were always visualized. Social services met with her to provide support during this lengthy admission. . At 28+0 weeks gestation, she went into active labor. Her cerclage was removed and she was 3cm/100%/0. Ultrasound confirmed breech. She underwent an uncomplicated primary classical cesarean section on ___. Liveborn male delivered from breech with apgars of 2 and 8. NICU staff was present for delivery and transferred her neonate immediately for prematurity. . Ms ___ remained afebrile and had no postoperative complications. She was discharged home on POD#4.
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10388043-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Keflex <ATTENDING> ___. <CHIEF COMPLAINT> 1. Enlarging pelvic mass. 2. Ovarian masses. 3. Recurrent metastatic breast cancer. <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Exploratory Laparotomy, Modified radical Hysterectomy, Bilateral Salpingo-Oophorectomy, Cystoscopy 2. ___ single lumen chest power Port-a-cath placement via the left internal jugular vein <HISTORY OF PRESENT ILLNESS> ___ woman with a history of a right-sided invasive lobular carcinoma diagnosed in ___. She underwent right breast partial mastectomy and sentinel lymph node biopsy on ___. Sentinel nodes were positive as well as the surgical margins. She had a reexcision with a right axillary dissection on ___. Her final stage was stage IIA, pT1 pN1. She was treated with dose-dense AC and weekly Taxol accompanied by Avastin, which she continued for a total of one year, completing in ___. She went on to take tamoxifen following that. She was also treated with adjuvant radiation therapy. She was followed closely by her medical oncologist in ___. She relocated to the ___ area to be closer to family and recently been diagnosed with recurrence that is metastatic. As part of her initial workup, she underwent a CT scan of the chest, abdomen and pelvis. This showed a 3 x 1.5 cm mass in the soft tissues of the right neck. Additionally, there was a 4 x 2 x 1.4 cm mass on the right side of the neck and a 1.3 cm right supraclavicular node. CT of the abdomen and pelvis showed a very large lobulated heterogeneously enhancing mass measuring 22 x 13 x 18.5 cm. Her ovaries were also heterogeneous and quite enlarged, the left measuring up to 6.5 cm and the right measuring 5.6 cm. There was no retroperitoneal, mesenteric, pelvic, or inguinal lymphadenopathy. She had a bone scan done, which showed osteoblastic metastatic lesions to the seventh rib, sternum and the L5 sacral area on the left. There was a possible lesion as well in L1. Given the abdominal and pelvic findings and the concern of a secondary GYN process, she was referred for urgent consultation. She stated that back in ___ with her initial diagnosis, she was told that she had a fibroid. She recalled being told it was the size of a quarter, however, did state that her gynecologist could feel it on exam. She denied any pelvic or abdominal pain. She noticed increased abdominal girth for the past few years and despite diet and exercise changes she has not been able to decrease her pant size. She noted urinary frequency and had thought most of this was due to her postmenopausal state since completing chemotherapy. She denied any vaginal bleeding with her last menstrual period approximately ___ years ago. Her gynecologic history was otherwise unremarkable. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Stage IIA lobular carcinoma of the right breast. It was ER/PR positive, HER-2 negative, diagnosed in ___. Recurrence ___. Lymphedema. Hypothyroidism. PAST SURGICAL HISTORY: ___, the lumpectomy followed by reexcision and axillary node resection at ___ in ___. OB History: She is a G0. GYN History: She denies any abnormal Pap smears. Her last was in ___ and was normal. She is not sexually active. She did take the birth control pills for ___ years. She has been on tamoxifen as noted above. She denies any other significant gynecologic issues in the present or past. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her father has multiple myeloma. There is a maternal aunt with a diagnosis of leukemia. She denies any breast, ovarian, or uterine cancers. There are no colon cancers. She did not undergo BRCA testing as part of her breast cancer diagnosis. There is significant diabetes, high blood pressure and heart disease on both the maternal and paternal side of her family. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 09: 20PM BLOOD WBC-16.0*# RBC-4.78 Hgb-13.5 Hct-40.7 MCV-85 MCH-28.2 MCHC-33.2 RDW-13.0 RDWSD-40.6 Plt ___ ___ 09: 20PM BLOOD Plt ___ ___ 09: 20PM BLOOD Glucose-133* UreaN-11 Creat-0.8 Na-137 K-4.4 Cl-102 HCO3-21* AnGap-18 ___ 09: 20PM BLOOD Calcium-8.5 Phos-4.0 Mg-1.5* ___ 05: 03PM BLOOD Type-ART pO2-235* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 ___ 05: 03PM BLOOD Lactate-3.3* ___ 05: 50PM BLOOD Lactate-4.3* ___ 04: 10PM BLOOD Hgb-12.6 calcHCT-38 ___ 05: 03PM BLOOD Hgb-9.9* calcHCT-30 ___ 05: 50PM BLOOD Hgb-11.6* calcHCT-35 ___ 05: 03PM BLOOD freeCa-1.04* ___ 07: 05AM BLOOD WBC-14.0* RBC-4.07 Hgb-11.8 Hct-35.1 MCV-86 MCH-29.0 MCHC-33.6 RDW-13.2 RDWSD-41.3 Plt ___ ___ 06: 15AM BLOOD WBC-6.6 RBC-3.34* Hgb-9.4* Hct-29.0* MCV-87 MCH-28.1 MCHC-32.4 RDW-12.9 RDWSD-40.5 Plt ___ ___ 06: 15AM BLOOD Plt ___ ___ 06: 15AM BLOOD ___ PTT-28.1 ___ ___ 06: 15AM BLOOD ___ ___ 01: 00AM BLOOD Glucose-131* UreaN-13 Creat-0.9 Na-135 K-3.6 Cl-99 HCO3-24 AnGap-16 ___ 01: 00AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2 <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. LORazepam 1 mg PO Q6H: PRN insomnia, nausea, anxiety 2. Fenofibrate 160 mg PO DAILY 3. Levothyroxine Sodium 112 mcg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice per day Disp #*60 Tablet Refills: *1 3. Enoxaparin Sodium 30 mg SC Q12H Start: after discharge RX *enoxaparin 40 mg/0.4 mL 40 mg syrigne daily Disp #*28 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Please take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 5. 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 #*50 Tablet Refills: *0 6. Fenofibrate 160 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. LORazepam 1 mg PO Q6H: PRN insomnia, nausea, anxiety <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> 1. Enlarging pelvic mass. 2. Ovarian masses. 3. Recurrent metastatic breast cancer. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparotomy, modified radical hysterectomy, bilateral salpingo-oophorectomy, and cystoscopy. Preliminary pathology showed metastatic lobular breast cancer. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with dilaudid PCA, IV toradol and tylenol. She also received a TAP block intraoperatively. Her diet was advanced without difficulty and she was transitioned to oral tylenol, ibuprofen and oxycodone. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Of note, she received 2 units packed red blood cells intraoperatively. In the PACU, her hematocrit was 40.1 and noted to be 35.1 on POD#1. On POD#1, she felt dizzy and nauseous and was noted to have a BP of 77/44. Repeat BP was ___ and workup showed negative orthostatics and repeat Hct was stable at 32.1. This episode resolved and was likely vasovagal vs medication effect given the negative orthostatics and stable hematocrit. For her hypothyroidism, she was continued on her home dose of levothyroxine. Given the recurrence of her breast cancer on preliminary pathology, ___ was consulted for port placement to facilitate chemotherapy. She was made NPO on ___ and a single lumen port from a left IJ was placed ___. Her diet was advanced without difficulty after her procedure. By post-operative day 4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10388546-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine <ATTENDING> ___. <CHIEF COMPLAINT> CC: abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy total abdominal hysterectomy bilateral salpingo-oophorectomy omentectomy splenectomy rectosigmoid resection and reanastomosis with protective ileostomy optimal primary cytoreduction <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ woman who was called into the emergency department by Dr. ___ concern for obstruction from what is believed to be ovarian malignancy. Ms. ___ reports that she has had several weeks of abdominal discomfort and bloating. She was seen by her primary care doctor and had an outpatient CT last ___ that demonstrated a 6cm right adnexal mass adjacent to the sigmoid, omental caking, a 1.2cm splenic lesion, and mild-moderate ascites. The liver and lung bases were unremarkable. She developed nausea/vomiting from the PO contrast, and was then seen at the ___ emergency room where she received IV hydration and antiemetics. As there was no evidence of bowel obstruction or renal failure, she was discharged home so that she could fly to ___ with plan for work-up on her return. While in ___, she had increased pain and was unable to have a bowel movement. She was admitted to a hospital there, but deferred surgery at that time. She just arrived back in ___ today. She reports that her last normal bowel movement was on ___ (over a week ago). She has been taking colace and miralax with minimal benefit. She has very little appetite, but otherwise denies nausea or emesis. She continues to feel bloated. She denies any difficulties with voiding. Denies fever/chills, SOB/CP, palpitations, or dizziness. Her CA-125 from ___ is 103.2 <PAST MEDICAL HISTORY> Obstetrical History: G3P3 -SVD x 3, uncomplicated per pt Gynecologic History: -Menarche: ___ -Reports regular menses. Denies h/o menorrhagia or dysmenorrhea -Went through menopause in her early ___. -Last Pap test in ___ was negative -Denies history of abnormal Paps -Denies h/o fibroids, cysts -Last mammogram in ___ normal -Denies history of breast disease -Denies h/o pelvic infections or STIs <PAST MEDICAL HISTORY> - hypothyroidism s/p thyroidectomy (Pathology was Oncocytic (Hurthle cell) neoplasm with atypical features) - colonic adenoma in ___. Last colonoscopy ___ with diverticulosis but otherwise no abnormalities - osteopenia - lumbar spondylosis Past Surgical History: - left thyroid lobectomy and isthemectomy (___) - completion thyroidectomy (___) performed because previous pathology not clear if malignancy or not <SOCIAL HISTORY> ___ <FAMILY HISTORY> -Brother died of colon cancer diagnosed in his ___ -Another brother died of brain cancer -Niece diagnosed with breast cancer in her ___ -Denies a family history of ovarian, uterine, or cervical malignancy <PHYSICAL EXAM> On Admission: VS: 98.8 84 137/63 16 99% RA Gen: comfortable appearing Caucasian woman, presents with her husband and her sister CV: rate ___, normal rhythma, no murmur Resp: CTAB, good air movement throughout, no crackles or wheezes Abd: hypoactive bowel sounds presents, softly distended, nontender to palpation Extremities: good perfusion, no edema, calves nontender DISCHARGE EXAM: AVSS, NAD RRR, CTAB Abdomen soft, NT, ND, nl BS Ostomy site pink, putting out liquid brown stool and gas Left JP drain site dry and healing with steristrips Mild erythema on inferior third of vertical paramedian incision. no induration or TTP. Incision otherwise c/d/i and healing well with steristrips. Extremities 1+ pitting edema overally improved, NT soft bilaterally <PERTINENT RESULTS> ADMISSION LABS: ___ 04: 45PM BLOOD WBC-12.0*# RBC-4.74 Hgb-13.8 Hct-41.1 MCV-87 MCH-29.0 MCHC-33.5 RDW-13.9 Plt ___ ___ 04: 45PM BLOOD Neuts-76.4* Lymphs-17.6* Monos-5.1 Eos-0.6 Baso-0.3 ___ 04: 45PM BLOOD ___ PTT-26.3 ___ ___ 04: 25PM BLOOD ___ ___ 04: 45PM BLOOD Glucose-78 UreaN-11 Creat-0.6 Na-136 K-3.9 Cl-97 HCO3-24 AnGap-19 ___ 11: 00AM BLOOD Albumin-4.1 Calcium-8.3* Phos-3.4 Mg-1.9 ___ 04: 45PM BLOOD CEA-1.6 ___ 08: 25PM BLOOD CA ___ -Test Day of discharge: ___ 05: 29AM BLOOD WBC-14.1* RBC-2.66* Hgb-8.1* Hct-24.1* MCV-91 MCH-30.3 MCHC-33.5 RDW-14.6 Plt ___ ___ 05: 29AM BLOOD Glucose-101* UreaN-6 Creat-0.4 Na-139 K-4.2 Cl-105 HCO3-27 AnGap-11 ___ 05: 29AM BLOOD Calcium-7.5* Phos-4.6* Mg-1.9 ___ PATHOLOGY: 1. Omentum, biopsy (A-J): Metastatic adenocarcinoma, see synoptic report. 2. Uterus and cervix (K-Q): - Metastatic adenocarcinoma, present on anterior and posterior uterine serosa. - Leiomyoma, measuring up to 1.2 cm. - Unremarkable cervix and atrophic endometrium. 3. Spleen (R): No carcinoma seen. See addendum for microscopic description of the splenic nodule. 4. Omentum (S-W): Metastatic adenocarcinoma, see synoptic report. 5. Anastomotic donut (X): Unremarkable colonic segment. 6. Rectosigmoid colon, bilateral fallopian tubes and ovaries (Y-AL): Ovarian adenocarcinoma extending into the colonic serosa circumferentially with construction but not complete obstruction of the bowel. No colonic mucosal involvement. Ovary Synopsis Staging according to ___ Joint Committee on Cancer Staging Manual -- ___ Edition, ___ MACROSCOPIC Specimen Type: Right salpingo-oophorectomy, left salpingo-oophorectomy, hysterectomy, omentectomy, rectosigmoid colon. Tumor Site Dominant Side (2x larger): Bilateral. Surface Involvement: Present. Tumor Size Greatest dimension: 7 cm. Other organs/Tissues Received: Rectosigmoid colon, spleen. MICROSCOPIC Histologic Type: Serous, carcinoma. Histologic Grade: G3: poorly differentiated. Washings/cytology: Not applicable. Fallopian tube Serosal implant. Uterus Serosa: Implant. Endometrium: Negative. Omentum: Implant, macroscopic. EXTENT OF INVASION Primary Tumor TNM (FIGO): pT3c (IIIC): Peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension and/or regional lymph node metastasis. Regional Lymph Nodes: pNX: Cannot be assessed. Lymph Nodes: None submitted. Distant metastasis: pMX: Cannot be assessed. Venous/lymphatic vessel invasion (V/L): Present. Comments: The degree of parenchymal ovarian involvement is limited; this may represent a primary peritoneal carcinoma. Entire tubal fimbria has been examined microscopically <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 137 mcg PO DAILY <DISCHARGE MEDICATIONS> 1. Levothyroxine Sodium 137 mcg PO DAILY 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*100 Tablet Refills: *1 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 #*60 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*100 Capsule Refills: *1 5. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Capsule Refills: *0 6. Rolling Walker <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> stage IIIC peritoneal cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___ were admitted to the gynecologic oncology service after undergoing the procedures listed below. ___ have recovered well after your operation, and the team feels that ___ are safe to be discharged home. Please follow these instructions: . * 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. * ___ may eat a regular diet. * Continue to follow up with Ostomy nurses recommendations . Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
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Ms. ___ was admitted to the GYN oncology service for further evaluation of her adnexal mass and symptoms of obstruction, which were attributed to likely ovarian cancer. The decision was made to continue her admission until planned surgery due to a failure to thrive. She was begun on total parenteral nutrition on hospital day #3. On (HD #7) ___ she underwent optimal cytoreduction with an exploratory laparotomy, a total abdominal hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with primary anastomosis, omentectomy, splenectomy, and diverting ileostomy, see operative report for details. Final pathology showed metastatic ovarian adenocarcinoma, see pathology report for details. She was admitted to the intensive care unit for close postoperative monitoring due to intraoperative hypotension and concern for fluid overload. She was extubated on postoperative day #1, remained hemodynamically stable, and was transferred to the floor on POD #2. Below is a summary of her course by system: # Postoperative care: postoperative pain was controlled with a thoracic epidural and IV medications until she was ultimately transitioned to oral medications without difficulty. She had two ___ drains that put out decreasing amounts of serosanguinous fluid and where removed on POD #7. Staples were removed POD#9, and ___ erythema was noted. Keflex was begun for presumed cellulitis. The tape from her JP drain site caused skin blistering--these were monitored and showed no signs of infection. # Heme: She received 3 units of packed red cells intraoperatively and remained hemodynamically stable throughout her recovery. Her hematocrit slowly drifted to 24.1, and on the day of discharge she received 2 units of packed red cells in anticipation of undergoing chemotherapy. In total, she received 5 units of pRBC during her hospitalization. # ID: Her WBC count was noted to peak at 17.5 during her recovery, but she remained afebrile without focal complaints. Urinalysis was negative, and culture contaminated. Her leukocytosis improved without intervention. She was ultimately treated for presumed incisional cellulitis for a planned 10 day course. #GU: Her creatinine remained normal. By POD#5 she was ambulating well enough for the foley to be discontinued, and she voided without difficulty. # GI: NGT was removed POD#3, the ostomy began to discharge bowel contents, and her diet was advanced to regular by POD#7. Her TPN was weaned accordingly, and triglycerides and LFTs were normal. The Ostomy nurse provided teaching and care. Asymptomatic oral thrush was treated with nystatin swish with noted improvement. # Health maintenance: due to her splenectomy, she received Menactra, Haemophilus B Conj, Pneumovax 23 vaccines prior to discharge. She remained on prophyiclactic lovenox, pneumatic compression boots, PPI and incentive spirometer throughout her admission. She was discharged on POD #10 ambulating with a cane, voiding, on a regular diet, and passing some rectal flatus. She felt confident in her ability to care for her ostomy, and she was set up for home ___, Ostomy care, and home ___ visits (was was prescribed a walker to use as needed). She has follow up scheduled with Dr. ___ in medical oncology and Dr. ___ ___ GYN oncology surgeon.
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10388546-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine <ATTENDING> ___. <CHIEF COMPLAINT> Stage IIIC primary peritoneal cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ileostomy takedown <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ w/ stage IIIC peritoneal serous adenocarcinoma s/p debulking surgery/chemo. She underwent optimal cytoreduction surgery with a TAH-BSO, rectosigmoid resection, primary anastomosis,omentectomy, splenectomy and diverting ileostomy on ___. She subsequently underwent six cycles of adjuvant carboplatin and paclitaxel with Dr. ___ with the last dose administered on ___. CT scan on ___ showed an indeterminate pelvic nodularity. Ileostomy takedown was delayed given these findings and that she was continuing to work on energy and nutrition. CT scan on ___ showed that the area of concern in the posterior right pelvis was less apparent than on the prior study and most likely did not represent recurrent disease. CA-125 level was drawn on ___ and was normal at 11. There were no complications with ileostomy except that it greatly affected her quality of life. After further discussion of the risks and benefits, the patient agreed to proceed with an ileostomy takedown. <PAST MEDICAL HISTORY> Obstetrical History: G3P3 -SVD x 3, uncomplicated per pt Gynecologic History: -Menarche: ___ -Denies h/o menorrhagia or dysmenorrhea -Went through menopause in her early ___. -Last Pap test in ___ was negative -Denies history of abnormal Paps -Denies h/o fibroids, cysts -Last mammogram in ___ normal -Denies history of breast disease -Denies h/o pelvic infections or STIs <PAST MEDICAL HISTORY> - hypothyroidism s/p thyroidectomy (Pathology was Oncocytic (Hurthle cell) neoplasm with atypical features) - colonic adenoma in ___. Last colonoscopy ___ with diverticulosis but otherwise no abnormalities - osteopenia - lumbar spondylosis Past Surgical History: - left thyroid lobectomy and isthemectomy (___) - completion thyroidectomy (___) performed because previous pathology not clear if malignancy or not <SOCIAL HISTORY> ___ <FAMILY HISTORY> -Brother died of colon cancer diagnosed in his ___ -Another brother died of brain cancer -Niece diagnosed with breast cancer in her ___ -Denies a family history of ovarian, uterine, or cervical malignancy <PHYSICAL EXAM> PHYSICAL EXAMINATION: GENERAL: She is well appearing, in no acute distress, and presents with her son and her husband. CARDIOVASCULAR: ___ is regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended, without any palpable masses. There is a pink normal-appearing loop ileostomy in the right upper quadrant. EXTREMITIES: Normal, with no edema or calf tenderness. PELVIC: She has normal female external genitalia. There are no vulvar or vaginal lesions. A bimanual exam shows a supple cuff without masses, tenderness, or nodularity. Rectal exam appreciates an intact anastomosis without stricture or constraint. There is stool proximal to this suture line. Rectal tone is normal. 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 Ext: nontender, nonedematous <PERTINENT RESULTS> ___ 07: 20AM BLOOD WBC-7.1 RBC-3.31* Hgb-10.0* Hct-31.0* MCV-94 MCH-30.1 MCHC-32.2 RDW-13.8 Plt ___ ___ 07: 20AM BLOOD WBC-6.6 RBC-3.21* Hgb-9.8* Hct-30.4* MCV-95 MCH-30.4 MCHC-32.2 RDW-14.1 Plt ___ ___ 07: 40AM BLOOD WBC-9.7 RBC-3.08* Hgb-9.5* Hct-28.5* MCV-93 MCH-30.9 MCHC-33.4 RDW-13.8 Plt ___ ___ 08: 10AM BLOOD WBC-13.8*# RBC-3.18* Hgb-10.0* Hct-29.8* MCV-94 MCH-31.4 MCHC-33.6 RDW-14.1 Plt ___ ___ 07: 20AM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-142 K-3.8 Cl-106 HCO3-28 AnGap-12 ___ 07: 20AM BLOOD Glucose-98 UreaN-7 Creat-0.7 Na-140 K-3.9 Cl-104 HCO3-30 AnGap-10 ___ 07: 40AM BLOOD Glucose-66* UreaN-10 Creat-0.7 Na-140 K-3.6 Cl-105 HCO3-25 AnGap-14 ___ 08: 10AM BLOOD Glucose-107* UreaN-10 Creat-0.6 Na-135 K-3.5 Cl-101 HCO3-25 AnGap-13 ___ 07: 20AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.6 ___ 07: 20AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.7 ___ 07: 40AM BLOOD Calcium-7.6* Phos-2.5* Mg-1.9 ___ 08: 10AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.6 <MEDICATIONS ON ADMISSION> synthroid ___ <DISCHARGE MEDICATIONS> 1. Ibuprofen 400 mg PO Q8H: PRN pain take with food, no more than 2400mg in 24 hrs RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hrs Disp #*30 Tablet Refills: *0 2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H: PRN pain don't take >4g of acetaminophen in 24 hrs. don't mix with alcohol or driving RX *oxycodone-acetaminophen 2.5 mg-325 mg ___ tablet(s) by mouth every 6 hrs Disp #*30 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 4. Lorazepam 0.5 mg IV Q4H: PRN anxiety <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ileostomy take down <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecology oncology service after undergoing ileostomy takedown. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with Dilaudid IV/Toradol/tylenol. The patient's diet was advanced slowly after being kept NPO for 24 hrs. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Her NG tube was removed on POD #1 and she was advanced to sips, then to clears, then to a mechanical soft diet after she passed flatus. The patient tolerated the nutritional transition well, and was able to tolerate a regular diet. The patient continue to pass flatus, and did not have any nausea and vomiting. She was started on her home medications for hypothyroidism. By post-operative day 4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10392686-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> codeine <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic organ prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total vaginal hysterectomy, left salpingo-oophorectomy, uterosacral suspension, anterior and posterior repair, cystoscopy <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 11: 10AM BLOOD WBC-9.9 RBC-4.32 Hgb-12.5 Hct-39.1 MCV-91 MCH-28.9 MCHC-32.0 RDW-12.8 RDWSD-41.9 Plt ___ <MEDICATIONS ON ADMISSION> atenolol 50mg qdaily, atorvastatin 20mg qdaily, cobalamin 2500mg qdaily, metformin 500mg bid, omeprazole 20mg qdaily, sitagliptin 100mg qdaily, tramadol-acetaminophen 37.5mg/325mg q6h, aspirin delayed release 325mg qdaily, cholecalciferol 1000U qdaily, cinnamon bark 2000mg qdaily <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID do not exceed 4000mg in 24 hours RX *acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 3. Ibuprofen 400 mg PO Q8H: PRN Pain - Moderate take with food RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills: *1 4. TraMADol 25 mg PO Q6H: PRN pain may cause sedation. do not drink alcohol or drive while taking tramadol RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #*25 Tablet Refills: *0 5. Atenolol 50 mg PO DAILY 6. Omeprazole 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic organ prolapse, urinary incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a total vaginal hysterectomy, left salpingo-oophorectomy, uterosacral suspension, anterior and posterior repair, cystoscopy for symptomatic stage III uterovaginal 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 Dilaudid. Her diet was advanced without difficulty and she was transitioned to PO Tramadol, Ibuprofen, and Acetaminophen. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her vaginal packing (placed intra-operatively) was also removed on post-operative day 1. Her home dose of sitagliptin and metformin were held, and she was placed on an insulin sliding scale for her type 2 diabetes. Her fingersticks ranged from 116-124. She was continued on her atenolol during this hospital By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10394190-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> E-Mycin <ATTENDING> ___. <CHIEF COMPLAINT> Bilateral hand parasthesias with paraperesis of legs. Pelvic mass on imaging. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Lumbar puncture under fluoroscopy EMG/NCS Laparoscopic bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ RHM s/p bilateral mastectomies for breast cancer presented with a constant burning sensation in the hands, accompanied by paraesthesia. She also has paraesthesias in the following areas: perioral, vertex of the head, buttocks and upper thighs since ___. In the past week she has had weak legs and difficulty walking. Of note she does not complain of bowel or bladder incontinence and she mentioned that her sensation was normal for both processes. She was seen by Dr ___ in Dr ___ clinic, and she is a direct admission from clinic for MRI brain, c-spine, t-spine. Torso CT, MRI brain, C- and T-spine +/-. ROS +abdominal distension, tooth decay, no palpitations, no dyspnea, no fevers, no recent weight loss, no seizures, no syncopal episodes. <PAST MEDICAL HISTORY> 1. Breast cancer - Ductal carcinoma in situ in ___, grade I with positive margins after which she underwent reexcision on ___, again the margins were positive and in ___, she underwent left mastectomy, 21 lymph nodes were negative. It was decided not to treat her with tamoxifen. In ___, 1 cm lump in the right breast palpated. Mammogram and ultrasound showed a 1.5-cm solid nodule in the medial inferior right breast. Ultrasound-guided biopsy showed invasive ductal carcinoma, grade III, measuring 1.2 cm with evidence of lymphatic vascular invasion, ER/PR positive, HER-2/neu negative. Right mastectomy on ___ ductal carcinoma size 1.5 x 1.21 x 1.0 cm. The surgical margins were free. LVI present. Histologic grade II. All the lymph nodes were negative with two sentinel lymph nodes being negative. 2. simple cyst involving the left adnexa thought unlikely malignant; nl Ca-125 3. Spinal stenosis with chronic lower back pain since her ___, 4. Diverticulitis in ___. 5. One flare of ulcerative colitis in ___. 6. Fatty liver disease. 7. Hypertension. 8. PMR, responding to course of steroids. 9. Thrombophlebitis in ___ following a fracture. 10. Osteoporosis. 11. Hypothyroidism. 12. Hypercholesterolemia. 13. History of tachycardia since approximately ___ which has been worked up as outpatient by Holter monitor and echocardiogram. 14. No history of coronary artery disease, MIs, or cardiac catheterization. Stress test in ___ showed no ischemic EKG changes and no anginal symptoms. 15. Scoliosis. 16. Depression. 17. ___ at ___ showed bifrontal atrophy, started on neurontin w/o effect. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Paternal grandmother with breast cancer of unknown age, no history of ovarian, colon, or pancreatic cancer. Father had bladder cancer and two of her brothers had lung cancer, both of them were smokers. Positive h/o DM in sister. <PHYSICAL EXAM> T98, BP 128/82, HR 103, SpO2 98% on room air Genl: Looks ___ in the room HEENT: no meningismus, oral Neck: Cervical lymphadenopathy, suprascapular lymphadenopathy CV: Heart sounds irregularly irregular Chest: Slight wheeze. Dressing over mastectomy scar Abd: Distended abdomen with hepatomegaly, approximately 7 cm below the costal margin. She has shifting dullness. Bowel sounds are present. She had a rectal examination in ___ clinic, which was normal, and she declined another exam. Ext: Edematous legs, thighs show signs of fluid loss (loose skin folds), the calves have pitting edema +2, with venous eczema changes, the feet are edematous. Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says "world" backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. Reading intact. Registers ___, recalls ___ in 5 minutes. No right-left confusion. No evidence of apraxia or neglect. Cranial Nerves: Fundoscopic examination reveals sharp disc margins. Pupils equally round and reactive to light, 4 to 2 mm bilaterally.Visual fields are full to confrontation. Extraocular movements intact bilaterally without nystagmus. Sensation intact to pinprick V1-V3 (also around the mouth). Slight left facial asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk and tone bilaterally. No observed myoclonus, asterixis, or tremor. No pronator drift. Del Tri Bi WE FE FF IP H Q DF PF TE R ___ ___ +3 ___ 5 5 L ___ ___ +3 ___ 5 5 Sensation: Intact to light touch and cold sensation throughout her arms, in her legs her light touch is normal around L2. Pinprick is down to L2 b/l, and in her right arm it is down in the ulnar distribution. Joint position sense is down in her feet. Vibration sense down to the knees bilaterally. No extinction to DSS. Reflexes: 2 and symmetric throughout. Toes downgoing bilaterally. Coordination: finger-nose-finger, finger-to-nose, fine finger movements, and RAM normal. Gait: Not assessed, as she feels exhausted. <PERTINENT RESULTS> ___ 05: 15PM BLOOD WBC-4.9 RBC-3.83* Hgb-12.7 Hct-37.4 MCV-98 MCH-33.2* MCHC-34.1 RDW-13.8 Plt ___ ___ 05: 15PM BLOOD ___ PTT-24.4 ___ ___ 07: 30AM BLOOD ESR-20 ___ 05: 15PM BLOOD Glucose-91 UreaN-8 Creat-0.8 Na-137 K-3.8 Cl-95* HCO3-33* AnGap-13 ___ 05: 15PM BLOOD ALT-18 AST-55* AlkPhos-311* TotBili-0.6 ___ 06: 43AM BLOOD Cryoglb-NEGATIVE ___ 06: 43AM BLOOD calTIBC-159* ___ Ferritn-666* TRF-122* ___ 06: 41AM BLOOD CEA-3.9 ___ 07: 30AM BLOOD CRP-7.3* ___ 06: 43AM BLOOD PEP-NO SPECIFI IgG-1180 IgA-178 IgM-128 IFE-NO MONOCLO ___ 06: 41AM BLOOD CA ___ - 43 ___ 02: 19PM CEREBROSPINAL FLUID (CSF) WBC-1 ___ Polys-35 ___ ___ 02: 19PM CEREBROSPINAL FLUID (CSF) TotProt-78* Glucose-57 CT Abd/Pelvis ___: 1. No definite mass or nodule is noted within the lungs to suggest primary lung cancer. No concerning lymphadenopathy is visualized. 2. A 39 x 48 mm cystic structure at the expected location of the left adnexum is very concerning for a primary ovarian mass. Pelvic ultrasound is recommended for further evaluation. 3. Relatively large soft tissue defect within the right anterior chest wall,which is most likely post-surgical. There is also cystic structure adjacent to this area, which suggests a prior intervention at this region. Please correlate clinically. 4. Fatty liver with focal areas of fatty sparing. 5. Cholelithiasis, with no evidence of cholecystitis. 6. Severe S-shaped scoliosis of the thoracolumbar spine. <MEDICATIONS ON ADMISSION> Citalopram [Celexa] 10 mg as needed Furosemide [Lasix] 40 mg Tablet daily nr Hydrocodone-Acetaminophen [Norco] 10 mg-325 mg Tablet once a day Levothyroxine 25 mcg once a day nr Lorazepam [Ativan] 0.5 mg Tablet as needed nr Omeprazole [Prilosec] 20 mg Capsule, Delayed Release(E.C.) prn <DISCHARGE MEDICATIONS> 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp: *35 Tablet(s)* Refills: *0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *0* 6. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp: *60 Tablet(s)* Refills: *2* 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Left adnexal mass Sensory neuronopathy Paraneoplastic syndrome History of right mastectomy with axillary lymph node dissection in ___ <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call if you have fevers or chills, increased abdominal pain, difficulty with urination, inability to tolerate oral intake, redness or drainage from your incision sites or any other concerns. No driving, heavy lifting for two weeks.
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NEUROLOGY SERVICE ___ RHM s/p bilateral mastectomies for breast cancer presented with a constant paraesthesia in her hands and a proximal myopathy. She also has considerable weakness of her legs with involvement of various sensory modalities. In addition, she has a left facial. With her history of breast cancer, smoking history and alcohol history, malignant etiology for the findings needed to be excluded hence she had CT torso which was negative. She also had MRI of head and spine that showed some spondylosis and slight flattening of cord but not enough to explain her symptoms. She has LP under fluoroscopy given her severe scoliosis that did not she signs of infection but send out labs for paraneoplastic syndrome pending. She was followed up with EMG/NCS which showed either sensory neuropathy or neuronaxonapathy hence further corroboration for paraneoplastic. Given that she has questional ovarian cyst/mass per previous scans seen on CT torso/pelvis, Ob/Gyn was consulted. She was scheduled for lap BSO per Dr. ___ on ___. She was treated with IVIG. She continued to have severe painful parasthesia of both hands. She was initially started on Neurontin which was titrated up to 900 TID but given no relief, she was also started on Trileptal with decent relief. Hence she is to continue on current dose of Trileptal and Neurontin. She will be followed per Dr. ___ for neurology as outpatient. GYNECOLOGIC ONCOLOGY SERVICE Pt was transferred to Gyn Oncology on ___ for pre-operative evaluation for planned Laparoscopy on ___. Pre-op EKG and CXR were normal. Pt was noted to have neutropenia (WBC 3) and thrombocytopenia (plt 80) prior to the OR likely due to IVIG effect. She underwent a bowel prep. On ___ she underwent an uncomplicated laparoscopy with bilateral salpingo-oophorectomy for a adnexal mass which was simple in appearance and likely benign. Her neurologic symptoms remained unchanged pre and post-operatively. Her post-operative course was uncomplicated and she was discharged to a rehab facility on POD#1.
| 2,372
| 471
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10398265-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> induction of labor for post-term gestation <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <PERTINENT RESULTS> Hct 27.5% <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *35 Tablet(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *20 Tablet(s)* Refills: *0* 3. Analpram-HC ___ % Cream Sig: One (1) apply as directed Rectal every ___ hours as needed for pain for 2 weeks. Disp: *1 45 gm* Refills: *1* 4. Dermoplast ___ % Aerosol Sig: One (1) spray Topical every ___ hours as needed for pain for 2 weeks. Disp: *1 spray bottle* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine postpartum instructions
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prolonged induction of labor with cytotec x 3, foley bulb, pitocin, epidural.NSVD of a female infant, 3785 gm, Apgars ___, over 2nd degree laceration.
| 356
| 52
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10398616-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Ceclor / Clindamycin / Levaquin / Epinephrine / Keflex <ATTENDING> ___. <CHIEF COMPLAINT> endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy, pelvic washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph node sampling. <HISTORY OF PRESENT ILLNESS> The patient is a ___ G3, P3 sent by Dr. ___ for consultation regarding a new diagnosis of endometrial cancer. She has experienced very slight vaginal spotting for the past several weeks. She was evaluated by Dr. ___ was found to have renal cysts that are likely benign. She was to have a cystoscopy but this has not been arranged as yet. She saw Dr. ___ performed an endometrial biopsy and this revealed grade 1 endometrial carcinoma, endometrioid type. She had no other complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Significant for a benign heart murmur, spinal stenosis. PAST SURGICAL HISTORY: Two spinal fusion surgeries from C2 to T2. ALLERGIES TO MEDICATIONS: Penicillin and clindamycin. OB HISTORY: Vaginal delivery x3. GYN HISTORY: Last Pap smear was ___. Last mammogram in ___ and normal. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Significant for mother with colon cancer in her ___. <PHYSICAL EXAM> GENERAL: Well developed and obese. HEENT: Sclerae anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. BREASTS: Without masses. ABDOMEN: Soft and pendulous and without palpable masses. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was normal. Bimanual and rectovaginal examination was limited by body habitus. The uterus and adnexa were not palpable. The cervix was normal to palpation. There was no cul-de-sac nodularity and the rectal was intrinsically normal. <PERTINENT RESULTS> ___ 01: 30AM BLOOD WBC-13.4*# RBC-4.08* Hgb-10.9* Hct-34.6* MCV-85 MCH-26.6* MCHC-31.4 RDW-14.5 Plt ___ ___ 01: 08AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-TR ___ 01: 08AM URINE ___ Bacteri-NONE Yeast-NONE Epi-<1 <MEDICATIONS ON ADMISSION> Advair, Prilosec. <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 Q4-6H () as needed. Disp: *60 Tablet(s)* Refills: *0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 4. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed. 5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation BID (2 times a day). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrial carcinoma <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience fever > 101, 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.
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Ms. ___ was admitted after having undergone an exploratory laparotomy, pelvic washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymph node sampling. The case was uncomplicated. The details of the surgery are available in a separate operative note elsewhere. Her postoperative course was notable for one elevated temperature to 100.6, for which a CBC and a urine sample were sent. Neither of which were evident for infection, and she remained afebrile for the rest of the hospital stay. She was discharged home on POD #2, in stable condition: afebrile, stable vital signs, ambulant, tolerating a regular diet, voiding spontaneously and with her pain controlled.
| 1,073
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10408526-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Shellfish / codeine <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 @ ___ 0d transfer from ___ with onset of regular uterine CTX beginning at around 1400. Reports she was on vacation at ___ when she started having regular ctxn. She then presented to the hospital where she was found to have SVE ___. She was then started on Mag for neuroprotection at ___, ampicillin for GBS unknown. She received her first dose of BMZ for lung maturity at ___. Prior to transfer to ___, she received Indocin 50mg for tocolysis. Patient reports that she is still having ctxns, q5-7. Denies fever, chills, other abdominal pain, abdominal trauma, dysuria, vaginal discharge, vaginal bleeding, DFM, LOF. Had recent sexual intercourse last night. <PAST MEDICAL HISTORY> PNC: ___ ___ by LMP - Labs Rh pos/Abs neg/Rub I /RPR NR /HBsAg neg /HIV neg /GBS unk - Screening: LR ERA - FFS: normal anatomy - GLT: normal - Issues: *) s/p MVA on ___. Had neg eval in triage. Noted to have epigastric pain during this eval and had normal PIH labs *) anxiety: on Prozac 20mg qd PObHx: G1 PGynHx: No history of LEEP or other cervical procedure PMHx: anxiety PSHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: ___ 23: 20BP: 120/58 (73) ___ ___: 83 ___ 00: 31BP: 130/73 (85) ___ 00: 46BP: 116/66 (78) General: NAD. Does not appear intoxicated or to be having regular painful CTX. Cardiac: RRR Pulm: CTAB Abdomen: soft, no fundal tenderness, CTX palpable Ext: ___ sign absent, no erythema, no edema SSE: Normal external anatomy, cervical os visually closed, no blood in vaginal vault. SVE: 2-3/100/0->+1 NST: 120/mod var/+accels/-decels TOCO: q5-6 BPP: VTX, ___, AFI: 11.1 EFW: 1563g <PERTINENT RESULTS> ___ WBC-14.8 RBC-3.38 Hgb-10.1 Hct-30.7 MCV-91 Plt-218 ___ Neuts-87.5 ___ Monos-2.5 Eos-0.1 Baso-0.3 Im ___ AbsNeut-12.94 AbsLymp-1.28 AbsMono-0.37 AbsEos-0.01 AbsBaso-0.05 ___ URINE Color-Straw Appear-Clear Sp ___ ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ OTHER BODY FLUID CT-NEG NG-NEG R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS <MEDICATIONS ON ADMISSION> prenatal vitamins prozac <DISCHARGE MEDICATIONS> 1. FLUoxetine 20 mg PO DAILY 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - pre-term contractions - arrested pre-term labor <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for preterm contractions. You were given betamethasone, a steroid which helps the baby's lungs among other benefits. Your contractions and cervical exam remained stable and you are now safe to be discharged home. Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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___ y/o G1 admitted at 31w0d in preterm labor. On arrival, she continued to contract painfully and changed her cervix to 4cm. She was continued on indomethacin for tocolysis and Magnesium for neuroprotection. She got an epidural for pain control. She had no evidence of infection or abruption. Fetal testing was reassuring. Her contractions spaced significantly and on on repeat exam, she was felt to be 2-3cm dilated. The Magnesium was discontinued and her cervical exam remained unchanged. Her epidural was removed and she was transferred to the antepartum service for observation. The indomethacin was discontinued once betamethasone complete (___). She remained clinically stable without evidence of ongoing preterm labor. She was discharged to home on ___ and will have close outpatient follow up.
| 1,047
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10408526-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Shellfish / codeine <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 at 32+0, previously admitted ___ with PTC, initially on L&D on Mg and Indocin. Made BMZ complete ___, cervix stable at 2-3/100/0, discharged home ___. Presented again on ___ with increased cramping and mucousy discharge over the last 24 hours prior to presentation. Denied vaginal bleeding or loss of fluid. <PAST MEDICAL HISTORY> PNC: ___ ___ by ___ - Labs ___ pos/Abs neg/Rub I /RPR NR /HBsAg neg /HIV neg /GBS neg ___ - Screening: LR ERA - FFS: normal anatomy - GLT: normal - Issues: *) s/p MVA on ___. Had neg eval in triage. Noted to have epigastric pain during this eval and had normal PIH labs *) anxiety: on Prozac 20mg qd *) PTC PObHx: G1 PGynHx: h/o abnormal pap and colposcopy. No history of LEEP or other cervical procedure. PMHx: anxiety PSHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Physical Exam on Admission: --== VS: ___ 05: 14BP: 126/80 (90) ___ ___: 90 ___ 05: 15Temp.: 99.1°F ___ 08: 00Resp.: 16 / min General: NAD Cardiac: RRR Pulm: CTAB Abdomen: soft, no fundal tenderness Ext: soft, NT, no erythema, no edema SSE: Mucousy discharge in vault c/w mucous plug, membranes visible, cervix visually 3cm and thin SVE: 3-4/100/0 NST: 120/mod var/+accels/-decels TOCO: q5-6 BPP: VTX, ___ at ___ today EFW: 1563g ___ Physical Exam on Discharge: --== O: 98.3 PO 113 / 76 90 18 97 RA Gen: [x] NAD Resp: [x] No evidence of respiratory distress Abd: [x] soft [x] non-tender Ext: [x] no edema [x] non-tender <PERTINENT RESULTS> ___ 02: 40PM BLOOD WBC-14.5* RBC-3.56* Hgb-10.6* Hct-31.6* MCV-89 MCH-29.8 MCHC-33.5 RDW-12.8 RDWSD-41.4 Plt ___ ___ 02: 40PM BLOOD Neuts-75* Bands-0 Lymphs-16* Monos-6 Eos-2 Baso-0 ___ Myelos-1* AbsNeut-10.88* AbsLymp-2.32 AbsMono-0.87* AbsEos-0.29 AbsBaso-0.00* ___ 02: 40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 02: 40PM BLOOD Plt Smr-NORMAL Plt ___ ___ 02: 40PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 02: 45PM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG ___ 2: 45 pm SWAB Source: Vaginal. **FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> Meds: PNV, Prozac <DISCHARGE MEDICATIONS> 1. FLUoxetine 20 mg PO DAILY 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm contractions, arrested preterm labor <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for preterm contractions leading to arrested preterm labor. Your contractions and cervical exam remained stable and you are now safe to be discharged home. Please follow the instructions below: - Attend all appointments with your obstetrician and all fetal scans - Continue pelvic rest, nothing in the vagina, no sex, no douching Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ is a ___ gravida 1 admitted for monitoring for concern for pre-term labor. She was previously hospitalized making change to 2-3/100/0. She was discharged home in stable condition. She returned for repeat evaluation with painful contractions on ___ and was found to have made change to 3.5/100/0. She was admitted for close monitoring for rule out pre-term labor. She was made betamethasone complete as of ___ and was given a course of rescue betamethasone given her uncomfortable contractions and slow change to ___. She was rescue complete as of ___. She was closely monitored over her admission with reassuring fetal testing. She had an ultrasound on admission on ___ which was significant for BPP ___, MVP 3.9, cephalic position, well grown fetus of 1772g in the 38%. She remained stable and overall comfortable with mild cramping with no evidence of abruption, rupture of membranes, or infection. Her cervix remained stable over several exams with discharge exam of 3-4/100/0, fetal vertex well applied. She was discharged home on ___ in stable condition with pre-term labor precautions.
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10408562-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Sulfadiazine / adhesive <ATTENDING> ___. <CHIEF COMPLAINT> Dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ history of preeclampsia, 5 days status post C-section for preeclampsia presents evaluation of shortness of breath. She was delivered by c-section at 37 weeks gestational age after a failed induction of labor. She was started on labetalol during this admission and she was discharged two days prior to presentation. She stated that the night prior to presentation, she noticed increasing dyspnea while laying supine. She stood up to walk around and endorsed DOE and associated cough. She endorsed generalized malaise earlier in the day. She denies fevers and sick contacts but states that she "always runs hot." She endorsed that she had some chronic nasal congestion and rhinorrhea starting around ___ which had persisted so she saw a PCP who gave her a Z pack two weeks ago with resolution of her symptoms. She had developed leg swelling in the setting of her pre-eclampsia which she felt was stable. She called EMS and was brought to an OSH where she had SO2 85% on RA. A CTA of the chest demonstrated multifocal PNA, small pleural effusions, and no PE. She was given Levaquin, prednisone 60mg, and Lasix 40mg IV x1 with 2600cc of reported UOP. On arrival patient is tachycardic into the 100s-110s, which increases into the 120s and 130s with any exertion. She is hypertensive into the 180s systolic. She denies any headache, blurry or double vision. She denies chest pain, chest tightness although doesn't worse some dyspnea with any exertion. In the ED, initial vitals were: 98.5 ___ 20 96% 2L NC. Labs were notable for troponin <0.01, pBNP 1857, WBC 12.1, Hct 29.1, platelets 519, uric acid 6.9, ALT 19, AST 19, AP 119, lip 15, tbili 0.2, lactate 1.2. Urine and blood tox were negative. UA had 30 protein, negative leuk, <1WBC, neg glucose. CXR showed... EKG showed... She was given labetalol 600mg and magnesium and started on drips of both. A bedside TTE was unremarkable and she was admitted to the MICU On arrival to the MICU, the patient stated that she still felt SOB but denied other complaints. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations. Denies 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> Obesity, BMI 40 Gestational diabetes Pre-eclampsia S/p L4-L5 laminectomy Delivery by C-S <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father - deceased from MI @___, HTN, DM Mother - HTN Physical ___: -- EXAM ON ADMISSION: -- Vitals: T: 98.2 BP: 121/72 P: 94 R: 16 O2: 95% 2L NC General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated Lungs- Slight crackles in R base CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Incision c/d/i. GU- deferred, foley in place Ext- warm, well perfused, 2+ pulses, trace edema. Neuro- CNs2-12 intact, motor function grossly normal --=== EXAM ON DISCHARGE: --=== <PERTINENT RESULTS> -- LABS ON ADMISSION: -- ___ 07: 40AM ___ PTT-30.5 ___ ___ 07: 40AM PLT COUNT-519*# ___ 07: 40AM NEUTS-91.9* LYMPHS-7.0* MONOS-0.6* EOS-0.3 BASOS-0.2 ___ 07: 40AM WBC-12.1* RBC-3.58* HGB-9.5* HCT-29.1* MCV-81* MCH-26.5* MCHC-32.6 RDW-14.7 ___ 07: 40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07: 40AM TSH-3.6 ___ 07: 40AM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-3.8 MAGNESIUM-1.8 URIC ACID-6.9* ___ 07: 40AM proBNP-1857* ___ 07: 40AM cTropnT-<0.01 ___ 07: 40AM LIPASE-15 ___ 07: 40AM ALT(SGPT)-19 AST(SGOT)-19 ALK PHOS-119* TOT BILI-0.2 ___ 07: 40AM GLUCOSE-133* UREA N-13 CREAT-0.7 SODIUM-140 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18 ___ 07: 55AM LACTATE-1.2 ___ 08: 15AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 08: 15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 08: 15AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08: 15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 08: 15AM URINE HOURS-RANDOM CREAT-19 TOT PROT-41 PROT/CREA-2.2* --=== PERTINENT LABS: --=== --=== MICROBIOLOGY: --=== --=== IMAGING: --=== ___ TTE: Conclusions The left atrial volume is mildly increased. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is a trivial/physiologic pericardial effusion. Small bilateral pleural effusions. IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function.No valvular pathology or pathologic flow identified. Small bilateral pleural effusions. CXR ___ FINDINGS: There is minimal interval improvement in the previously seen mild to moderate pulmonary edema with small bilateral pleural effusions also noted. Multifocal upper lobe opacities, consistent with pneumonia, are better seen on the earlier CT from the same day. The heart and mediastinal contours are within normal limits. IMPRESSION: Minimal interval improvement in mild to moderate pulmonary edema with small bilateral pleural effusions. Bilateral upper lobe multifocal pneumonia is redemonstrated, but better evaluated on CT scan from same day. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Ibuprofen 600 mg PO Q6H: PRN pain 2. Labetalol 300 mg PO BID 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H: PRN pain 4. Docusate Sodium 100 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fluid overload with Pneumonia and pulmonary edema hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Routine post delivery care discussed medications to be taken reviewed
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___ s/p recent c-section for pre-eclampsia presenting with acute onset dyspnea, hypertension, and proteinuria. # Dyspnea/Hypoxia - CTA chest without evidence of PE. Per her imaging, this appears more likely infectious. She had slight peripheral edema suggesting a component of pulmonary edema. Given her recent hospitalization and exposure to azithromycin, she is at risk for MDR pathogens. She had a good response to IV lasix and was >1L negative for her first day of hospitalization and had good O2 sats >95% on room air. She had been started on Vancomycin and Cefepime, but given her quick clinical improvement it was thought that it was unlikely that she had an infection caused by a resistant organism. She was switched to Levofloxacin to complete an 8d course (___) # Pre-eclampsia - She presented with hypertension in the setting of proteinuria and recent diagnosis of pre-eclampsia, this is most likely consistent with worsening of her pre-eclampsia. Her BPs were well controlled on admission to the ICU with a labetalol drip. Following 6 hours of stable blood pressures, she was transitioned to a PO regimen of Captopril 12.5mg Q8H as she is not breastfeeding. Her SBPs ran 110s to 120s over the next ___ hours and there were plans to start Lisinopril 10mg the following morning. She was given 4g loading of Mg and continued on a Mg drip for 24h. # S/p c-section POD - incision appears c/d/i - further management with OB (needs staple removal) # H/o gestational DM - monitored QAC FSBG
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| 366
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10409785-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> bee stings <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding in known previa with three prior c/s <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G7P4 at ___ who is a transfer from ___ for concerns of vaginal bleeding. She describes waking up this morning and seeing about a 3cm x 5cm stain of bright red blood. The bleeding continued as she used the bathroom and she has intermittently seen quarter sized stains of bright red blood throughout the morning. She denies clots and denies abdominal pain. She also denies LOF and reports +FM. She has been experiencing occasional cramping throughout the last week. She denies lightheadedness and shortness of breath, chest pain and SOB. Exam at ___ noted a plum-sized clot in the vaginal vault today. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ trimester ultrasound - Labs: Rh pos/Abs neg/Rub I/RPR neg/HbsAg neg/HIV neg/GBS unknown - Screening: none - FFS: anterior placenta, complete previa - GTT: N/A - Ultrasound: ___: anterior placenta previa, suspicion for placenta accreta - Issues: #AMA #suspected placenta accrete #placenta previa #Hepatitis C: recently diagnosed VL 487,000 (?date) #subutex treatment: 8mg BID #tobacco use in pregnancy: 2 cigarettes per day #desires PPTL OBHx: - LTCS x 3 - SVD x 1 - SAB x 1 - TAB x 1 GYNHx: - hx of ovarian cysts PMH: - anxiety - bipolar disorder - PTSD (loss of mother at young age) - IVDU on subutex PSH: - laparoscopy for ovarian cysts at age ___ - LTCS x 3 - tonsillectomy and adenoidectomy - hx of dental work <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Liver cancer/breast cancer (mother, died at age ___ - Stomach cancer: grandfather - ___ cancer: maternal grandmother Physical ___: (on admission) Vitals: Temp 98.4 HR 65 BP 95/56 RR 18 General: NAD Abd: soft, gravid nontender Pelvic: normal external genitalia, well estrogenized vaginal tissue, 2 scopets of bright red blood in vaginal vault, visually closed, no evidence of pooling liquid, no clots FHT: 130/mod var/+accels/-decels Toco: rare contractions IMAGING Ultrasound ___: TAUS SIUP cephalic presentation, anterior placenta consistent with a placenta previa. AFV normal limits and FHR 137. Placenta reveals increased vascularity in the LUS and an area where the placental/myometrial interface is indistinct. EFW 749g (36%) <PERTINENT RESULTS> ___ WBC-9.9 RBC-4.26 Hgb-11.3 Hct-35.6 MCV-84 Plt-217 R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> subutex 8 mg BID Adderall 20 mg BID lorazepam 0.5 mg daily <DISCHARGE MEDICATIONS> 1. Nicotine Patch 14 mg TD DAILY RX *nicotine [Nicoderm CQ] 14 mg/24 hour apply 1 patch to skin q24hrs Disp #*30 Patch Refills: *2 2. Amphetamine-Dextroamphetamine 20 mg PO BID 3. Buprenorphine 8 mg SL BID 4. LORazepam 0.5 mg PO DAILY PRN anxiety <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal bleeding placenta acreta <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital for vaginal bleeding and a likely placenta acreta (placenta abnormally grown into the uterus). You were given betamethasone, a steroid which helps the baby's lungs among other benefits. You met with the neonatology, urology, anesthesia, and social work team to discuss the management around the time of your C-section. Your have had no further bleeding and you are now safe to be discharged home.
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Ms. ___ was admitted to the hospital for evaluation and monitoring. She received a course of antenatal steroids and was betamethasone complete on ___. She had an ultrasound in the ___ Maternal Fetal Medicine which was concerning for a possible placenta acreta. She was extensively counseled on these findings and the implications of possible need for cesarean hysterectomy at the time of delivery. She met with NICU, urology, and anesthesia. Surgical consents were reviewed and signed. In the event that a hysterectomy was not necessary, she was unequivocal that she would desire a tubal ligation and the Mass Health Consent was signed. In regards to her history of anxiety and substance abuse, her usual medications including subutex were continued. She notified her subutex provider of her hospitalization and a letter was provided documenting her hospital stay and last dose. After she was stable for five day without further bleeding, she was discharged home in stable condition with outpatient follow-up scheduled.
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10409785-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> bee stings <ATTENDING> ___. <CHIEF COMPLAINT> bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ total abdominal hysterectomy for placenta accreta <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G7P4 at ___ with a known ___ transferred from ___ for vaginal bleeding. She reports she experienced an episode of bright red bleeding at 03: 00am. The amount of blood on the bed was about the size of a normal pad. She did not have significant bleeding since initial bleed, and does not currently have a pad on. Reports she passed a small clot at ___. Denies abdominal pain and contractions. Denies abdominal trauma. No longer smoking, denies drug use. +AFM. Last ate at 20: 00 ___. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ trimester ultrasound - Labs: ___ pos/Abs neg/Rub I/RPR neg/HbsAg neg/HIV neg/GBS neg ___ - Screening: none - FFS: anterior placenta, complete previa - GTT: N/A - Ultrasound ___: 1,239gm, 51% - Issues: - AMA - placenta accreta: plan for cesarean hysterectomy with ovarian preservation - Hepatitis C: diagnosed this pregnancy, VL 487,000 on ___ - subutex treatment: 8mg BID - tobacco use in pregnancy: 2 cigarettes per day-> quit - admission ___ for first bleed OBHx: G7P4 - SVD x 1 - LTCS x 3 - SAB x 1 - TAB x 1 - current GYNHx: - h/o ovarian cysts PMH: - anxiety - bipolar disorder - PTSD (loss of mother at young age) - IVDU on subutex PSH: - laparoscopy for ovarian cysts at age ___ - LTCS x 3 - tonsillectomy and adenoidectomy - h/o dental work <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Liver cancer/breast cancer (mother, died at age ___ - Stomach cancer: grandfather - ___ cancer: maternal grandmother Physical ___: ADMISSION PHYSICAL EXAM: -- Temp.98.1°F BP: 111/66 (75) MHR: 75 General: NAD, comfortable appearing Abd: soft, gravid nontender GU: no pad in place, no active VB FHT: 130/mod var/+accels/-decels Toco: rare contractions TAUS: transverse, head maternal left Discharge exam: Gen - NAD Resp - no respiratory distress Abd - soft, NT, inc c/d/I with steristrips in place GU- voiding spontaneously, minimal spotting on pad Ext - nontender <PERTINENT RESULTS> ADMISSION LABS: --= ___ 02: 29PM WBC-8.6 RBC-4.12 HGB-11.2 HCT-35.1 MCV-85 MCH-27.2 MCHC-31.9* RDW-13.6 RDWSD-42.3 ___ 02: 29PM PLT COUNT-211 ___ 02: 29PM ___ PTT-30.1 ___ ___ 02: 20PM GLUCOSE-70 UREA N-6 CREAT-0.3* SODIUM-137 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14 ___ 02: 20PM estGFR-Using this ___ 02: 20PM ALT(SGPT)-24 AST(SGOT)-24 ___ 02: 20PM CALCIUM-8.2* PHOSPHATE-3.4 MAGNESIUM-4.0* URIC ACID-3.2 Discharge: ___ 02: 30AM BLOOD WBC-9.2 RBC-3.45*# Hgb-9.8*# Hct-29.2* MCV-85 MCH-28.4 MCHC-33.6 RDW-13.7 RDWSD-42.7 Plt ___ ___ 03: 45PM BLOOD ___ PTT-31.3 ___ ___ 04: 14AM BLOOD Glucose-81 UreaN-5* Creat-0.3* Na-139 K-3.9 Cl-103 HCO3-28 AnGap-12 ___ 04: 14AM BLOOD ALT-14 AST-25 LD(LDH)-181 AlkPhos-71 TotBili-0.4 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Buprenorphine 8 mg SL BID 2. Prenatal Vitamins 1 TAB PO DAILY 3. Amphetamine-Dextroamphetamine 20 mg PO BID 4. LORazepam 0.5 mg PO Q8H: PRN nausea <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q8H Do not take more than 4000 mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth q4-6hr Disp #*60 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Take with food to prevent GI upset. RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hr Disp #*60 Tablet Refills: *0 4. Nicotine Patch 7 mg TD DAILY RX *nicotine 7 mg/24 hour apply to skin qday Disp #*30 Patch Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drive while taking. RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6hrs Disp #*60 Tablet Refills: *0 6. Amphetamine-Dextroamphetamine 20 mg PO BID 7. Buprenorphine 8 mg SL BID 8. LORazepam 0.5 mg PO Q8H: PRN nausea <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean hysterectomy <DISCHARGE CONDITION> Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with a placenta accreta, and you delivered by Cesarean section and a subsequent hysterectomy due to the placenta acreta. Congratulations on the birth of your baby! You recovered well after surgery, and we feel it is now safe for you to be discharged home. Please follow the instruction below: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking oxycodone Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns. It was a pleasure taking care of you during your stay! Sincerely, Your ___ OB Care Team
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Ms. ___ was admitted to the antepartum service for monitoring of her bleeding in the setting of placenta previa/acreta. She had previously met with anesthesiology, urology, NICU and MFM for counseling about the planned preterm delivery and likely hysterectomy. She was made rescue betamethasone complete on ___. She was diagnosed with a UTI and started on treatment with macrobid. On ___, at 31w5d gestation, she experienced rupture of membranes. This was confirmed on examination. She was transferred to L&D. She had no bleeding or contractions. Magnesium was started for neuroprotection and latency antibiotics administered for infection prophylaxis. An OR team was assembled for delivery. She underwent an exploratory laparotomy, classical C-section with delivery of a viable preterm male infant, hysterectomy, and cystoscopy with bilateral ureteral stent placement and removal. Intraoperative findings were notable for likely placenta acreta, resulting in intraoperative hemorrhage. Please see operative report for full details. She received 6 unit PRBC + 4 units FFP, + 1 unit plt + 1 cryo + 420 cell saver for total products during the case. She presented to the ICU intubated after the procedure for close hemodynamic monitoring s/p C-section and total abdominal hysterectomy. On arrival to the FICU, patient was sedated and intubated. She was hemodynamically stable and serial labs showed stable hematocrits. She remained intubated overnight and was extubated uneventfully on ___. She was stable to leave the FICU on ___ and was transferred to the postpartum floor. Her postpartum and post-op course is summarized below: #Post-op: She had an uneventful postpartum course. Her foley was removed and she voided spontaneously. Her diet was slowly advanced and she was tolerating a regular diet by time of discharge. Her pain was initially controlled with IV dilaudid and toradol but she was transitioned to oral oxycodone/acetaminophen/ibuprofen when her diet was advanced. #UTI: patient found to have an E. coli pan sensitive UTI on ___. Started on macrobid on ___. Changed to ceftriaxone on ___ given unable to take PO immediately postop. After she was advanced to a regular diet, she was transitioned back to macrobid and completed her course on day of discharge. #H/o IV drug abuse on subutex BID: subutex was continued at her usual dose postpartum. A letter was provided to her prescriber to detail her hospital pain medication and last subutex dose. #H/o smoking: she continued her nicotine patch for smoking cessation #Hepatitis C: Her viral load in pregnancy 4000. Her LFTs were normal on admision. She had an uncomplicated recovery and was discharged home in stable condition on post-op day #4 with planned outpatient follow-up.
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10410901-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Erythromycin Base / Bacitracin <ATTENDING> ___. <CHIEF COMPLAINT> pre-eclampsia evaluation <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G4P0 @ ___ presents for ___ evaluation. She had elevated blood pressures in the office today. She currently denies vision changes, SOB, RUQ pain and epigastric pain. She does report a dull headache that she attributes to her sinus congestion. It is very mild right now and does not bother her. <PAST MEDICAL HISTORY> POBHx: G4P0 - TAB x 2 - SAB x 1 (T21 with SAB at 15 weeks) - G4 current PGynHx: Denies STDs, h/o abnormal Pap with colposcopy follow-up that was wnl PMH: Hepatitis C followed by Dr. ___ VL in ___ undetectable, baseline LFTs in ___, Abdominal diastasis s/p evaluation by Gen Surg without evidence of umbilical hernia, chronic tension headaches, exercise-induced asthma PSH: diagnostic laparoscopy to r/o endometriosis, D&C x 3 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Pulm: breathing comfortably on room air Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 09: 55AM BLOOD Hct-34.5 Plt ___ ___ 09: 15AM BLOOD Hct-34.6 ___ 10: 10AM BLOOD WBC-8.8 RBC-4.40 Hgb-14.2 Hct-41.1 MCV-93 MCH-32.3* MCHC-34.5 RDW-12.5 RDWSD-42.6 Plt ___ ___ 05: 08PM BLOOD WBC-9.1 RBC-4.26 Hgb-13.6 Hct-39.0 MCV-92 MCH-31.9 MCHC-34.9 RDW-12.4 RDWSD-41.1 Plt ___ ___ 09: 55AM BLOOD Creat-0.6 ___ 10: 10AM BLOOD Creat-0.5 ___ 05: 08PM BLOOD Creat-0.5 ___ 09: 55AM BLOOD ALT-30 AST-36 ___ 10: 10AM BLOOD ALT-26 AST-27 ___ 05: 08PM BLOOD ALT-25 AST-25 ___ 05: 08PM BLOOD UricAcd-4.5 <MEDICATIONS ON ADMISSION> cetirizine, PNV, albuterol <DISCHARGE MEDICATIONS> 1. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> gestational hypertention <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see instruction sheet
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Ms. ___ is a ___ y/o G4P1 who was admitted to the post partum service on ___ after spontaneous vaginal delivery complicated by gestational hypertension. She had normal pre-eclampsia labs on ___, but was started on labetalol 200 BID on ___ for elevated pressures. She also had some coccyx pain in the post partum period, which improved with tylenol, motrin, oxycodone, and heat packs. 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.
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10411345-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> postpartum hypertension found on routine screening <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p uncomplicated spontaneous vaginal delivery on ___ seen by ___ on ___, and found to have systolic blood pressures in the 150's. Patient also complaining of chest pressure. Pre-natal course was unremarkable although blood presures had slowly trended up toward the end of the pregnancy. Admit blood pressure on ___ was 136/89. She was sent to the emergency department where she was hypertensive to 166/99. She received 20mg IV Labetolol. A chest x-ray showed no acute cardiopulmonary abnormality. An EKG demonstrated normal sinus rhythm. Troponins sent and were negative. She was found, however, to have transaminitis and trace proteinuria. She received 4gm loading dose of Magnesium for presumed pre-eclampsia and transferred to labor and delivery for further monitoring. When she arrived on labor and delivery she denied headache, visual changes or right upper quadrant abdominal pain. The reported sensation of chest pressure was stable and she denies any chest pain, radiation to the arms. She has no nausea or vomiting. Her vaginal bleeding was improving and she was breastfeeding without difficulty. <PAST MEDICAL HISTORY> OBHx: TAB x 1 SVD ___, uncomplicated GYNHx: h/o abnormal pap s/p LEEP PMH: colonic polyps PSH: eye surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VS- 98.1 154/94 66 19 99%RA a&o x 3 comfortable, NAD CTAB RRR abd soft, nontender, FF below Umb No VB ___: 1+ edema to ___ knee 2+ DTR's ___ Results: ___ 10: 37PM ALT(SGPT)-139* ___ 10: 37PM URIC ACID-5.5 ___ 05: 45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM <MEDICATIONS ON ADMISSION> prenatal vitamin <DISCHARGE MEDICATIONS> 1. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp: *120 Tablet(s)* Refills: *2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 3. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for Pain. <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ 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> see OB discharge instruction sheet
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Ms ___ was continued on magnesium for 24 hours to reduce her risk of eclamptic seizure. She tolerated the Magnesium well and her urine output was adequate. She denies symptoms of Magnesium toxicity--shortness of breath or lethargy. Throughout her hospital stay she continued to deny symptoms of pre-eclampsia. Her chest pressure resovled spontaneously. On arrival to Labor and Delivery she was started on Labetalol for blood pressure control which was titrated up to 400mg BID by hospital day 1. By Hospital day 2 her liver function tests were trending down from ALT 130/AST 103-->ALT 103/AST 46. She was discharged home with ___ follow-up on Labetalol.
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10413427-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Codeine / doxycycline / Compazine <ATTENDING> ___ <CHIEF COMPLAINT> Fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic assisted laparoscopic supracervical hysterectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms ___ she is a ___ G3, ___ premenopausal Caucasian female here on L&D with known uterine fibroids, history of benign breast cysts and anxiety. She has been under care for worsening fibroid related bleeding. On review of her gynecologic symptoms, she reports regular menses every one month at baseline with three to four days of moderate to heavy flow. Over the last one year, she has noticed increasingly irregular bleeding occurring more frequently every two to four weeks with five to seven days of heavier and longer menses. She has denied pelvic pain or dysmenorrhea throughout. She denies any dyspareunia. Menometrorrhagia/fibroid evaluation by Dr. ___: -- PUS (___), at ___: UT 13.3 x 5.5 x 9.8 cm with multiple fibroids (largest fundal 6.1 x 5.7 x 5.1 cm). Endometrial thickening 2.3 cm heterogeneous, lack of definition of endomyometrial junction. Normal ovaries bilaterally. -- EMB (___) by Dr. ___: Proliferative endometrium. -- Labs (___), hematocrit 33.9. The patient's spouse is status post vasectomy. The patient is done with childbearing. Given the progressively worsening menometrorrhagia, the patient would like to proceed with fibroid treatment. She is not currently on any therapy at this time. <PAST MEDICAL HISTORY> OB History: G3, P2-0-1-2. 1. ___, C-section. Pregnancy complicated with duodenal atresia and breech presentation. 2. ___, elective repeat C-section. 3. ___, elective termination of pregnancy. GYN History: Menarche at age ___. LMP ___. Irregular menses every two to four weeks five to seven days of heavy and longer menses lasting five to seven days. Denies dyspareunia, pain with full bladder movement. Denies history of abnormal Pap. Last Pap ___ reportedly normal. Last mammogram ___, with breast cysts. The patient is sexually active, heterosexual, reports five sexual partners throughout life, currently monogamous with her spouse. Husband is status post vasectomy for contraception. Denies history of STDs. Medical Problems: 1. Uterine fibroids and menometrorrhagia. 2. Benign breast cysts bilateral. 3. Anxiety. Surgical History: 1. ___, C-section. 2. ___, C-section. 3. ___, D&C for TAB. 4. ___, laparoscopic cholecystectomy. 5. Wisdom tooth extraction. 6. Tonsillectomy. 7. Right breast fine needle aspiration one year ago, benign. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Reports mother recently diagnosed with breast cancer at age of ___ years. No maternal aunt in the family. The patient does have one sister who is alive and well. No other GYN cancers in the family. Denies any ovarian cancers. Paternal grandfather with lung cancer. Paternal grandfather, uncles, and aunt also with diabetes. Father with atrial fibrillation. No other family medical conditions. <PHYSICAL EXAM> On day of discharge: Afebrile, VSS NAD, Comfortable, appears well RRR CTAB Abd soft nontender nondistended, port sites clean dry intact No vaginal bleeding No peripheral edema <MEDICATIONS ON ADMISSION> Citalopram 20 Qday Ativan PRN <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *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. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroids, menorrhagia <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) and no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication
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Ms. ___ was admitted on ___ following uncomplicated robotic assisted supracervical hysterectomy for fibroids and menorrhagia. Please refer to operative note for full details. Her postoperative course was routine. She met postop milestones on POD 1 and was discharged to home in good condition.
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10414650-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> aspirin <ATTENDING> ___. <CHIEF COMPLAINT> loss of fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> Low transverse C/S <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G1P0 at 38w 1d with LOF, breech and +FM. Denies headache, vision changes, RUQ pain. PRENATAL CARE ___ ___ by 12wk u/s c/w LMP Labs: Rh+/Ab-/RPR-NR/HbSAg-neg/Rub-I/VZV-I/HIV-neg/GBS-pos Genetic Screening: PGD LR male, NIPT LR FFS: male, no anomalies, ant placenta GTT: 106 passed <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY - hypothyroidism - prolactinoma, pituitary microadenoma - nephrolithiasis - abnormal pap- +HPV PAST SURGICAL HISTORY - ureteral stents - septorhinoplasty - wisdom teech - tear duct dilation OBSTETRIC HISTORY Year | Outcome | Notes G1- current MEDICATIONS - PNV ALLERGIES - aspirin <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Physical Exam on Admission: Vitals ___ 21: 18Temp.: 98.1°F ___ 21: 49BP: 136/88 (99) ___ 21: 18BP: 142/98 (108) ___ 21: 19BP: 134/93 (103) ___ ___: 79 ___ ___: 77 Gen: A&O, comfortable CV: RRR RESP: CTAB ABD: soft, gravid, nontender EXT: no calf tenderness SVE: ___, grossly ruptured Toco: irreg ctx ___ FHT: 130 /moderate variability/+accels/-decels TAUS: breech _____________________________________________________ Physical Exam on Discharge: 24 HR Data (last updated ___ @ 405) Temp: 98.4 (Tm 98.9), BP: 139/84 (130-152/84-92), HR: 85 (69-85), RR: 18 (___), O2 sat: 98%, O2 delivery: ra Fluid Balance (last updated ___ @ 024) Last 8 hours Total cumulative 0ml IN: Total 0ml OUT: Total 0ml, Urine Amt 0ml Last 24 hours Total cumulative -970ml IN: Total 1280ml, PO Amt 1280ml OUT: Total 2250ml, Urine Amt 2250ml General: Resting in bed in no acute distress, A&Ox3 CV: Normal rate, regular rhythm. No murmurs, rubs, gallops Pulm: Lungs clear to auscultation bilaterally. No wheezes, crackles Abd: soft, mildly tender to palpation, fundus firm at 3cm below umbilicus Incision: clean, dry, intact, no erythema/induration Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 09: 45PM BLOOD WBC-14.3* RBC-3.55* Hgb-10.9* Hct-32.4* MCV-91 MCH-30.7 MCHC-33.6 RDW-13.6 RDWSD-45.1 Plt ___ ___ 09: 45PM BLOOD ___ PTT-24.5* ___ ___ 01: 10AM BLOOD WBC-9.4 RBC-3.02* Hgb-9.4* Hct-28.8* MCV-95 MCH-31.1 MCHC-32.6 RDW-13.5 RDWSD-46.8* Plt ___ ___ 09: 45PM BLOOD ___ ___ 10: 50AM BLOOD Glucose-130* UreaN-14 Creat-0.9 Na-141 K-3.7 Cl-103 HCO3-24 AnGap-14 ___ 10: 50AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.8 ___ 09: 45PM BLOOD ALT-41* AST-33 ___ 01: 10AM BLOOD ALT-77* AST-53* ___ 10: 50AM BLOOD TSH-3.1 ___ 06: 06AM URINE Hours-RANDOM Creat-116 TotProt-33 Prot/Cr-0.3* <MEDICATIONS ON ADMISSION> Prenatal vitamins <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Take with food RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 3. Labetalol 400 mg PO Q8H RX *labetalol 200 mg 2 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy resulting in C/S <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <DISCHARGE INSTRUCTIONS> per written instructions reviewed by nursing and OB providers ___: ___
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Ms. ___ presented to ___ and Delivery on ___ with loss of fluids and breech presentation. Decision made at that time to proceed with primary low transverse cesarean delivery. Postpartum, her course was complicated by preeclampsia, severe by blood pressures. Her serum labs were normal and P:C was 0.28 on ___. On the evening of ___, she had a sustained severe blood pressure requiring one dose of fast-acting nifedipine. She was started on nifedipine 30mg daily that day, and after 3 days, was transitioned to labetalol 200mg q8h and uptitrated to labetalol 400mg po q8h starting ___. She remained asymptomatic and well throughout this time. In addition, she had an episode of non-sustained tachycardia over the course of ___, for which complete workup, including EKG, repeat labs, and CTA were all reassuring. Etiology was thought to most likely be reflex tachycardia from nifedipine administration or insufficient oral intake. Her postpartum course was otherwise uncomplicated. Her pain was treated with oral pain medications. She was continued on her home levothyroxine. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced without incident. By postpartum day 6, her blood pressures were stabilized in the normal to mild-range on an oral antihypertensive regimen. In addition, 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.
| 1,273
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10416938-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Amoxicillin <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G0 presenting with RLQ pain for the past 1.5-2 days. The pain was sudden in onset, worsening, and constant. She has had some mild nausea but no emesis, no fevers/chills, diarrhea, or other associated symptoms. She has not used any pain medication today and has not required any pain medication in the ED - currently the pain is better. She does report a history of hemorrhagic cysts and has been to the ED once before for this type of pain, although this episode is much worse. With every menstrual cycle she typically feels some pain from what she presumes are cysts. <PAST MEDICAL HISTORY> GynHx: - regular cycles on OCPs - h/o abnormal Paps and colpo, most recent Pap normal OBHx: G0 MedHx: denies SurgHx: wisdom tooth extraction <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On evaluation in emergency room: Vitals - T: 99.2 BP: 125/62 HR: 64 RR: 16 General: NAD, resting comfortably CV: RRR Lungs: CTAB Abdomen: soft, non-distended, moderate TTP with deep palpation in the RLQ, no rebound/guarding Pelvic: no CMT, no TTP in the left adnexa or the uterus, marked TTP over the right adnexa, with adnexal fullness on the right <PERTINENT RESULTS> ___ 02: 00PM BLOOD WBC-5.6 RBC-4.43 Hgb-13.1 Hct-37.8 MCV-85 MCH-29.6 MCHC-34.7 RDW-13.4 Plt ___ ___ 02: 00PM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-137 K-4.3 Cl-106 HCO3-24 AnGap-11 ___ 02: 00PM BLOOD ALT-10 AST-19 AlkPhos-38 TotBili-0.2 ___ 02: 00PM BLOOD Lipase-37 ___ 02: 00PM BLOOD Albumin-4.1 ___ pelvic U/S: Right ovarian hemorrhagic cyst measuring 5.6 x 5.0 x 4.1 cm. Recommend 6 week follow-up pelvic ultrasound to assess for interval change. No evidence of current ovarian torsion, although intermittent torsion can not be excluded sonographically. <MEDICATIONS ON ADMISSION> MVI, OCP <DISCHARGE MEDICATIONS> MVI, OCP <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> right hemorrhagic cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call if you have recurrence of your severe abdominal pain, fever, feeling faint/dizzy, or any other concerns.
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Ms. ___ was admitted for abdominal pain, a hemorrhagic cyst on ultrasound, and a concern for torsion given the severity of her pain. She was made NPO and started on IV fluid hydration. Her labs and vital signs were normal and without evidence of infection or inflammation. Her pain notably improved on serial abdominal exams, which was reassuring. The final ultrasound read did not show evidence of current torsion. She was discharged on hospital day 2 with minimal pain not requiring medications, voiding and ambulating and eating a regular diet without difficulty. She was instructed to follow up with Dr. ___ and was given strict precautions to alert a physician if her pain or other concerning symptoms recur.
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10420866-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G0 presenting with acute onset lower abdominal pain, R>L accompanied by N/V beginning at 0100. Pain has been constant since onset and is somewhat improved at this time. Denies VB, fevers/chills. Has never experienced similar pain. No lightheadedness, shortness of breath or chest pain. Received morphine and zofran in ED. <PAST MEDICAL HISTORY> POb: G0 PGyn: regular menses, hx of ovarian cyst in distant past tx'd laparoscopically PMH: denies other than as above PSH: lsc surgery approx. ___ ago for ovarian cyst, does not believe anything was removed, but not sure as doctors talked with ___ parents at the time All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> O: HR 77 BP 134/86 RR 15 100%RA NAD RRR CTAB Abd soft, ND, diffusely TTP in lower quadrants, no guarding, +rebound Pelvic: + right adnexal fullness, non-enlaged uterus, no CMT, no vaginal bleeding, + TTP across lower abdomen, voluntary guarding with exam, no fibroids appreciated but exam limited by patient discomfort, cervix palpated as closed and nl Ext non-tender, no edema <PERTINENT RESULTS> Admission Labs: ___ 02: 45AM BLOOD ___ PTT-27.6 ___ ___ 02: 45AM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-140 K-3.7 Cl-104 HCO3-25 AnGap-15 ___ 02: 45AM BLOOD HCG-LESS THAN 5 CBC Trend: ___ 02: 45AM BLOOD WBC-11.8* RBC-5.15 Hgb-10.0* Hct-34.8* MCV-68* MCH-19.5* MCHC-28.8* RDW-19.3* Plt ___ ___ 11: 00AM BLOOD WBC-8.8 RBC-4.65 Hgb-9.2* Hct-31.2* MCV-67* MCH-19.9* MCHC-29.6* RDW-19.1* Plt ___ ___ 05: 40PM BLOOD WBC-6.3 RBC-4.58 Hgb-9.1* Hct-30.0* MCV-65* MCH-19.9* MCHC-30.5* RDW-19.2* Plt ___ Pelvic Ultrasound (___): IMPRESSION: 1. 5 cm hemorrhagic right ovarian cyst for which six-week followup imaging can be obtained by pelvic ultrasound, unless further characterized by MRI. Though vascular flow is seen, torsion of this ovary would be difficult to exclude. 2. Two pelvic masses measuring 5 and 3.8 cm which are most likely pedunculated or exophytic fibroids, however more complete assessment by non-emergent short term pelvic MRI is recommended. 3. Moderate volume of complex free fluid. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> None <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ruptured hemorrhagic cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were hospitalized for observation because of your abdominal pain. The pain resolved after one dose of morphine. It is likely the pain is due to a hemorrhagic cyst, which can be a normal finding. We observed you and felt that you were stable and that your blood counts were also at a safe level. If you develop increasing abdominal pain or nausea or vaginal bleeding, please call your doctor or present to the emergency room. See below for clinic number. You should follow-up in ___ clinic as instructed below because you have fibroids that need to be further characterized.
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Ms. ___ was admitted with abdominal pain likely secondary to a ruptured hemorrhagic cyst, but she was admitted for observation given free fluid evident on ultrasound as well as concern for intermittent torsion. She was observed throughout the day and received serial abdominal exams, which showed minimal tenderness that decreased throughout the day. She did not require any additional pain medication and only received zofran once. Her vital signs remained stable and her hemoglobin and hematocrit stablized. She was discharged home in good condition. Of note, her pelvic ultrasound showed two pelvic masses, measuring 5 and 3.8 cm which most likely represent exophytic fibroids, but pelvic MRI is recommended for follow-up. The patient is scheduled to be seen by the ___ clinic in ___.
| 963
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10421517-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Levaquin <ATTENDING> ___ <CHIEF COMPLAINT> - complex pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> - laparotomy - lysis of adhesions - resection of pelvic mass - right ureterolysis - partial infracolic omentectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ woman who was found to have a complex pelvic mass on imaging performed for evaluation of lymphedema. She elected to proceed with surgical management. <PAST MEDICAL HISTORY> - hypertension - hypercholesterolemia - dermatofibrosarcoma - lymphedema . - radical excision of dermatofibrosarcoma, left groin dissection - total abdominal hysterectomy for fibroids - bilateral salpingo-oophorectomy for endometriosis <SOCIAL HISTORY> ___ <FAMILY HISTORY> - maternal aunt and cousin with breast cancer <PHYSICAL EXAM> On discharge: Vitals - WNL General: NAD, sitting comfortably CV: RRR Lungs: CTAB Abdomen: soft, obese, minimal TTP, bowel sounds present, incision C/D/I with staples Ext: no calf TTP <PERTINENT RESULTS> ___ Hct-34.6 ___ WBC-11.3 Hgb-12.1 Hct-34.5 Plt ___ . ___ 08: 00AM BLOOD Creat-0.6 Na-137 K-4.4 Cl-102 ___ 08: 00AM BLOOD Mg-1.9 <MEDICATIONS ON ADMISSION> - atenalol - atorvastatin - aspirin <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: 60 Capsule(s) Refills: 0 2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: 50 Tablet(s) Refills: 0 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: 60 Tablet(s) Refills: 0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - pelvic mass <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please take your medications as prescribed. No strenuous activity or heavy lifting for 6 weeks. Please do not drive when taking narcotic pain medications. . Please call your doctor for the following: - fever greater than 100.4 - persistent nausea/vomiting - chest pain, difficulty breathing - severe or increasing pain, not relieved with medication - redness or discharge from your incisions - if your incisions re-open
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Ms. ___ underwent an laparotomy, lysis of adhesions, resection of pelvic mass, right ureterolysis, partial infracolic omentectomy. Please see the operative report in ___ for full details. Her course was complicated by nausea and vomiting on the morning of post-operative day #2, which resolved with bowel rest and anti-emetics. Her diet was slowly advanced, and she was tolerating a regular diet on discharge. Her hospitalization was otherwise uncomplicated and she was discharged home on post-operative day #4.
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10422574-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Kidney stones <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> LLQ pain HPI: ___ G3P2 at 32+2 with LLQ pain that woke her from sleep last night several times. Was able to fall back to sleep but awoke this AM and pain continued to come/go. No aggravating or alleviating factors. Also feels like increased discharge/pantyliner more damp starting over the weekend. Denies VB or CTX. +AFM. <PAST MEDICAL HISTORY> PCOS <PHYSICAL EXAM> ADMISSION <PHYSICAL EXAM> -VS: ___ 11: 51BP: 113/66 (75) ___ ___: 87 ___ 11: 54Temp.: 98.0°F ___ 11: 54Resp.: 18 / min -Gen: NAD -Abd: gravid, soft, minimally TPP LLQ, no rebound or gaurding -NST: 140, mod var, +accels, no decels -Toco: flat -SSE: physiologic discharge, neg pooling, neg nitrazine, neg ferning, cervix visually closed -SVE: deferred <PERTINENT RESULTS> ___ 04: 11PM BLOOD WBC-11.4* RBC-3.63* Hgb-10.4* Hct-32.5* MCV-90 MCH-28.7 MCHC-32.0 RDW-14.0 RDWSD-45.4 Plt ___ ___ 04: 11PM BLOOD UreaN-6 Creat-0.6 <MEDICATIONS ON ADMISSION> 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Tamsulosin 0.4 mg PO QHS 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Nephrolithiasis <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for kidney stones. Your pain improved overnight and you were stable for discharge in the morning. Will plan for increase in water intake throughout the day.
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Patient was admitted for pain with a history of kidney stones this pregnancy. Was found to have a 4mm UVJ stone on the left. She was admitted overnight for hydration and pain control. The case was discussed with urology and ___ 0.4mg QHS was added. On HD #2 patient felt well without pain and was deemed stable for discharge.
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10424199-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> cervical cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Interstial Vaginal Brachytherapy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ female who has not seen a doctor in many years, who suddenly developed left lower quadrant pelvic and left flank pain for which she went to an urgent care center. She was diagnosed with a urinary tract infection and was placed on antibiotics. She then developed brown foul smelling urine and went to the ED at ___ on ___, with CT of the abdomen and pelvis showing extensive diverticulosis, especially in the sigmoid, a 16 mm rim-enhancing collection within the sigmoid wall with an intramural abscess, a fistula between the bladder and bowel with the bladder filled with air, fluid and stool, and an 8 mm hypodensity in the right lobe of the liver. She was transferred to ___ on ___, and placed on ceftriaxone and Flagyl. She was discharged on ___, with a plan for outpatient colonoscopy and cystoscopy. On ___, right upper quadrant ultrasound revealed a 11 mm cyst in the right lobe of the liver. She was seen by Dr. ___ of ___ on ___, with flexible sigmoidoscopy revealing an obstructing neoplastic mass in the mid rectum, and he was unable to pass the scope proximally. Biopsy was no evidence of malignancy. On ___, Dr. ___ a diverting loop sigmoid colostomy, with peritoneal fluid showing no malignancy. On ___, barium study via the rectum showed a 10 cm occlusion of the sigmoid. She went to the ED on ___, with right flank pain, with CT renal stones showing right perinephric stranding and mild hydronephrosis. She was discharged on ___, on antibiotics. On ___, Dr. ___ an exploratory laparotomy, open low anterior resection with end ostomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and right ureterolysis with the assistance with Dr. ___. During the procedure, he noted deep solid chronic fibrosis of the pelvis involving the sigmoid and intimately involving the uterus, bilateral ovaries, bladder trigone, and a colovesicular fistula. Final pathology showed a squamous cell carcinoma that was positive for HPV ___ with perineural invasion and lymphovascular invasion, involving the colon and one pericolonic lymph node. The cancer also involved the left ovary and fallopian tube, and right ovary. The uterus was not identified and was likely completely replaced by the malignancy. During the procedure, cystoscopy by Dr. ___ showed feculent material and a fistula at the bladder base. She also placed temporary bilateral ureteral stents during the procedure. The patient was referred to Dr. ___ on ___, at which point he palpated firm tissue at the vaginal apex. Biopsy was consistent with moderately to poorly differentiated squamous cell carcinoma. On ___, PET-CT at ___ reportedly showed an intensely avid vaginal cuff mass and multiple avid pelvic, paraaortic and presacral lymph nodes going up to the level of L1. Pelvic MRI at ___ that same day showed that she was status post hysterectomy and oophorectomy. There was a 2.7 x 1.5 x 2.6 cm enhancing T2 hypointense mass largely replacing the vaginal cuff with restricted diffusion, consistent with residual or recurrent squamous cell carcinoma. There is mural involvement of multiple adjacent tethered small bowel loops and the mass was inseparable from and likely invading the posterior bladder dome and ___ pouch. There were 1.0 and 0.8 cm left pelvic sidewall lymph nodes and partially imaged enlarged retroperitoneal, paraaortic and iliac lymph nodes. Currently, the patient has an ostomy, but otherwise is doing extremely well. She occasionally has vaginal spotting with pelvic exams, but denies any abnormal vaginal discharge, pelvic or abdominal pain, diarrhea or constipation through her ostomy, rectal bleeding, dysuria, hematuria, urinary frequency, urgency or incontinence, or lower extremity edema. Her energy and appetite are at baseline, although she is very thin, and she denies any recent weight loss. <PAST MEDICAL HISTORY> Oncologic Hx: ___: Low anterior resection of the rectum with end ostomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy ___ cuff recurrence and numerous involved pelvic and para-aortic nodes by PET/CT. EBRT to pelvic and para-aortic lymph nodes to 55 Gy with concurrent chemotherapy Brachytherapy <PAST MEDICAL HISTORY> none PSH: as above ObGyn: G0. Menopause at age ___. Meds: OMEPRAZOLE, ONDANSETRON, PROCHLORPERAZINE, ACETAMINOPHEN All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Brother died at age ___ of throat cancer and sister died at age ___ of throat cancer, both were smokers. <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM --======== BP: 93/45. Heart Rate: 127. Weight: 90.7 (With Clothes; With Shoes). BMI: 16.1. Temperature: 98.0. Resp. Rate: 16. ECOG performance status is 0. Pain ___. GENERAL: Thin, cachectic, female, in no acute distress. HEENT: Normocephalic and atraumatic. Extraocular muscles are intact. No conjunctival injection. No scleral icterus. NECK: Supple with no thyroid masses. LYMPH NODES: No cervical, supraclavicular or inguinal lymphadenopathy. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2. No murmurs, rubs or gallops. ABDOMEN: Soft, nontender and nondistended with normoactive bowel sounds. There is an ostomy in the left lower pelvis. GYNECOLOGIC: External genitalia are unremarkable. The remainder of the examination is limited due to pain, likely due to a skin reaction from radiation. Speculum examination demonstrates a flatter friable mass at the cuff that bleeds slightly with manipulation. On bimanual examination, there is a friable nodular mass at the vaginal cuff, significantly decreased in size and extent. On rectovaginal examination, which was limited, the residual mass measures about 3 cm wide and 1 cm sup-inf. Rectal tone is normal and there is minimal amount of blood on the examining fingers. EXTREMITIES: No clubbing, cyanosis or edema. MUSCULOSKELETAL: No spinal tenderness and no flank tenderness. NEUROLOGIC: Alert and oriented x3. Casual gait is narrow based and normal. --======== PHYSICAL EXAM ON DISCHARGE: --======== On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, no rebound/guarding GU: no active bleeding from vulva, scant blood on pad. ___: nontender, nonedematous <PERTINENT RESULTS> --======== LABS ON ADMISSION --======== None --======== IMAGING ON ADMISSION --======== None --======== RELEVANT LABS: --======== ___ 07: 40 WBC 5.2RBC 2.95* Hgb 8.6* Hct 26.2*MCV 89 MCH 29.2MCHC 32.8RDW 17.6*RDWSD 49.0*Plt Ct ___ ___ 07: 40 Calcium 8.7 Phos 4.0 Mg 1.5* ___ 07: ___ --======== RELEVANT IMAGING: --======== ___ CT CHEST: 1. No evidence of pulmonary embolism or aortic abnormality, however assessment of subsegmental pulmonary arteries in the lower lobes is somewhat limited due to respiratory motion artifact. 2. Small left pleural effusion with adjacent compressive atelectasis. Dependent atelectasis is also seen on the right. 3. Severe emphysema. 4. Pulmonary nodules measure up to 5 mm in mean diameter. Recommend attention on follow-up studies. --======== LABS ON DISCHARGE --======== ___ 07: ___ ___ 07: 40 Glucose 118*1 UreaN 16 Creat 0.8Na 136K 3.6 Cl 97 HCO3 30 AnGap 13 ___ 07: 40 Calcium 8.7 Phos 4.0 Mg 1.5* ___ 07: 40 WBC 5.2 RBC 2.95* Hgb 8.6* Hct 26.2*MCV 89MCH 29.2MCHC 32.8RDW 17.6*RDWSD 49.0*Plt Ct ___ <MEDICATIONS ON ADMISSION> 1. omeprazole 20 mg capsule,delayed release 1 tab in a.m and may repeat during day capsule(s) by mouth 2. Acetaminophen Extra Strength 500 mg tablet ___ tablet(s) by mouth as needed for pain <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN constipation use while taking oxycodone RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *1 2. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drink alcohol and drive. Partial fill upon request. RX *oxycodone 5 mg ___ tablet(s) by mouth Q4HR Disp #*50 Tablet Refills: *0 3. Acetaminophen 500 mg PO Q4H: PRN Pain - Mild 4. Omeprazole 20 mg PO BID PRN GERD <DISCHARGE DISPOSITION> Home <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> BRACHYTHERAPY DISPO: Dear Ms. ___, . You were admitted to the gynecologic oncology service for brachytherapy. You have recovered well after your treatment, 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 doctor. * Your activities depend on how you feel. It is important to balance your activities at home with frequent rest periods, particularly during the first week. * 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 ___. Call your doctor at ___ for: * Excessive vaginal irritation * Vaginal bleeding * Vaginal discharge that has a bad odor or unusual odor * Fever (temperature greater than ___ F) * Constipation or diarrhea that lasts longer than a day * Severe pain * Continued burning or pain on urination
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Ms. ___ was admitted to the gynecologic oncology service for placement of interstitial implant on ___ brachytherapy . Please see operative report for full details. 1)Brachytherapy She received treatments from ___ until ___ for a total of 5 sessions. She was maintained on bedrest and a clear diet throughout this time. Acute pain service was managing her epidural while the implants were in place. While inpatient, she received 5 doses of radiation therapy. She was premedicated with Ativan before each radiation treatment. She completed her last dose of radiation therapy on ___. Her implant was removed bedside later that morning. APS then removed her epidural without any complications. Then,her foley catheter was removed and she voided spontaneously. She was transitioned to oral acetaminophen and oxycodone for pain. By the end of day ___, she was tolerating a regular diet and voiding spontaneously. Physical therapy was consulted to ensure that she was ambulating safely and independenlty. She was then discharged home in stable condition with outpatient follow-up scheduled. 2)Oxygen Desaturation On ___ her oxygen saturation decreased and she became mildly tachycardic raising concern for possible PE. Patient was asymptomatic and breathing comfortably. Chest CT was ordered and showed no evidence of PE. Patient was deemed safe for discharge.
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| 282
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10425084-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Breast Pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Surgical consult I&D left breast abscess surgical consult I&D left breast abscess <HISTORY OF PRESENT ILLNESS> Patient is a ___ yo G2___ 17days s/p LTCS for twins who presents with L breast erythema and inflammation. Patient noted fevers, erythema, and heat on ___ and eventually defervesced on ___. Patient recorded fevers to 102.7. Patient reports seeing her ob last week and beginning a 10 day course of kefzol for a wound infection at her ___ site as well as this breast inflammation. She noted increased induration and raised surface beginning on ___. Patient notes that she has continued to breastfeed successfully from both sides. She denies any other symptoms including n/v, abdominal tenderness, SOB, pain, dysuria, leg pain. Patient states that she presents to gyn triage because she was seen by her ob in clinic for a f/u and her MD desired ___ more thorough workup. ObHx: - ___ LTCS of twins at ___ GA c/b HTN and proteinuria - SAB x 1 <PAST MEDICAL HISTORY> none <SOCIAL HISTORY> Married. No tob/EtOH/drugs <PHYSICAL EXAM> On admission: 97.3, 75, 113/76, 20 Gen: awake and alert, comfortable, using breast pump, friend bedside CV: ___ lungs: CTAB breasts: left breast with ~6cm area of erythema with central desquamation, indurated, nonfluctuant, warm to touch, TTP, just superior to the areola. Right breast without any of the above symptoms. back: no CVAT abd: soft, NT, ND, +bs, Phannensteil with small area of erythema right superior aspect, otherwise appears to be healing well. GU: no VB Extr: no TTP/edema <MEDICATIONS ON ADMISSION> kefzol 500mg QID, day ___ ibuprofen acidophillus PNV Fe <DISCHARGE MEDICATIONS> 1. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp: *40 Tablet(s)* Refills: *0* 2. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Left breast abscess <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per nursing discharge instruction sheet Call office if any further concerns with breast pain, redness, leakage from I&D site, fever or any other concerns Ok to shower and wash skin Antibiotics and pain med as prescribed.
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Pt admitted for IV antibiotic treatment of left breast mastitis vs abscess. While in gyn triage, pt seen by ultrasound and attempt was made to aspirate abscess however, only 5cc of fluid could be drained. Pt began treatment with Nafcillin IV and continued her current Keflex which she was on for her wound infection. Pt remained afebrile. On HD#2, surgery consulted and I&D'ed abscess. Antibiotics changed to Vancomycin. Pt's wound was packed with iodoform packing and changed twice per day. Abscess continued to improve. Pt d/c'ed on HD#3 on PO Bactrim with follow up with Dr. ___ as an outpatient.
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10426280-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal wound debridement <HISTORY OF PRESENT ILLNESS> ___ G1P1 ___ s/p SVD (___) presenting with worsening severe burning vaginal pain for several hours. Pregnancy notable for elevated GLT, normal 3hr oGTT. IUGR diagnosed at ___ with EFW 12% AC<1%. Patient underwent augmentation of labor at 38w1d for SROM. Intrapartum patient developed gestational hypertension. Delivery notable for 1 nuchal cord cut and clamped at perineum. Postplacental Liletta IUD placed under US-guidance. First degree vaginal laceration repaired with ___ vicryl. Rectal exam normal. On postpartum day #2, ___ (___) documented patient reported "increased discomfort in right vaginal area" and had edema on right labia, which was moderately soft and tender on exam. She encouraged ___ baths and comfort measures. Patient reported for the first 3 days, she took Tylenol and Ibuprofen q6 and had minimal soreness. Patient was eating, voiding, ambulating, and breastfeeding without issues. Reports this afternoon she started to have burning introital pain, which was different from perineal soreness. Reports pain became more severe this evening and was unable to void ___ pain. Had no issues voiding throughout the day prior to the severe pain. Patient now in triage reporting ___ severe burning introital pain. Denies any fevers/chills, N/V, dizziness, SOB, chest pain, HA. Unsure if her bladder is full at this time given her severe pain. Scant bleeding. Confirmed nothing in the vagina since delivery. Denies history of tobacco use, diabetes, steroids. Last took Tylenol 1g and Ibuprofen 600mg at ___. NPO since ___. <PAST MEDICAL HISTORY> OBHx: - G1: SVD c/b gHTN GynHx: - history of gHSV, took Valtrex at end of pregnancy, denies preceeding symptoms - denies fibroids, endometriosis, ovarian cysts PMH: hypothyroidism PSH: denies Meds: levothyroxine All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> ___ <PHYSICAL EXAM> Physical Exam on Admission: Vitals: ___ 22: 07Temp.: 97.8°F ___ 22: 07Resp.: 28 / min ___ 22: 08BP: 134/82 (94) ___ ___: 75 ___ 23: 42Temp.: 98.2°F ___ 23: 42Resp.: 16 / min ___ 23: 43BP: 134/90 (100) ___ ___: 59 Gen: significant discomfort while sitting prior to Morphine -> slight discomfort and rest and significant discomfort with exam after Morphine Breasts: nontender and without lesions bilaterally, no overlying skin changes, no cracks in nipples, no evidence of engorgement Pulm: nl work of breathing Abd: soft, no fundal tenderness, nontender in all 4 quadrants SVE: severe pain at 0700 region ~2cm inside introitus, unable to tolerate bimanual exam to assess for cervical motion tenderness SSE: - cervix: ~1cm dilated, nontender when palpated and manipulated with scopette inside external os, scant physiologic appearing discharge - perineum: vertical laceration inferior to introitus 0600 approximated, nontender, and normal appearing - vagina: - 2cm of running suture on inner left labia nontender and healing well - 3cm inside 0700 region of introitus is a 2-3cm x 1cm region of running sutures that is severely tender to even light palpation with gray wound edges, loose mucousy green discharge/slough, appears infected and likely necrotic Ext: no calf tenderness/swelling/pain _ ________________________________________________________________ Physical Exam on Discharge: Fluid Balance (last updated ___ @ 1718) Last 8 hours No data found Last 24 hours Total cumulative 718ml IN: Total 1618ml, IV Amt Infused 1618ml OUT: Total 900ml, Urine Amt 900ml 24 HR Data (last updated ___ @ 338) Temp: 97.9 (Tm 97.9), BP: 117/75 (117-1126/74-88), HR: 63 (63-82), RR: 18, O2 sat: 97% (97-99), O2 delivery: ra PE: General: NAD, A&Ox3 Lungs: No respiratory distress, normal work of breathing Abd: soft, nontender, fundus firm at cm below umbilicus, no RUQ tenderness GU: external genitalia wnl Lochia: minimal Extremities: no calf tenderness <PERTINENT RESULTS> ___ 12: 28AM BLOOD WBC-11.3* RBC-3.63* Hgb-11.0* Hct-32.9* MCV-91 MCH-30.3 MCHC-33.4 RDW-12.9 RDWSD-42.5 Plt ___ ___ 12: 28AM BLOOD Neuts-70.4 Lymphs-18.0* Monos-7.4 Eos-2.2 Baso-0.2 Im ___ AbsNeut-7.96* AbsLymp-2.03 AbsMono-0.84* AbsEos-0.25 AbsBaso-0.02 ___ 05: 45AM BLOOD WBC-8.9 RBC-3.30* Hgb-9.7* Hct-30.5* MCV-92 MCH-29.4 MCHC-31.8* RDW-12.9 RDWSD-43.0 Plt ___ ___ 05: 45AM BLOOD Neuts-68.9 ___ Monos-6.0 Eos-2.5 Baso-0.2 Im ___ AbsNeut-6.13* AbsLymp-1.85 AbsMono-0.53 AbsEos-0.22 AbsBaso-0.02 ___ 12: 28AM BLOOD Glucose-78 UreaN-12 Creat-0.7 Na-142 K-4.0 Cl-105 HCO3-18* AnGap-19* ___ 12: 28AM BLOOD Calcium-10.1 Phos-2.9 Mg-1.9 ___ 06: 02AM BLOOD Lactate-0.6 ___ 12: 28AM URINE Color-Straw Appear-Clear Sp ___ ___ 12: 28AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG ___ 12: 28 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 12: 45 am SWAB Site: VAGINA Source: vaginal wound. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Preliminary): Procedural pathology pending <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *2 2. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet by mouth four times a day Disp #*20 Tablet Refills: *0 3. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK RX *estradiol 0.01 % Apply to the inside of your vagina 2 times a week Disp #*1 Tube Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild/Fever Reason for PRN duplicate override: Alternating agents for similar severity RX *ibuprofen 600 mg 1 tablet by mouth every six (6) hours Disp #*50 Tablet Refills: *2 5. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet by mouth every four (4) hours Disp #*5 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal wound infection s/p debridement and repair Gestational hypertension s/p Vaginal delivery ___ <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the Gynecology service from ___ for concern for an infection around your incision. You had the wound cleaned out in the OR on ___. 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. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ presented to ___ Triage with vaginal pain, with physical exam concerning for vaginal wound breakdown and infection. She required narcotics for pain management on initial presentation, and through the night. In addition, she was unable to urinate and required Foley catheter placement for a 600cc diuresis. She was admitted to the Postpartum floor on the Gynecology service for IV antibiotics and was added on to the OR schedule for ___. On the morning of ___ she underwent wound debridement and repair under sedation. The procedure was uncomplicated, please see operative report for more information. After her procedure, her Foley was discontinued in the PACU and she was able to void spontaneously. Her pain was initially controlled with oral ibuprofen and acetaminophen. However, she was nervous to go home without better pain control so stayed overnight for observation and managed her pain with oxycodone as needed. On the morning of ___, she was transitioned to oral cephalexin. Her pain was under adequate control, she was ambulating and voiding without issue. She was deemed stable for discharge that morning with close outpatient follow up.
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10427545-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> preterm labor, di di twins <MAJOR SURGICAL OR INVASIVE PROCEDURE> -- <HISTORY OF PRESENT ILLNESS> ___ G4P1 @ 35+ wks with di di twins, reduced from triplets, h/o short cervix, one twin with thanatophoric dysplasia and polyhydramnios, presents with preterm labor. <PAST MEDICAL HISTORY> Primary hyperparathyroidism <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> AVSS NAD RRR CTAB ABD gravid, NT EXT NT, NE SVE ___ <PERTINENT RESULTS> ___ 10: 15AM HBsAg-NEGATIVE ___ 10: 15AM HIV Ab-NEGATIVE ___ 10: 15AM URINE HOURS-RANDOM ___ 10: 15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG ___ 10: 15AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 10: 15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 10: 15AM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 10: 15AM URINE MUCOUS-RARE ___ 08: 30AM WBC-7.1 RBC-3.64* HGB-9.2* HCT-28.0* MCV-77* MCH-25.2* MCHC-32.8 RDW-15.0 ___ 08: 30AM PLT COUNT-446* <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 hr Disp #*40 Tablet Refills: *0 2. OxycoDONE (Immediate Release) 10 mg PO Q3H: PRN pain RX *oxycodone 10 mg 1 tablet(s) by mouth q 3 hr Disp #*30 Tablet Refills: *0 3. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR QID PRN hemorrhoids RX *hydrocortisone 2.5 % small amount cream(s) rectally QID prn Disp #*1 Tube Refills: *0 4. Outpatient Physical Therapy out patient ___ for separated symphysis pubis after vaginal delivery <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p vaginal delivery of twins pubic symphysis separation <DISCHARGE CONDITION> stable ambulating with walker <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> See discharge instructions. Pelvic rest for 6 weeks.
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Pt admitted and had NVD of twin pregnancy. Post partum she had pelvic pain which was likely due to separated pubic symphysis. This improved with ___ and she was disharged home on postpartum day 3.
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10433390-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Valium <ATTENDING> ___. <CHIEF COMPLAINT> symptomatic fibroids, vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, R Salpoingo-Oophorectomy <HISTORY OF PRESENT ILLNESS> The patient is a ___ G3 A3 postmenopausal woman who presents today for consideration of total abdominal hysterectomy with bilateral salpingo-oophorectomy. I have seen ___ several times this year for a complaint of intermittent postmenopausal spotting and bleeding. This sometimes is heavy over the course of the last several years and she has had a thorough workup to evaluate this postmenopausal bleeding, which has included no less than four endometrial biopsies. The last biopsy I performed for her was as recent as ___ and was revealing only for atrophic endometrium and benign squamous mucosa. A recent ultrasound on ___ reveals a submucosal fibroid measuring over 3 cm. The fibroid is slightly increased in size compared to prior ultrasounds from ___. She also has a persistent 1.6-cm right ovarian cyst. This cyst is also somewhat increased in size from previous measurements on ultrasound several years ago. The patient remains very frustrated with this ongoing intermittent postmenopausal bleeding, which is secondary to submucosal fibroid. She has been thinking about and strongly wishes to proceed with definitive therapy via hysterectomy at this time. She denies any significant abdominal or pelvic pain. She is aware of the persistent nature of the right ovarian cyst and would prefer to have her ovaries removed at the time of hysterectomy. Her GYN history is notable for cervical cone biopsy in ___ for cervical dysplasia and her Pap smears have remained normal since that time. Her last Pap smear, which I performed for her was in ___ of this year and it was completely normal. That Pap smear was taken on ___. She has no complaints of bowel or bladder dysfunction. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Notable for migraine headaches and GE reflux. PAST SURGICAL HISTORY: Notable for a laparotomy in ___ for a large left ovarian cyst and ovarian cystectomy was performed and the pathology was benign. She is also status post two D&Cs for SABs. These were in the first trimester and she is status post cervical cone biopsy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> colorectal cancer in mother Physical ___: PHYSICAL EXAMINATION: HEART: Today, regular rate and rhythm. LUNGS: Clear. ABDOMEN: Soft, nontender, nondistended with no palpable masses. A well-healed transverse skin incision. PELVIC: Exam reveals no inguinal adenopathy. The cervix is somewhat shortened in its appearance and slightly scarred from her cone biopsy. The uterus is not particularly enlarged, anteverted, mobile and nontender. There are no adnexal masses. On Discharge: NAD, well-appearing RRR CTAB Abd soft, approp tender, incision c/d/i Ext without edema, NT <PERTINENT RESULTS> ___ 07: 50AM BLOOD WBC-11.8* RBC-4.23 Hgb-11.8* Hct-35.5* MCV-84 MCH-27.8 MCHC-33.2 RDW-13.3 Plt ___ <MEDICATIONS ON ADMISSION> Medications - Prescription ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation Aerosol Inhaler. 2 puffs(s) mouth q ___ hrs prn BUDESONIDE [PULMICORT FLEXHALER] - Pulmicort Flexhaler 180 mcg/actuation Breath Activated. 2 puffs(s) inhaled twice a day as needed for prn --wrise out mouth after use and brush teeth. EPINEPHRINE [EPIPEN] - EpiPen 0.3 mg/0.3 mL (1: 1,000) injection,auto-injector. inject one, wait 20 mins, inject a second one above SUMATRIPTAN SUCCINATE - sumatriptan 100 mg tablet. 1 tablet(s) by mouth with fluids at the onset of a headache, may repeat in 2 hours as needed **Do not exceed 2 tablets in 24 hours** Medications - OTC CALCIUM CITRATE-VITAMIN D3 - calcium citrate-vitamin D3 315 mg-200 unit tablet. 2 Tablets(s) by mouth once a day - (OTC) CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 1,000 unit capsule. 3 Tablet(s) by mouth once a day COD LIVER OIL - Dosage uncertain - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg tablet,delayed release. 1 Capsule(s) by mouth Half an hour prior to breakfast <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 #*40 Capsule Refills: *0 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H: PRN shortness of breath 3. Albuterol Inhaler ___ PUFF IH Q4H: PRN shortness of breath 4. Omeprazole 20 mg PO DAILY 5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain do not drive. take with food. do not exceed 4000mg acetaminophen in 24 hours. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 6. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation BID prn shortness of breath 7. 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 #*40 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, It was a pleasure caring for you during your stay here at ___. You recovered well after your surgery and were felt to be safe to be discharged to home. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecology service after undergoing a total abdominal hysterectomy and right salpingo-oophorectomy. Her post-operative course was uncomplicated and she met all post-op milestones including tolerating a regular diet, controlling pain with oral medication, ambulating and voiding spontaneously without a foley catheter. She was discharged home in stable condition on post-operative day #1. She will follow up with Dr. ___ as scheduled.
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10434280-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> post menopausal bleeding with endometrial adenocarcinoma on endometrial biopsy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total lapaorscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection, and cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ who reports ___ months of postmenopausal bleeding. She underwent an endometrial biopsy on ___ which showed "complex glandular proliferation". Pelvic US on ___ demonstrated an 8.9 x 3.9 x 5.3 cm anteverted uterus. There was a small fibroid measuring 1.6 cm. The endometrium was heterogeneous and thickened and measured 6 mm. There was a echogenic lesion with cystic spaces within the endocervical canal measuring 2.4 cm. The ovaries were not visualized however there were no adnexal masses and no free fluid. She underwent a repeat endometrial biopsy on ___. This demonstrated endometrial adenocarcinoma, endometrioid type, FIGO grade 1 with focal squamous metaplasia. The biopsy is in the process of being reviewed here at ___. The patient was referred to GYN oncology for further evaluation and treatment recommendations. Since then she continues to have light spotting. She otherwise feels well and denies any pain or discomfort. She denies any early satiety, unintentional weight changes, nausea/vomiting, SOB/CP, increased abdominal girth, abdominal or pelvic pain, vaginal discharge, or change in her bowel or bladder habits. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> History of an upper GI bleed from a gastric ulcer in ___ in the setting of NSAID use Sleep apnea Obesity Type 2 diabetes Hypertension Osteoarthritis Hyperlipidemia History of melanoma History of pseudogout History of herpes zoster dermatitis of the eyelid History of major depression Past Surgical History: Open cholecystectomy in ___ Open myomectomy in ___ Past OB History: Gravida 1 para 1 Spontaneous vaginal delivery in ___ Past GYN History: - Menopause at age ___ - Denies history of pelvic infections or STIs -OCP and HRT use for ___ years each -Known uterine fibroids <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of GYN cancer; her sister died in ___ of breast cancer, age ___. No colon cancer in the family. <PHYSICAL EXAM> Pre-operative physical exam: GENERAL: No acute distress, well developed, well nourished, appears younger than stated age. HEENT: NC/AT, sclera anicteric SKIN: Warm and dry. NEUROLOGIC: Alert and oriented x 4. NECK: Supple no mass LYMPHATICS: No palpable supraclavicular, cervical, or inguinofemoral lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. BACK: No spinal or cva tenderness. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds, without palpable masses or hepatosplenomegaly. Right upper quadrant incision. Large ___ incision. EXTREMITIES: Nontender, no edema bilaterally. PELVIC: -External female genitalia: normal -Vagina: no lesions -Cervix: no lesions, not expanded -Uterus: not enlarged, nontender -Adnexa: no palpable masses RECTAL: deferred Day of Discharge physical exam: AVSS Gen: Patient is well appearing, no acute distress. Alert and oriented x 3. Cardiac: RRR, no murmurs Chest: CTAB Abd: soft, non-distended. Mild tenderness elicited with palpation near incision sites. No rebound or guarding. Dressings c/d/i. Extremities: Pboots on. No erythema or swelling present. <PERTINENT RESULTS> ___ 01: 11PM GLUCOSE-201* UREA N-7 CREAT-0.9 SODIUM-141 POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 ___ 01: 11PM CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-1.7 ___ 01: 11PM WBC-14.3* RBC-4.51 HGB-12.6 HCT-39.6 MCV-88 MCH-27.9 MCHC-31.8* RDW-16.3* RDWSD-52.3* ___ 03: 40PM UREA N-9 CREAT-0.7 SODIUM-140 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16 ___ 03: 40PM ALT(SGPT)-20 AST(SGOT)-18 ALK PHOS-110* TOT BILI-0.3 ___ 03: 40PM WBC-12.5* RBC-5.09 HGB-14.0 HCT-43.5 MCV-86 MCH-27.5 MCHC-32.2 RDW-16.4* RDWSD-51.3* ___ 03: 40PM PLT COUNT-369 <MEDICATIONS ON ADMISSION> Glipizide Metformin Synthroid HCTZ Lisinopril Venlafaxine <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H do not exceed 4000mg acetaminophen in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *0 3. Ibuprofen 400 mg PO Q6H: PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity do not drink alcohol or drive while taking RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp #*15 Tablet Refills: *0 5. GlipiZIDE 10 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Glargine 30 Units Bedtime Insulin SC Sliding Scale using REG Insulin 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Venlafaxine XR 225 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrial cancer * Final pathology pending * <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing a total laparoscopic hysterectomy, bilateral salingoophorectomy, pelvic lymphadenectomy, lysis of adhesions and cystoscopy for endometrial cancer. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, Tylenol and ibuprofen as needed(pain meds). Her home medications for her T2DM, HTN, hypothyroidism and depression were restarted POD0. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10434539-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> groin swelling <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo w h/o stage IIIA vulvar squamous cell carcinoma s/p right anterior radical vulvectomy w/ bilateral inguinofemoral sentinel LND on ___ found to have bilateral (L>R) inguinal lymphocele s/p ultrasound-guided left groin lymphocele aspiration on ___, now with recurrent lymphocele, admitted for ___ guided drain placement. She reports swelling started ___ days after radical vulvectomy, right greater than left at first. The left side got progressively more swollen and painful. She saw Dr. ___ in clinic on ___ and had it drained on ___. She reports feeling significant relief of pain and swelling immediately following ___ drainage of left side. Starting last night around 10pm, she reports increased swelling and pain. The pain is described as sharp with intermittent increased shooting pain. Pain from swelling is currently a 7 out of 10. She has tried ice packs with some relief. Hot pack in hospital helped significantly. Ibuprofen improves pain at incision but not from swelling. She has not taken the oxycodone recently due to nausea. She also endorses pain at the incision site in vulva that is 5 out of 10. She reports pain with urination which is stable and is improved with ___ baths and ___ bottles. This morning, she noticed warmth and erythema from the left groin incision. She used bacitracin ointment with significant improvement. She endorses two clots of bright red blood from the vagina yesterday morning. Used two washcloths. Does not use pads due to irritaiton. No bleeding since last night. LMP ___, lasted through ___, no bleeding since until yesterday. Endorses yellow vaginal discharge. Has been taking stool softeners since surgery due to constipation. Reports diarrhea today. Denies fevers, chills, CP, SOB. Workup: long standing hx of lichen sclerosis ___: vulva bx demonstrating full-thickness squamous atypia ___ ___ second read of ___: vulvar bx differentiated ___ ___: right vulvar WLE and CO2 laser destruction of the perineum and bx of the perineum; pathology revealed ___ and lichen sclerosus ___: vulva biopsy demonstrating condyloma acuminate at 4'oclock and 7 o'clock, and lichen sclerosus at 11 o'clock ___: Lichen sclerosus on perineum and invasive squamous cell carcinoma, moderately differentiated on anterior vulva, grade 2, LS, negative margins ___: pap smear negative ___: PET CT without e/o metastatic disease - ___ - R anterior radical vulvectomy with b/l inguinofemoral SLND; metastatic squamous cell carcinoma involving 1 of 2 LN, no residual carcinoma in vulva <PAST MEDICAL HISTORY> OBHx: G4P3, SVDx3 Gynecologic History: Long-standing history of lichen sclerosis. LMP ___. Periods have been very irregular lately. Most recent pap was ___ negative IUD in place for contraception <PAST MEDICAL HISTORY> Lichen sclerosis Past Surgical History: WLE vulva (___), R anterior radical vulvectomy and b/l SLND (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of ovarian, breast, uterine, cervical, vaginal, or colon cancer or other malignancies. Mother had hysterectomy for ovarian cyst. There is also family history of diabetes, high blood pressure and heart disease. <PHYSICAL EXAM> At time of discharge General: well-appearing, NAD CV: RRR Pulm: lungs CTAB Abd: soft, NTND, +BS Extremities: WWP, no TTP or edema <PERTINENT RESULTS> ___ 09: 41PM GLUCOSE-88 UREA N-10 CREAT-0.9 SODIUM-141 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 ___ 09: 41PM CALCIUM-9.1 PHOSPHATE-2.6* MAGNESIUM-2.0 ___ 09: 41PM WBC-8.2 RBC-4.71 HGB-13.8 HCT-40.7 MCV-86 MCH-29.3 MCHC-33.9 RDW-13.8 RDWSD-43.3 ___ 09: 41PM NEUTS-54.1 ___ MONOS-6.5 EOS-2.8 BASOS-0.5 IM ___ AbsNeut-4.44 AbsLymp-2.95 AbsMono-0.53 AbsEos-0.23 AbsBaso-0.04 ___ 09: 41PM PLT COUNT-260 <MEDICATIONS ON ADMISSION> - Lidocaine ointment - Silver sulfadiazine 1% cream - Zofran 4mg q8hr PRN - Ibuprofen 800mg - Oxycodone 5mg PRN - Docusate <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever This medication is available over the counter. Do not take more than 4000mg in 25 hours. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Recurrent Lymphocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, ___ were admitted to the gynecologic oncology service for monitoring of your lymphocele (lymph node swelling), which recurred after your recent drainage. ___ have recovered well and the team feels that ___ are safe to be discharged home. Please follow these instructions: * 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. * ___ may eat a regular diet. * It is safe to walk up stairs. Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * ___ should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, ___ may remove them. * If ___ have staples, they will be removed at your follow-up visit. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if ___ are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where ___ are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service for worsening pain and enlarging left groin lymphocyst after undergoing aspiration of the left groin 2 days prior to presentation. On hospital day 2, she had shrinking of the left groin lymphocyst and the planned drain placement was deferred. Her pain also improved. She was thus discharged on HD#2. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10436098-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> "Pressure" <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year old G3P2 at ___ presents with intermittent pressure in lower abdomen since yesterday. The pain comes and goes and is located bilaterally lower abdomen. It feels like contractions and has gotten much worse today. She denies vaginal bleeding. +AFM. She has been having some leaking fluid for the past few weeks and overall feels abnormal (abdominal pain for the past few weeks, intermittent nausea and vomiting, chest pain with deep breaths reproducible withe pressure and not like burning pain). She denies illicit drug use. No fever/chills. +dysuria. No vaginal itching or irritation. <PAST MEDICAL HISTORY> PNC: - ___ ___ by first trimester U/S - Labs: A+/ab neg/RPRNR/RI/HIV neg/HepBsAg - Screening: LR ERA - FFS: wnl - ultrasound ___: 569 (38%) - Issues: *bleeding in first trimester *placental cyst (7 x 14mm adjacent to cord insertion) OBHx: G3P2, SVD x 2 at term, largest baby 7#1oz PMH: +migraines PSH: denies surgery GYNHx: fibroids, hx of abnl paps w/ normal f/u <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Upon admission T 98.3, BP 101/63, HR 95, RR 20 Gen: NAD CV: RRR Abd: soft, tender on left lower quadrant with palpation. uterus non-tender and ~30 week sized. SVE: Externally fingertip, internally closed, 40% effaced, soft, mid-position -> 1cm/60/-2, ballotable FHT: 140s/mod var/no decels/AGA accels TOCO: q4-5 min TAUS: vertex, AFI 7.19 Upon Discharge Doing well, no complaints No palpable contractions <PERTINENT RESULTS> ___ 04: 00PM URINE MUCOUS-RARE ___ 04: 00PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE EPI-7 ___ 04: 00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR ___ 04: 00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04: 10PM OTHER BODY FLUID FETALFN-NEGATIVE ___ 06: 52PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 06: 52PM URINE HOURS-RANDOM ___ 07: 05PM ___ PTT-27.2 ___ ___ 07: 05PM PLT COUNT-233 ___ 07: 05PM NEUTS-64.6 ___ MONOS-6.0 EOS-1.1 BASOS-0.2 ___ 07: 05PM WBC-6.8# RBC-3.89* HGB-11.8* HCT-35.5* MCV-91 MCH-30.2 MCHC-33.1 RDW-13.7 ___ 07: 05PM ___ ___ 07: 05PM estGFR-Using this ___ 07: 05PM GLUCOSE-72 UREA N-5* CREAT-0.4 SODIUM-140 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14 <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> None <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pre-term labor <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> patient to go home on rest patient not to return to work until re-evaluated by YGC or MBM
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Ms. ___ was admitted into L&D for observation for concern for preterm labor. She was given steroids for lung maturity and was started on indocin for tocolysis until betamethasone complete. Her labor arrested at 1cm dilation. She was then transferred to the antepartum service. During her short stay on the antepartum service, she had no more complaints and didn't any more painful contractions. She was therefore reassessed after she was 24 hrs from her dose of betamethasone and the team felt that she was safe to be discharged. She was discharged home with preterm labor precautions and in good condition.
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10436098-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total vaginal hysterectomy, right salpingectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 3, para 3 with a symptomatic fibroid uterus, worsening dysmenorrhea, who saw nurse practitioner, ___, on ___. At that visit, uterine fibroids options for treatment was reviewed. The patient at that time requesting definitive therapy in the form of hysterectomy. She is not interested in future childbearing. She is status post tubal ligation. The patient was seen on ___, again by nurse practitioner, ___, who did an endometrial biopsy showing late secretory endometrium and placement of Mirena IUD in an attempt to relieve her symptoms related to her fibroid uterus until she had a consultation with me. The patient presents today to discuss definitive therapy. <PAST MEDICAL HISTORY> PNC: - ___ ___ by first trimester U/S - Labs: A+/ab neg/RPRNR/RI/HIV neg/HepBsAg - Screening: LR ERA - FFS: wnl - ultrasound ___: 569 (38%) - Issues: *bleeding in first trimester *placental cyst (7 x 14mm adjacent to cord insertion) OBHx: G3P2, SVD x 2 at term, largest baby 7#1oz PMH: +migraines PSH: denies surgery GYNHx: fibroids, hx of abnl paps w/ normal f/u <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> VSS Gen: NAD CV: RRR Lungs: CTA Abd: soft, NT, ND Ext: non-tender, no edema <PERTINENT RESULTS> ___ 12: 00AM GLUCOSE-121* UREA N-9 CREAT-0.8 SODIUM-138 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15 ___ 12: 00AM estGFR-Using this ___ 12: 00AM WBC-14.4*# RBC-3.67* HGB-10.8* HCT-33.2* MCV-91 MCH-29.4 MCHC-32.5 RDW-13.3 RDWSD-44.4 ___ 12: 00AM PLT COUNT-215 <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: * No tub baths for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing transvaginal hysterectomy, right salpingectomy, cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid/toradol. She was triggered on ___ for blood pressures in the ___. On assessment, her exam was benign and her other vitals were stable. she was making good urine output. Her hematocrit was checked and was 33.2. 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 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*0 2. Ibuprofen 600 mg PO Q6H:PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Fibroid uterus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10437015-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding, pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p dilation and curettage <HISTORY OF PRESENT ILLNESS> ___ year old G1P0 presents as a transfer from ___, where she initially presented today with lower abdominal pain. Of note, she had a termination of pregnancy at ___ ___ 8 days ago, and had been doing well until about 1 day prior to presentation. The night prior to presentation, she started having a constant annoying pain. She was able to sleep through this using motrin and a heating pad. This afternoon, after her lunch break, she started having more constant pain that was so severe she could no longer work. Nothing really makes it better. She has also been feeling very lightheaded and dizzy in the setting of the pain. In addition, while she had virtually no bleeding following the procedure, she started having spotting on ___, following by passage of clots on ___ and day of presentation, going through a pad an hour. No nausea, vomiting, diarrhea, dysuria, fever or chills, although she does not a low grade fever of 100.1 at home. At the ___, she was started on IV clindamycin and given IM ceftriaxone. An exam was notable for +CMT and uterine tenderness, as well as heterogeneous material within the uterus on ultrasound concerning for possible retained products, although nothing was vascularized. <PAST MEDICAL HISTORY> GYNHx: - normal menses, not that crampy. every month - denies STDs - not currently sexually active - No GYN concerns or prior procedures - No history of pelvic pain PMH: denies PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> Exam on day of discharge: Gen: NAD CV: RRR P: CTAB Abd: soft, nontender, nondistended, no rebound or guarding GU: pad with minimal spotting Ext: WWP <PERTINENT RESULTS> ___ 02: 53PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02: 53PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 02: 53PM URINE RBC-66* WBC-4 BACTERIA-NONE YEAST-NONE EPI-1 ___ 02: 53PM URINE RBC-66* WBC-4 BACTERIA-NONE YEAST-NONE EPI-1 ___ 10: 35PM WBC-9.6 RBC-3.66* HGB-11.2 HCT-33.1* MCV-90 MCH-30.6 MCHC-33.8 RDW-12.4 RDWSD-41.0 ___ 10: 35PM WBC-9.6 RBC-3.66* HGB-11.2 HCT-33.1* MCV-90 MCH-30.6 MCHC-33.8 RDW-12.4 RDWSD-41.0 ___ 10: 35PM PLT COUNT-227 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills: *0 3. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*28 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 #*30 Tablet Refills: *0 5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills: *0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> retained products of conception <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the Gynecology service with abdominal pain and vaginal bleeding, concerning for an infection and retained products of conception. You underwent an additional procedure to evacuate the uterus, which was uncomplicated. You have recovered well and it is safe for you to go home. You have been given prescriptions for pain medication, please take these medications as needed. You have also been given prescriptions for antibiotics. Please DO NOT consume alcohol while taking these antibiotics. Please take all of the antibiotic pills prescribed for the full 14 day course.
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Ms. ___ was admitted to the Gynecology service in the setting of vaginal bleeding and pelvic pain, concerning for endometritis and retained products of conception following a D&C at ___ on ___. She was admitted to the hospital and started on IV gentamicin and clindamycin for presumed endometritis. A pelvic US demonstrated findings concerning for retained products of conception. The patient was counseled extensively regarding management options and elected to proceed with a repeat dilation and curettage to remove the retained products of conception. She was taken to the OR on ___ for D&C. The procedure was uncomplicated. Please see full procedure note for details. Post operatively, she received PO oxycodone, Tylenol, and ibuprofen for pain control with good effect. Her diet was advanced to a regular diet, which she tolerated without nausea or vomiting. She was voiding independently without issue. She was maintained on IV antibiotics until ___, at which point she was transitioned to PO doxycycline and flagyl. She was discharged home on a 14 day course of this regimen. On hospital day ___/POD1 she was discharged home in stable condition with appropriate follow up care and instructions.
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10442812-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Lithium / plaster / steris strips / Macrobid / Abilify <ATTENDING> ___. <CHIEF COMPLAINT> endometrial polyp / pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> hysteroscopy, D&C, polypectomy, Mirena IUD placement <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> None <MEDICATIONS ON ADMISSION> - Effexor 75 mg po daily - Levothyroxine sodium 150 mcg po daily w/ 225 mcg once a week - Buproprion HCl ER 300 mg po daily - Potassium 2400 mg po daily - Triamterene-HCTZ 37.5/25 mg po daily - Depakote ER 1500 mg po daily - Klor-Con M20 60 mg po daily - Valtrex 1 gram po daily - Sucralfate 3 gram po daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild please take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *1 3. BuPROPion XL (Once Daily) 300 mg PO DAILY 4. Divalproex (EXTended Release) 1500 mg PO QHS 5. Levothyroxine Sodium 175 mcg PO DAILY 6. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 7. Venlafaxine XR 75 mg PO QHS <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial polyps / pelvic pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for IV fluids prior to your surgery for your diabetes insipidus. You then underwent an uncomplicated hysteroscopy, polyp removal, D&C, and Mirena IUD placement. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service pre-operatively for IV fluid given her history of diabetes insipidus and inability to be NPO overnight. On ___, patient underwent hysteroscopic polypectomy, D&C, and Mirena IUD placement. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV toradol. Her diet was advanced without difficulty, and she was transitioned to PO ibuprofen and Tylenol. By post-operative day 0, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10444964-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> irregular bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, re-exploration and vaginal cuff re-sewing, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ initially presented with complaints of irregular bleeding. She moved here from ___ ___ years ago, and never had any problems prior to last ___. Menses were q month, light flow, lasting ___ days, with no spotting. In ___ she developed persistent bleeding, with a period which began ___ and continued until ___. The bleeding was light but daily, no clots. However, she developed severe cramping at night, and could feel a mass over her lower abdomen, esp when arising from sleep. Denies bowel or bladder complaints. Not sexually active for several years. Lost some weight last year , a few pounds, but no recent weight loss. Appetite is poor. She was offered various options for medical and surgical management and has decided to go forward with surgery due to continued irregular bleeding and discomfort. She requests preservation of the ovaries and removal of the cervix; she has reviewed the information given her and looked online for information. All consent forms were signed. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Asthma. PAST SURGICAL HISTORY 1. D&C. 2. SVD: Hopsitalized for hyperemesis gravidarum during most of pregnancy. Menstrual History Menses: 14 X Q month X ___ days Clots: Yes. Metrorraghia: Yes. Dysmenorrhea: Yes. Any change: Yes. Menopausal symptoms: Hot flushes: Yes. Night sweats: Yes. Insomnia: Yes. Preventative Maintenance Last pap: ___. Result: NORMAL. Last mammogram: ___. Result: NORMAL. Infection/STI history: None. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: ___ cancer, died at ___, had heavy bleeding and underwent hysterectomy at ___, ? cervical vs uterine cancer. Deceased. Children: A&W. <PHYSICAL EXAM> On postoperative check: VS - 98.5, 99.0 103/59 86 16 99% RA I/O - sips + 7000 IVF (incl 3u prbc in OR) / ___ UOP + EBL 1200 A+O NARD RRR CTAB Abd soft, appr ttp, +BS, no R/G, ND, dsg c/d/i Pad w/min VB. Foley with 100mL cyu in bag Ext NT NE pboots on <PERTINENT RESULTS> ___ 12: 27PM BLOOD Hct-20.6*# ___ 06: 53PM BLOOD WBC-16.5*# RBC-3.66* Hgb-11.4*# Hct-31.5*# MCV-86 MCH-31.0 MCHC-36.1* RDW-14.0 Plt ___ ___ 06: 19AM BLOOD WBC-12.3* RBC-3.11* Hgb-9.7* Hct-27.0* MCV-87 MCH-31.0 MCHC-35.7* RDW-13.9 Plt ___ ___ 01: 45PM BLOOD WBC-9.7 RBC-2.91* Hgb-9.1* Hct-25.1* MCV-86 MCH-31.1 MCHC-36.1* RDW-13.8 Plt ___ ___ 08: 00AM BLOOD WBC-10.5 RBC-2.66* Hgb-8.3* Hct-23.6* MCV-89 MCH-31.0 MCHC-35.0 RDW-13.9 Plt ___ ___ 11: 00AM BLOOD WBC-9.2 RBC-2.74* Hgb-8.5* Hct-24.9* MCV-91 MCH-31.1 MCHC-34.3 RDW-13.8 Plt ___ ___ 06: 19AM BLOOD ___ PTT-24.4 ___ ___ 01: 45PM BLOOD ___ PTT-23.3 ___ ___ 06: 19AM BLOOD ___ ___ 01: 45PM BLOOD ___ <MEDICATIONS ON ADMISSION> ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) orally every 6 hours as needed FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs(s) orally twice a day as needed INHALATIONAL SPACING DEVICE [AEROCHAMBER] - Inhaler - use with flovent inhaler twice a day TOPIRAMATE [TOPAMAX] - 25 mg Tablet - 4 Tablet(s) by mouth at bedtime - No Substitution <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp: *45 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for pt request. Disp: *1 inhaler* Refills: *3* <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> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit.
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Ms. ___ underwent a total abdominal hysterectomy complicated by a postoperative hypotension requiring pressors and suspected subfsacial hematoma in the recovery room requiring re-exploration in the operating room, 3 units of packed red blood cells transfusion for an intraoperative Hct of 20.6, re-sewing of the vaginal cuff, and cystoscopy. She was found to have an arterial bleed form the junction of the vaginal cuff and right cardinal ligament. Please see the operative reports for full details. She remained hemodynamically stable with a stable hematocrit and normal vital signs throughout the remainder of her hospital course. Her postoperative course was complicated by complaints of chest pain in the recovery room following her second procedure, and EKG was negative and cardiac enzymes were negative on 2 serial checks. This pain spontaneously resolved, and it was not felt to be due to demand ischemia or other acute cardiac etiology. She remained without complaints of chest pain throughout the rest of her hospitalization. On postoperative day 1 she developed contact skin blisters from the surgical tapes used postoperatively, and these were treated with vaseline, bacitracin and gauze without evidence of infection or cellulitis. On postoperative day 1 she was slow to advance her diet, and she was found to be hypokalemic to a K of 3.1. This was repleted with supplementary oral potassium, she promptly advanced her diet to regular without difficulty and never developed symptoms of hypokalemia. She met all postoperative milestones by postoperative day 4, including voiding, ambulating, tolerating a regular diet, and having her pain well-controlled with oral medications. She was discharged in good condition and follow was scheduled with Dr. ___ as an outpatient.
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10444964-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> adhesive tape <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal Pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ s/p TAH ___ complicated by hemodynamic instability in the PACU requiring urgent ex-lap with finding of hemoperitoneum and arterial bleeding at vaginal cuff. Her recovery was overall uncomplicated until early this morning, when she was awoken by severe lower abdominal cramping pain, nausea, and emesis. She had multiple episodes of bilious emesis through the night before presenting to the ED this morning. Pt reports that she has had bowel movements since surgery, most recently this morning, when she passed a small amount of stool. She also states that she has had intermittent passage of small amounts of flatus. Has been tolerating a regular diet. Denies fevers, chills, dysuria, vaginal bleeding, chest pain, shortness of breath, or any other associated symptoms. Upon arrival to the ED, pt's VS were stable. She received 4mg of morphine and 4mg zofran. She tolerated PO contrast for CT scan. Denies nausea/emesis since arrival, but very uncomfortable with abdominal pain. <PAST MEDICAL HISTORY> GynHx: History of menorrhagia/fibroid uterus. ObHx: SVD x 1, TAB x 1 MedHx: Asthma, migraines SurgHx: TAH/ex-lap as above; D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> PE: VS 98.6 92 132/83 16 98%RA Gen: ___ woman, pleasant and conversant but appears uncomfortable with intermittent episodes of more severe pain. CV: RRR, nl S1/S2 Lungs: CTAB Abd: Softly distended, diffusely tender to palpation. Approx 4cm ecchymotic area in midline approx 5cm superior to incision. Incision clean/dry/intact with staples. Scabbing lateral to incision (pt reports secondary to tape reaction). Voluntary guarding. Difficult to assess for rebound given pt's significant discomfort. Bowel sounds appreciated. Ext: No edema/tenderness Pelvic: Deferred <PERTINENT RESULTS> ___ 08: 01AM BLOOD WBC-9.6 RBC-4.04*# Hgb-12.2# Hct-35.1*# MCV-87 MCH-30.2 MCHC-34.7 RDW-14.1 Plt ___ ___ 06: 28AM BLOOD WBC-5.3 RBC-3.61* Hgb-10.5* Hct-31.4* MCV-87 MCH-29.0 MCHC-33.4 RDW-13.7 Plt ___ ___ 08: 01AM BLOOD Neuts-85.6* Lymphs-10.1* Monos-3.1 Eos-0.4 Baso-0.8 ___ 06: 28AM BLOOD Neuts-51.5 ___ Monos-10.5 Eos-4.0 Baso-0.4 ___ 08: 01AM BLOOD Plt ___ ___ 06: 28AM BLOOD Plt ___ ___ 08: 01AM BLOOD Glucose-134* UreaN-12 Creat-0.6 Na-138 K-4.1 Cl-100 HCO3-24 AnGap-18 ___ 06: 31AM BLOOD Glucose-88 UreaN-3* Creat-0.5 Na-138 K-4.0 Cl-104 HCO3-28 AnGap-10 ___ 08: 01AM BLOOD ALT-29 AST-22 AlkPhos-114* TotBili-0.5 ___ 08: 01AM BLOOD Lipase-67* ___ 08: 01AM BLOOD Albumin-4.4 Calcium-10.0 Phos-1.9* Mg-1.8 ___ 06: 31AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0 ___ 01: 47PM BLOOD Lactate-1.3 Imaging: CT abd/pelvis on ___: 1. Fluid-filled, slightly dilated small bowel loops with transition point in the pelvis near vaginal cuff, in combination with moderate amount of free fluid and mesenteric stranding is concerning for early complete or partial small-bowel obstruction. 2. Moderate amount of free fluid might be indirect sign of early ischemic changes. KUB on ___: Oral contrast is seen within the colon down to the level of the sigmoid colon. There is a nonobstructive bowel gas pattern with air seen down to the level of the rectum. There is no evidence of free intra-abdominal air. The lung bases are clear. <MEDICATIONS ON ADMISSION> Albuterol, fluticasone, topamax, ibuprofen, colace, and percocet <DISCHARGE MEDICATIONS> 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). <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> ___ <DISCHARGE INSTRUCTIONS> You were admitted with a partial small bowel obstruction. You were managed conservatively and your symptoms improved. You may continue to eat a regular diet.
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Ms. ___ was admitted to the Gynecology service on ___ for small bowel obstruction and treated medically with supportive care. A CT obtained on admission showed a small bowel obstruction with transition point and stranding concerning for developing ischemia or complete obstruction. She remained without nausea or vomiting, and her abdominal pain was well controlled with minimal medication. An abdominal plain film obtained on hospital day three showed contrast in the colon and no evidence of small bowel obstruction. By hospital day four, she had passed flatus and a small bowel movement and was advanced to a clear diet without difficulty, and her pain was noted to have subjectively improved. She was discharged home in good condition on hospital day five tolerating a regular diet and with return of bowel function. She will follow-up with Dr. ___.
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10456432-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ___ <ATTENDING> ___. <CHIEF COMPLAINT> pregnancy complicated by ___ disease type 2B <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean section <HISTORY OF PRESENT ILLNESS> ___ is a ___ gravida 2, para 1 ___ ___, she is ___ weeks. Pregnancy is complicated by low platelets, vWd Type 2B, macrosomia, GDMA2, gHTN. Her plts at the start of pregnancy were mid ___ and have dropped into the 20's. She is here for an elective c-section given fetal macrosomia. The indication for delivery is GHTN. <PAST MEDICAL HISTORY> Prenatal course: O+/Ab neg/RPRnR/RBI/Hbsag neg/HIV neg Elevated GLT (144) GTT 98/170/179/88 ___ EFW 4334g, >90% and AC is out of range PMH: Type 2 vWF: dx ___ extensive family history PSH: LEEP -> ___ had bleeding that required bld transfusion and humate to resolve Tonsillectomy Wisdom teeth removal <SOCIAL HISTORY> ___ <FAMILY HISTORY> Strong h/o ___ disease, including postpartum hemorrhage requiring infusion of factor concentrate <PHYSICAL EXAM> Admission: General: Well-nourished, well-developed woman in NAD Neck: Supple, no thyromegaly Cardiac: RRR, no murmurs, rubs or gallops Chest: Clear to auscultation bilaterally, no wheezes, crackles or rubs Breast exam with no masses, no skin changes, no axillary lymph nodes Abdominal exam: S=D, no masses appreciated, no pain, rebound or guarding Extremities: No skin changes and no edema Pelvic: 1.5cm/soft/high, unengaged head <PERTINENT RESULTS> ___ 01: 30PM BLOOD Plt Ct-23* ___: 14PM BLOOD WBC-11.8* RBC-4.60 Hgb-13.7 Hct-39.9 MCV-87 MCH-29.7 MCHC-34.3 RDW-15.9* ___ 06: 40AM BLOOD WBC-7.9 RBC-3.03* Hgb-9.1* Hct-26.8* MCV-89 MCH-29.9 MCHC-33.8 RDW-16.1* Plt Ct-30* ___ 01: 20PM BLOOD VWF AG-172* VWF CoF-160 ___ 01: 07PM BLOOD ACA IgG-5.4 ACA IgM-13.8* ___ 01: 14PM BLOOD Lupus-POS ___ 01: 07PM BLOOD Creat-0.6 ___ 01: 07PM BLOOD UricAcd-6.4* ___ 01: 07PM BLOOD ALT-19 <MEDICATIONS ON ADMISSION> 1. INSULIN LISPRO [HUMALOG KWIKPEN] - 100 unit/mL Insulin Pen - as directed start with ___ (b-fast/lunch/dinner) units at mealtimes 2. OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day 3. PNV CMB#14-IRON FUM-FOLIC ACID [NATACHEW] - 29 mg-1 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day 3. NPH INSULIN HUMAN RECOMB [HUMULIN N PEN] - 100 unit/mL (3 mL) Insulin Pen - 7 units qhs <DISCHARGE MEDICATIONS> 1. Breast pump Sig: One (1) as needed: Medical grade . Disp: *1 * Refills: *0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *0* 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for Constipation. 5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for Dyspepsia. 6. Dibucaine 1 % Ointment Sig: One (1) Appl Topical PRN (as needed) as needed for to perineum. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> CS Type 2b ___ D/O Gestational HTN Gestational Diabetes Type II <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> given
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Patient was admitted for an elective cesarean section due to fetal macrosomia. Please see the full operative report for details of the surgery. She received a transfusion of two 6-packs of platelets in the operating room, followed by another 2 packs postpartum. Her platelets were 23 pre-operatively and stabilized to the ___ postpartum. Due to her ___ disease and low VWD factor, she also received one transfusion of Humate P and Amicar for 30 hours. She also received 3 unites of packs red blood cells postpartum and her hematocrit stabilized in the ___ range. She also had gestational hypertension and gestational diabetes requiring insulin. Her blood pressure on admission was 143/81 but remained within normal limits postpartum without medication. Her labs were not remarkable for pre-eclampsia. Her fingersticks were disctontinued on postpartum day 2 as her blood glucose was within acceptable range. She has followup arranged at ___. Her pain regimen avoided NSAID's, but her pain was well-controlled with first a dilaudid PCA and then percocet. She was discharged on postpartum day 5 without signs of abnormal bleeding, her pain well-controlled on oral medications, her vital signs stable and within normal limits, ambulating, voiding, and eating a regular diet. She was given instructions to follow up with her OB/Gyn in 1 and 6 weeks, as well as for an oral glucose tolerance test and appointment at ___.
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10459458-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Morphine <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G0 with progressively worsening RLQ pain for 2 days. It felt like menstrual cramps but became more severe, prompting evaluation at ___ office yesterday, where she was sent to ED for evaluation. Ms. ___ endorsed nausea. She denied emesis, fever, chills, CP, SOB, abnl vaginal discharge, changes in bowel/bladder habits. In the ED, a CT abd/pel showed no evidence of appendicitis but did note a degenerating fibroid. A pelvic U/S confirmed fibroid uterus, normal ovaries and flow bilaterally. Her uterus was 9.2 x 6.9 x 7.2cm, anteverted, with large 6cm likely anterior fibroid. She also had an unremarkable RLQ abd U/S. <PAST MEDICAL HISTORY> PGYNHX: - LMP: ___ - Paps: denies abnl - STIs: denies - contraception: condoms PMH/PSH: denies <SOCIAL HISTORY> RN at ___, denies T/E/D, sexually active, feels safe at home and in relationship <PHYSICAL EXAM> VS: 98.0 102 121/72 18 96TS GENERAL: NAD CARDIO: RRR PULM: CTAB ABDOMEN: soft, TTP RLQ, no R/G, ND EXTREMITIES: NT bilaterally <PERTINENT RESULTS> ___ 10: 40AM BLOOD WBC-8.9 RBC-4.94 Hgb-11.1* Hct-33.7* MCV-68* MCH-22.5* MCHC-33.1 RDW-14.5 Plt ___ ___ 10: 40AM BLOOD Glucose-109* UreaN-7 Creat-0.8 Na-138 K-3.8 Cl-103 HCO3-25 AnGap-14 ___ 10: 40AM BLOOD ALT-23 AST-23 AlkPhos-89 TotBili-0.1 ___ 11: 40AM URINE UCG-NEGATIVE ___ 11: 40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp: *60 Capsule(s)* Refills: *0* 2. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain: do not drink or drive while on this medication. Disp: *60 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Degenerating fibroid <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 because of abdominal pain presumed to be from a degenerating fibroid. You had a CT and ultrasound which noted fibroids in your uterus, and an anterior fibroid that is in the process of degenerating and may be causing your symptoms. You had an uncomplicated stay and were discharged home in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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Ms. ___ was admitted for observation and pain control for abdominal pain presumed to be related to a degenrating fibroid. Her pain was treated with percocet and dilaudid. Her vital signs, abdominal exam, and laboratory values remained stable. She had an uncomplicated stay and was discharged home on hospital day 3 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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10462407-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Genetic predisposition to endometrial cancer given Lynch Syndrome <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p total laparoscopic hysterectomy and bilateral salpingoophorectomy <HISTORY OF PRESENT ILLNESS> ___ woman with a history of colon cancer seen in consultation for a risk reducing hysterectomy and bilateral oophorectomy. She meets criteria for Lynch Syndrome per ___ criteria, though genetic testing has been negative. Her colon cancer was diagnosed at age ___ and poorly differentiated. Her father and paternal grandfather had colon cancer diagnosed at age ___ and her father had over 20 adenomas in the colon over the last several years. Her mother died at age ___ from transitional cell cancer of the renal pelvis. <PAST MEDICAL HISTORY> Colon cancer, HTN, HLD, stress incontinence, infertility <SOCIAL HISTORY> ___ <FAMILY HISTORY> Patient's father and paternal grandfather had colon cancer diagnosed at age ___ and her father had over 20 adenomas in the colon over the last several years. Her mother died at age ___ from transitional cell cancer of the renal pelvis. <PHYSICAL 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 ___: nontender, nonedematous <PERTINENT RESULTS> ___ 02: 37PM GLUCOSE-126* UREA N-12 CREAT-0.7 SODIUM-137 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13 ___ 02: 37PM estGFR-Using this ___ 02: 37PM CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-1.9 ___ 02: 37PM WBC-5.9 RBC-4.10 HGB-12.7 HCT-38.8 MCV-95 MCH-31.0 MCHC-32.7 RDW-11.5 RDWSD-40.1 ___ 02: 37PM PLT COUNT-114* <MEDICATIONS ON ADMISSION> Atenolol 100mg QD Atenolol 50mg QAM Diazepam 5mg prn HCTZ 12.5mg QAM Simvastatin 20mg Trazodone 100mg QHS prn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain 2. Atenolol 100 mg PO QAM 3. Atenolol 50 mg PO QPM 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Ibuprofen 600 mg PO Q6H: PRN Pain 6. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain 7. Simvastatin 20 mg PO QPM <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p total laparoscopic hysterectomy and bilateral salpingoophorectomy for risk reduction in the setting of Lynch Syndrome <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 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing TLH-BSO and cystoscopy for risk reduction in the setting of Lynch Syndrome. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with dilaudid IV and toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, tylenol and ibuprofen for pain control. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10464873-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cramping, spotting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ who presents after a fall at 10: 30am today. She reports she fell getting out of the car today and fell on her low back. Did not hit her abdomen. She subsequently experienced one spot of red on her underwear and started having lower abdominal cramping. No further bleeding. No LOF. +AFM. Denies other trauma, safety concerns, abnormal vaginal discharge, h/o infections, recent intercourse, constipation, dysuria, fevers/chills. <PAST MEDICAL HISTORY> PNC: - ___ ___ - Labs: Rh pos/Ab neg/HIV neg/Rub immune/RPRNR /HBsAg neg/HIV neg/GBS unknown - Screening LR ERA - FFS WNL - GLT WNL - Issues: teen pregnancy OBHx: G1P0 GYNHx: never had a pap. Denies h/o fibroids, cysts, STIs. PMHx: denies PSHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: ___ ___: 98 ___ 14: 05BP: 106/67 (77) ___ 14: 10Temp.: 97.9°F FHT: 130/mod/+accel/-decel Toco: q1min, does not appear to be having regular painful ctxs SVE: LCP at 15: 15 SSE: NEFG, moderate white discharge in vault, no blood in vault. cervix appears LCP. TAUS: cephalic, MVP 5.6cm, ___ On discharge: Vitals: 98.3 99 / 55 102 16 97 Gen: NAD Resp: no evidence of respiratory distress Abd: soft, gravid, non-tender Ext: no edema, non-tender Date: ___ Time: ___ FHT: 130/mod var/+accels/one isolated variable, no other decels Toco: irritable Date: ___ Time: 0958 FHT: 140/mod var/+accels/no decels Toco: flat <PERTINENT RESULTS> ___ WBC-14.2 RBC-3.85 Hgb-9.3 Hct-30.4 MCV-79 Plt-291 ___ ___ PTT-26.8 ___ ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR* ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ BODY FLUID CT-NEG NG-NEG URINE CULTURE (Final ___: NO GROWTH. R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREPTOCOCCI. SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: YEAST. SPARSE GROWTH. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> prenatal vitamins <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm contractions and vaginal bleeding after a fall symptomatic 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 hospital with preterm contractions and vaginal bleeding after a fall. You were monitored for 3 days without any evidence of further vaginal bleeding. You received betamethasone for fetal lung maturity. Your contractions and cervical exam remained stable. All of your fetal testing have been reassuring. You also received an iron infusion for your anemia. We think it is now safe for you to go home. Please follow the instructions below: - Attend all appointments with your obstetrician and all fetal scans - Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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___ G1P0 admitted at 30w6d for observation after a fall. On admission, Ms ___ appeared comfortable and no blood was visible on sterile speculum exam. Although there was irritability on toco, she had no evidence of preterm labor. Fetal fibronectin was negative. Fetal testing was reassuring. She received a course of betamethasone for fetal lung maturity (complete ___. She remained clinically stable and was discharged to home on ___. In regards to her history of symptomatic anemia, she received her 2nd dose of Feraheme on ___. She will have close outpatient follow up.
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10467577-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ivp dye / Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic bilateral salpingo-oophorectomy, omental biopsy <HISTORY OF PRESENT ILLNESS> ___ yo with history of cervical cancer, colon fistula, HIV, CKD, DVT/PE on Coumadin, and known large pelvic mass, was admitted to medicine for a CHF exacerbation which resolved with conservative measures. Gyn onc was consulted for her known but enlarging pelvic mass. An abdominal CT from ___ demonstrates a 19.1 x 17.8 cm mass that appears similar to the prior study. There was also a lobulated soft tissue density overlying the lower pelvis just above the bladder and uterus as noted previously ~7.4 cm and a soft tissue density about the pelvic sidewalls and about the rectal soft tissues as well. An ultrasound obtained in ___ during her CHF exacerbation demonstrated a cystic pelvis mass measuring 16.7 x 16.2 x 15.4 cm. A CA125 was obtained and was 220. The pelvic mass was first noticed on imaging in ___ at ___ ___. A plan was made for observation at that time. In ___, she presented to ___ for nausea, vomiting, and diarrhea and underwent a CT scan that noted a complex mass with internal vascularity. She had a gynecology oncology consult at ___ at that time, and a PET/CT was obtained with no FDG avidity in the ~12cm mass. CA 125 drawn at ___ in ___ (13) ___ (32) were normal. <PAST MEDICAL HISTORY> - HIV on HAART: acquired through sexual contact when pt was in her ___. Well controlled for many years, w/undetectable viral load and CD4 counts fluctuating 390s-500 - HTN - Dyslipidemia and HAART-related lipodystrophy - DM II, now insulin dependent - Osteoarthritis - Osteoporosis - GERD - Depression - Urinary retention (patient intermittently self catheterizes) <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: Reviewed and found to be not relevant to this illness/reason for hospitalization. <PHYSICAL EXAM> Discharge <PHYSICAL EXAM> ___ ___ Temp: 97.9 PO BP: 154/78 R Lying HR: 68 O2 sat: 98% O2 delivery: 2L nc ___ 2341 Temp: 98.2 PO BP: 119/64 R Lying HR: 76 RR: 18 O2 sat: 94% O2 delivery: Ra ___ 1520 Temp: 98.5 PO BP: 121/62 HR: 72 RR: 18 O2 sat: 97% O2 delivery: RA Physical Exam Gen: NAD CV: RRR Pulm: somewhat increased work of breathing which is patient's baseline, CTAB Abd: soft, appropriately tender. incisions C/D/I. GU: pad with minimal spotting Ext: wwp, pboots on and active bilat <MEDICATIONS ON ADMISSION> abacavir 300'', albuterol prn, alprazolam 1mg hs, amlodipine 5', atorvastatin 20', symbicort'', efavirenz 600'hs, lovenox 60, erythropoietin, escitalopram 10', furosemide 40'', gabapentin 100''', loperamide 2mg', metoprolol tartrate 50'', mirtazapine 15'hs, pantoprazole 40', raltegravir 400'', trazodone 100'hs, warfardin 2mg', insulin NPH 16a/20p <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *2 2. TraMADol 25 mg PO Q6H: PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 3. Abacavir Sulfate 300 mg PO BID 4. Albuterol Inhaler ___ PUFF IH Q4H: PRN wheezing, shortness of breath 5. amLODIPine 5 mg PO DAILY 6. Efavirenz 600 mg PO QHS 7. Enoxaparin Sodium 60 mg SC Q24H RX *enoxaparin 60 mg/0.6 mL 60 mg SC twice daily Disp #*6 Syringe Refills: *2 8. Escitalopram Oxalate 10 mg PO DAILY 9. Furosemide 40 mg PO BID 10. 70/30 16 Units Breakfast 70/30 20 Units Dinner 11. Metoprolol Tartrate 50 mg PO BID 12. Raltegravir 400 mg PO BID 13. Warfarin 2 mg PO DAILY 14.Outpatient Physical Therapy Ankle foot orthosis Diagnosis: Right ankle foot drop <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: . Laparoscopic instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * 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. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service after undergoing LSC BSO, omental biopsy, lysis of adhesions for 25cm pelvic mass. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV morphine. Her diet was advanced without difficulty and she was transitioned to PO tramadol and tylenol. On post-operative day #1, her urine output was adequate so her Foley catheter was removed. She was unable to void and initiated self straight-caths, which is her baseline. She was seen by ___, who recommended home ___. She was set up with ___ and ___ services for home. Per her PCP, she was restarted on her therapeutic anticoagulation with coumadin 2mg daily and lovenox 60mg daily on post-operative day 2. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10470481-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ___ <ATTENDING> ___ ___ Complaint: heavy bleeding due to fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingectomy <HISTORY OF PRESENT ILLNESS> ___ yrs. G1 P1 Patient's last menstrual period was ___. She presents for pre-op visit for planned surgery, total abdominal hysterectomy, bilateral salpingectomies She has a history of heavy bleeding due to fibroids. She is s/p gastric bypass ___ years ago (she lost 200 lbs) so she does not absorb iron so the bleeding has lead to severe iron deficiency anemia to the point where she has ___, leg cramps etc. Most recently, she started skipping periods last year (no menses ___ but has had heavy monthly bleeding since ___. Her HCT ___ was 27.9 with a ferritin of 3.8 despite having gotten IV iron on ___ and ___. Her last PUS was ___ which showed a 12 x 9 x 11 cm multi-fibroid uterus ranging in size from 4-7mm. She had an endometrial biopsy ___ with Dr ___ showed secretory endometrium. Her cavity sounded to >15 cm. Of note, the patient tried a Mirena in ___. At that time, her cavity measured only 7-8 cm. The IUD was expelled. She had a 3 month course of Lupron ___. She had a repeat course of IV iron ___ HCT improved from 27 to 38. However, her uterus did not shrink in size She decided on pursuing UAE. She was referred to ___ at ___ but there was an issue with her appointment and she never had her consult and then declined referral back to ___ or any ther ___ department. She decided to proceed with definitive surgical therapy. Due to her large uterus and the large rolls of extra skin on her abdomen, the decision was made to proceed with abdominal hysterectomy. She had a repeat courses of IV iron in ___ and ___. <PAST MEDICAL HISTORY> Her medical history is noteworthy for: 1) hypertension 2) type 2 diabetes on insulin with hemoglobin A1c of 5.8% 3) moderate obstructive sleep apnea by home sleep study ___ with recommendation for CPAP/BiPAP 4) chronic low back pain with lumbar radiculopathy secondary to disc disease 5) severe iron deficiency anemia (serum iron 17, iron saturation 4%), no GI source, likely GYN 6) vitamin D deficiency 7) leiomyoma of the uterus 8) menorrhagia 9) cervical dysplasia 10) positive H. pylori antibody 11) hepatic steatosis by ultrasound study She has no surgical history. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is noted for obesity and diabetes and cancer in her mother who is deceased. She is single and is currently unemployed and does have a ___ daughter. <PHYSICAL EXAM> Physical Exam on Presentation: Constitutional: well developed, well nourished female Estimated body mass index is 46.99 kg/(m^2) as calculated from the following: Height as of this encounter: 5' 6" (1.676 m). Weight as of this encounter: 291 lb 2 oz (132.1 kg). Thyroid: non-tender, not enlarged, no palpable mass Chest: clear to auscultation Heart: regular rate, rhythm Breasts: no masses, no nipple discharge, no skin or nipple changes Abdomen: 2 large rolls of excess skin/pannus (pt s/p bariatric surgery), fundus palpable at umbilicus. Extremities: normal, no cyanosis, no clubbing, no edema Neurological: alert and oriented Pelvic: External Genitalia: no lesions or inflammation Vagina: no lesions Pelvic Supports: normal, no hernias or prolapse Cervix: no lesions, no cervical motion tenderness Uterus: 20 week size Adnexa: no masses Anus and Perineum: normal Physical Exam on Day of Discharge: General: Comfortable, alert, no acute distress HEENT: isolated swelling in right upper lip (likely from ET tube) CV: RRR, normal s1 and s2, no m/r/g Pulm: normal work of breathing, CTAB Abd: soft, mildly and appropriately tender to palpation in the lower abdomen at the incision site, nondistended, low transverse incision is clean/dry/intact Back: mild TTP paraspinal in lower back Extremities: warm, calves non-tender, no edema, pneumoboots in place bilaterally <MEDICATIONS ON ADMISSION> omeprazole 20, trazado 50 hS prn, alprazolam 0.5 HS prn, sertraline 100 <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild do not exceed 4000mg in 24 hrs RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as needed Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day as needed Disp #*60 Capsule Refills: *1 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate do not drink or drive on this medication; causes sedation RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as needed Disp #*40 Tablet Refills: *0 4. Omeprazole 20 mg PO DAILY 5. Sertraline 100 mg PO DAILY 6. TraZODone 50 mg PO QHS: PRN insomnia <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a total abdominal hysterectomy and bilateral salpingectomy for symptomatic fibroid uterus. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid, Toradol, and TAP block. 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 oxycodone and tylenol. She was continued on her home medication sertraline for depression, trazodone for insomnia, oxycodone 10mg for chronic lower back pain (and written for ___ additional oxycodone for surgical pain). Her fingersticks were monitored while inpatient and she was written for an insulin sliding scale while inpatient given her history of type II diabetes. Her oxygen saturations were continuously monitored given her history of obstructive sleep apnea. She was started on subcutaneous heparin three times daily for DVT prophylaxis. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10476499-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / montelukast <ATTENDING> ___. <CHIEF COMPLAINT> adnexal masses <MAJOR SURGICAL OR INVASIVE PROCEDURE> LAPAROSCOPIC BILATERAL SALPINGOOPHORECTOMY; LYSIS OF ADHESIONS; URETEROLYSIS FOR EXTENSIVE RETROPERITONEAL FIBROSIS; CYSTOSCOPY <PHYSICAL EXAM> Gen: NAD CV: RRR Pulm: Breathing comfortably on RA Abd: soft, nondistended, appropriately mildly TTP, incision site dressings c/d/I, no rebound or guarding, no ecchymosis Ext: WWP, no edema or TTP, pneumoboots in place <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY: PRN heart burn 2. biotin 2,500 mcg oral DAILY 3. Vitamin D ___ UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth Every 6 hours as needed Disp #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation - First Line Can take with oxycodone to prevent constipation. RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice per day as needed Disp #*28 Tablet Refills: *0 3. Enoxaparin Sodium 40 mg SC DAILY Please follow instructions given before discharge. RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Daily Disp #*14 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain Please take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #*40 Tablet Refills: *0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Do not operate heavy machinery or drink while using. RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #*6 Tablet Refills: *0 6. biotin 2,500 mcg oral DAILY 7. Omeprazole 20 mg PO DAILY: PRN heart burn 8. Vitamin D ___ UNIT PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> left ovarian cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the gynecology service after your 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. We have also prescribed you a blood thinner medication given your history of a pulmonary embolism. You have received teaching about how to administer the lovenox shot. Please follow your instructions, as well as those below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing LAPAROSCOPIC BILATERAL SALPINGOOPHORECTOMY; LYSIS OF ADHESIONS; URETEROLYSIS FOR EXTENSIVE RETROPERITONEAL FIBROSIS; CYSTOSCOPY. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with morphine and toradol. Her urine output was adequate and the Foley was removed. On post-operative day 1, she was started on lovenox for a two week course given her history of pulmonary embolism. By post-operative day 1, she was tolerating a regular diet, ambulating, and her pain was well controlled. She was discharged in stable condition with appropriate follow up.
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10477365-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abnormal uterine bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> 31 G2P1011 with history of PE (___) and unprovoked LUE DVT x 1 (___), currently anticoagulated on xarelto, presents with heavy vaginal bleeding x4 days. Patient presented to ___ over the weekend due to heavy bleeding and feeling faint and TVUS revealed no IUD in the uterus. She was discharged without any medications. She continues to pass quarter size blood clots and has crampy pelvic and back pain. She reports fatigue, lightheadedness, and headaches. Denies CP/SOB. <PAST MEDICAL HISTORY> PGyn: Not currently sexually active in the past month, but has a male partner. Had been amenorrheic with IUD in place until now. Prior to this had moderate flow and regular monthly periods. POb: G1 TAB, G2 c-section for arrest of dilation and NRFHT PMH: obesity, sickle cell trait, hx of PE and LUE DVT, asthma, hx of expelled IUD in ___ PSH: c-section, wisdom teeth, D&C <SOCIAL HISTORY> denies etoh/tobacco/drug use <PHYSICAL EXAM> Admission PE VS 98.1 106->91 123/58 98% orthostatics: lying ___ standing 126/78 105 Gen: NAD CV: RRR Pulm: CTAB Abd: obese, soft, NT Pelvic: 25cc clot evacuated from cervical os with 2 scopettes of BRB, closed os, no CMT, unable to appreciate uterus or adnexa due to habitus Ext: NT, no edema Discharge 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 GU: pad with minimal spotting Ext: no TTP <PERTINENT RESULTS> ___ 10: 37AM HCT-27.6* ___ 06: 26AM HCT-26.6* ___ 07: 35PM CREAT-0.9 ___ 07: 35PM estGFR-Using this ___ 07: 35PM HCG-<5 ___ 07: 33PM WBC-10.5 RBC-3.79* HGB-10.9* HCT-29.3*# MCV-77* MCH-28.6 MCHC-37.0* RDW-13.9 ___ 07: 33PM PLT COUNT-248 ___ 07: 33PM ___ PTT-34.9 ___ ___ 07: 33PM ___ KUB FINDINGS: The bowel gas pattern is nonspecific and nonobstructive. There are no abnormally dilated loops of small or large bowel. There is no evidence of pneumatosis or pneumoperitoneum. The visualized osseous structures are unremarkable.No soft tissue calcifications or radiopaque foreign bodies are detected. IMPRESSION: No IUD detected. <MEDICATIONS ON ADMISSION> xarelto 20mg daily, pulmicort prn, albuterol prn, folic acid, iron, MVI, Vit D <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain do not exceed 4g in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 RX *acetaminophen 500 mg ___ tablet(s) by mouth q6 hours Disp #*30 Tablet Refills: *0 2. Ferrous Sulfate 325 mg PO BID Take with stool softener (Colace). Goal 1 bowel movement daily without straining. RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 3. MedroxyPROGESTERone Acetate 10 mg PO DAILY RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills: *1 4. Rivaroxaban 20 mg PO/NG DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abnormal uterine bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after presenting with heavy vaginal bleeding. You were started on provera to help with the vaginal bleeding. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the GYN service with abnormal uterine bleeding. She was started on provera 10mg daily. Her bleeding improved and by time of discharge, her HCT was stable at around 27. Her xarelto was immediately held due to possibility of OR procedure but was resumed when patient's bleeding improved. Given the question of expelled IUD, a KUB was obtained which showed no IUD. By time of discharge, she was tolerating a regular diet, ambulating independently, and bleeding had improved. She was then discharged home in stable condition with outpatient follow-up scheduled
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10480005-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Uterine carcinosarcoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection, and para-aortic lymph node dissection <HISTORY OF PRESENT ILLNESS> ___ female wiith carcinosarcoma found on D&C, ___. She initially reports scant vaginal bleeding approximately 1 month ago. Vaginal bleeding became heavy and she was seen at ___ for evaluation. She was then referred to her PCP who then referred her to Dr. ___ D&C. She denies any vaginal bleeding since her procedure, ___. She reports some lower abdominal discomfort but does not require any pain medication. She denies any change in bowel or bladder habits but does report decreased appetite x 1 month. She denies any n/v or abdominal distention. Additionally, her last CBC revealed anemia but she denies any SOB, HA,CP or dizziness. <PAST MEDICAL HISTORY> Osteoporosis <SOCIAL HISTORY> Non smoker, no ETOH use or drug use, lives part time in ___ and ___, no DV <PHYSICAL EXAM> On discharge: Afebrile, normal vital signs Gen: NAD, well appearing CV: RRR PULM: CTAB ABD: soft, Non tender, non distended, incisions clean/dry/intact. No rebound/guarding <PERTINENT RESULTS> ___ 06: 40AM BLOOD WBC-12.7*# RBC-3.01* Hgb-7.9* Hct-24.0* MCV-80* MCH-26.3* MCHC-33.0 RDW-13.0 Plt ___ ___ 06: 40AM BLOOD Neuts-81.1* Lymphs-11.2* Monos-7.1 Eos-0.5 Baso-0.1 ___ 06: 40AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8 ___ 06: 40AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-135 K-4.1 Cl-102 HCO3-25 AnGap-12 <DISCHARGE INSTRUCTIONS> Dear Ms. ___ . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing total laparoscopic hysterectomy, bilateral salpingo-oopherectomy, pelvic and paraaoritic lymph node dissection. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid. Her diet was advanced without difficulty and she was transitioned to oral pain medications. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Patient has a longstanding history of anemia with a preop Hct of 29. Her post operative Hct was 24 and therefore she received 2 units of packed red blood cells prior to discharge. There was no evidence of acute bleeding. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ 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 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Do not drive. RX *oxycodone 5 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 taking narcotics. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 4. Ibuprofen 400 mg PO Q6H:PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*1 5. Ferrous Sulfate 325 mg PO TID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: uterine carcinosarcoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10486853-DS-26
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Biaxin <ATTENDING> ___ <CHIEF COMPLAINT> Fallopian tube cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, omentectomy, peritoneal biopsies, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ year-old woman who presents for total laparoscopic hysterectomy and omentectomy for fallopian tube cancer, which was discovered after risk-reducing bilateral salpingo-oophorectomy on ___. <PAST MEDICAL HISTORY> Past Psychiatric History: -Major Depressive Disorder with psychotic features, recurrent, severe, Anxiety Disorder Hospitalizations: (1) ___ - psychosis - during breast cancer tx (tx not specified) (2) ___ - ___ @ ___ for depression w/ psychotic features, underwent ECT (3) ___ - ___ @ ___ for depression w/ psychotic features, underwent ECT Neuropsych testing: (___) Frontal executive and attentional problems - see full report in OMR. SA's/SIB none Psychiatrist: Dr. ___ (previously seeing Dr. ___ ___ PAST MEDICAL HISTORY: Hypothyroidism Essential Tremor History of breast cancer ___ and ___, s/p right mastectomy; chemotherapy and radiation on both; BRCA1 positive <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother and maternal grandmother lived to older ages without cancer. Her mother had a first cousin with breast cancer. On her father's side, her paternal grandmother died at age ___, questionably of cervical cancer. <PHYSICAL EXAM> AVSS Gen: NAD Cards: Regular rate and rhythm Pulm: Clear in all lung fields Abd: soft, non-tender, non-distended, no rebound or guarding Incision: clean/dry/intact Ext: no calf tenderness, pneumatic boots in place <MEDICATIONS ON ADMISSION> levothyroxine, lorazepam, mirtazapine, primidone, seroquel, calcium, docusate <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain: do not exceed 4g tylenol in 24hours. Disp: *30 Tablet(s)* Refills: *0* 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Primidone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fallopian tube cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You underwent a total laparoscopic hysterectomy and omentectomy. Your surgery was uncomplicated. Please avoid heavy lifting. Do not place anything in the vagina or have intercourse until after your post-operative appointment. Please take your medication as directed. Please keep your post-operative as scheduled. Please call for fever >100.4, chills, nausea, vomiting, chest pain, shortness of breath, heavy vaginal bleeding, abdominal pain not relieved by pain medication, redness or purulent drainage from your incision, or any other questions or concerns.
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The patient is a ___ who underwent a total laparoscopic hysterectomy and omentectomy for fallopian tube cancer. Her surgery was uncomplicated. Please see operative report for full details. The patient's post-operative course was uncomplicated. She was initially on IV Dilaudid for pain control, but she was quickly transitioned to oral medication with advancement of her diet to regular. Her foley was discontinued on post-operative day #1, and she voided spontaneously. The patient was continued on all of her home medication and discharged to home on post-operative day #2 in good condition.
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10487633-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery D and C Placement Bakri Balloon Transfused 2 units <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, Vital signs stable Neuro/Psych: no acute distress, Oriented x3, Affect Normal Heart: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft, appropriately tender, fundus firm, incision clean/dry/intact Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 08: 02AM BLOOD WBC-7.3 RBC-3.18* Hgb-8.6* Hct-27.6* MCV-87 MCH-27.0 MCHC-31.2* RDW-14.0 RDWSD-43.5 Plt ___ ___ 06: 51AM BLOOD WBC-8.3 RBC-2.68* Hgb-7.1* Hct-23.4* MCV-87 MCH-26.5 MCHC-30.3* RDW-14.4 RDWSD-44.4 Plt ___ ___ 07: 38AM BLOOD WBC-10.3* RBC-2.75* Hgb-7.3* Hct-23.1* MCV-84 MCH-26.5 MCHC-31.6* RDW-14.1 RDWSD-42.4 Plt ___ ___ 10: 19PM BLOOD WBC-12.9* RBC-2.64* Hgb-6.9* Hct-22.3* MCV-85 MCH-26.1 MCHC-30.9* RDW-13.7 RDWSD-42.0 Plt ___ ___ 05: 45PM BLOOD WBC-11.0* RBC-3.23* Hgb-8.5* Hct-28.1* MCV-87 MCH-26.3 MCHC-30.2* RDW-13.6 RDWSD-42.5 Plt ___ ___ 08: 33AM BLOOD WBC-5.2 RBC-4.40 Hgb-11.4 Hct-38.2 MCV-87 MCH-25.9* MCHC-29.8* RDW-13.6 RDWSD-42.3 Plt ___ ___ 08: 02AM BLOOD Plt ___ ___ 06: 51AM BLOOD Plt ___ ___ 07: 38AM BLOOD Plt ___ ___ 07: 38AM BLOOD ___ PTT-32.6 ___ ___ 10: 19PM BLOOD Plt ___ ___ 05: 45PM BLOOD Plt ___ ___ 05: 45PM BLOOD ___ PTT-27.5 ___ ___ 08: 33AM BLOOD Plt ___ ___ 07: 38AM BLOOD ___ 05: 45PM BLOOD ___ 07: 38AM BLOOD Glucose-68* UreaN-10 Creat-0.6 Na-139 K-4.0 Cl-106 HCO3-24 AnGap-9* ___ 10: 19PM BLOOD Glucose-69* UreaN-9 Creat-0.6 Na-134* K-3.8 Cl-102 HCO3-23 AnGap-9* ___ 07: 38AM BLOOD Calcium-7.9* Phos-4.5 Mg-1.6 ___ 10: 19PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.3* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 25 mcg PO DAILY 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth BID PRN Disp #*30 Capsule Refills: *0 2. Ferrous Sulfate 325 mg PO DAILY 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hrs PRN Disp #*30 Tablet Refills: *0 4. Levothyroxine Sodium 25 mcg PO DAILY 5. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Term pregnancy, delivered Spontaneous vaginal delivery complicated by postpartum hemorrhage. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Refer to RN discharge packet Monitor for signs and symptoms of anemia. Start a iron supplement, Floradix. Take it twice a day.
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Ms. ___ had a spontaneous vaginal delivery on ___. Her postpartum course was complicated by postpartum hemorrhage (EBL 1400mL) secondary to lower uterine segment atony and cervical friability. She received ___, cytotect, TXA, and methergine and required an OR take-back for D&C with Bakri balloon placement, vaginal packing, and urinary foley. Patient tolerated the procedure well. Please see op report for more details Her bakri, foley, and vaginal packing were removed 24 hours after placement. Of note, patient had an episode of non sustained vT x2 while on L&D telemetry notable for an EKG with right bundle branch block for which she remained asymptomatic and with no further episodes the remainder of her stay on telemetry. She received 2 total units of pRBCs due to symptomatic anemia in the setting of a Hct <24, which she tolerated well ( ___ and ___. By postpartum day 3 after vaginal delivery, he tolerated a regular diet, voided spontaneously without issue, and ambulated independently. She was deemed stable for discharge with a plan set for postpartum follow up.
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10488182-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ciprofloxacin / Demerol / Nitroglycerin / Morphine / Clindamycin / Benzonatate / eucalyptus / Iodinated Contrast Media - IV Dye / scents / Toprol XL / Ranexa / Hydromorphone <ATTENDING> ___ <CHIEF COMPLAINT> constipation, vaginal pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> vault suspension, sacrospinous ligament fixation, posterior colporrhaphy <HISTORY OF PRESENT ILLNESS> The patient is a ___ year old woman initially referred for gynecologic consultation regarding vaginal pressure and lower pelvic discomfort and needing to splint during a bowel movement. On exam, she was found to have a ___ posterior enterocele, ___ rectocele, and vault prolapse. She was fitted with a size 2 pessary, which she wore from ___ to ___ on ___. Eventually, the patient elected to proceed with a more permanent option in the form of a vaginal procedure. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> # NSCLC of LLL - completion of CyberKnife therapy. - received 20 Gy x3 fractions to the left lower lobe nodule, which was biopsy proven non-small cell lung cancer. - completed her treatment on ___. - Last seen for follow-up in ___ evidence of recurrent disease # COPD, emphysema: on home O2 # GERD # OSA on CPAP # Tracheobronchomalacia # fibromyalgia # atrial fibrillation # MAC # CAD s/p 2 stents to the LAD # Immunoglobulin deficiency, on immunoglobulin injections Past Surgerical History: 1. s/p post-tonsillectomy 2. appendectomy 3. hysterectomy 4. Tracheobronchial stent placement and removal <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Breast, Ovarian or Colon cancer. <PHYSICAL EXAM> Pre-operative initial exam: 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. Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: absent-hysterectomy Uterus: absent-hysterectomy Adnexa: no masses non tender. POP-Q Exam: Aa: -2 Ba: -2 TVL: 7.5 D: C: -6 ___: 2.5 PB: 2 Ap: + 0.5 Bp: + 0.5 Discharge exam: <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Amoxicillin 500 mg PO DAILY 2. Tiotropium Bromide 1 CAP IH DAILY 3. Lorazepam 1 mg PO HS 4. Verapamil SR 120 mg PO BID 5. Guaifenesin ER 1200 mg PO Q12H 6. Rosuvastatin Calcium 40 mg PO DAILY 7. Montelukast 10 mg PO DAILY 8. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH DAILY 9. Clopidogrel 75 mg PO DAILY 10. Omeprazole 20 mg PO BID 11. Aspirin 81 mg PO DAILY 12. albuterol sulfate unknown inhalation prn 13. Amitriptyline 50 mg PO HS <DISCHARGE MEDICATIONS> 1. Amoxicillin 500 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH DAILY 5. Montelukast 10 mg PO DAILY 6. Rosuvastatin Calcium 40 mg PO DAILY 7. Tiotropium Bromide 1 CAP IH DAILY 8. Verapamil SR 120 mg PO BID 9. albuterol sulfate 0 puffs INHALATION PRN wheezing 10. Amitriptyline 50 mg PO HS 11. Guaifenesin ER 1200 mg PO Q12H 12. Lorazepam 1 mg PO HS 13. 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 #*50 Tablet Refills: *1 14. Cyclobenzaprine 10 mg PO TID ___ cause drowsiness. RX *cyclobenzaprine 5 mg ___ tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills: *1 15. Ibuprofen 400 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 16. OxycoDONE (Immediate Release) 2.5-5.0 mg PO Q4H: PRN pain ___ cause drowsiness. Take with stool softeners to prevent constipation. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills: *0 17. Omeprazole 20 mg PO BID 18. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 19. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY Please take while you still have foley in place RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth once a day Disp #*10 Capsule Refills: *0 20. Phenazopyridine 100 mg PO TID Duration: 3 Days RX *phenazopyridine 100 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills: *3 21. Lidocaine Jelly 2% 1 Appl TP PRN pain Can apply to outside of labia if having irritation from catheter. RX *lidocaine HCl 2 % apply to external area if having irritaion at catheter site ___ hours Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> rectocele, vaginal vault prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ , You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks or until approved by Dr. ___. * 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 *) 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 ___ clinic for catheter removal. Please call for an appointment at ___. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a vault suspension, sacrospinous ligament fixation, posterior colporrhaphy. 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. She was not able to void spontaneously and her Foley catheter was replaced for 800 cc of urine. Her Foley catheter was replaced and she was instructed in its care. Her diet was advanced without difficulty and she was transitioned to oral pain medications. By post-operative day 2, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10490001-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamides) / Penicillins / Oxycodone <ATTENDING> ___ <CHIEF COMPLAINT> postmenopausal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, washings, cystoscopy <HISTORY OF PRESENT ILLNESS> This patient is a ___ woman who initially presented with evaluation for post-menopauseal bleeding in ___. She first developed an episode of heavy vaginal bleeding in ___. She is referred to this clinic by Dr. ___ for further management and care. She has a history of a fibroid uterus and underwent a pelvic ultrasound because of this "enlarged" uterus in ___. At that time, the endometrial cavity echos measured 1.4 cm. The uterus itself was anteverted and measured 8 x 4 x 4.9 cm. . She had a previous biopsy revealing an atypical glandular focus on biopsy. Additional sampling was obtained with hysteroscopy, D&C and this was normal. We thought we are fairly well out of the woods, but she developed further bleeding. A biopsy was performed that revealed once again a minute fragment of glandular crowding similar to seen on prior biopsy. ___ and ___ husband are here for discussion only. Today, over the course of a 20-minute time period, I reviewed with ___ and ___ husband the finding of the abnormal endometrium on biopsy. I discussed with her my concerns for the possibility that the recurrent glandular crowding that were seen may represent a small focus of endometrial hyperplasia, which may progress to invasive cancer of the endometrium. I discussed with her that she has two options for care and the first is to perform once again a hysteroscopy, D&C, and sampling of the endometrium. I discussed with her that if this sampling is normal that close observation may be undertaken but that I would be concerned for the possibility of malignancy developing and that if she were to develop further postmenopausal bleeding, we would be concerned for the possibility of hyperplasia and cancer. I discussed another option for care, which was for laparoscopically assisted vaginal hysterectomy. I discussed the possibility of just simply performing a hysterectomy. She would like to proceed with laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: She has no history of asthma, hypertension, mitral valve prolapse, or thromboembolic disorder. She underwent a colonoscopy ___ years ago. Her mammogram is up to date. . PAST SURGICAL HISTORY: None. . OB/GYN HISTORY: Her last real menstrual cycle was ___ years ago. She is gravida 0 woman. She was not sexually active until she got married later in life and never had an abnormal Pap smear, pelvic infection. She has never had an ovarian cyst. The fibroids have been noted previously as described above. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her aunt had breast cancer, but she has no other family history of ovarian, endometrial, or colon cancer. She does report that her sister had a hysterectomy in the past, but she is uncertain why. She had another sister who has also had a hysterectomy, again it was unclear as to whether this was due to a malignancy or not. <PHYSICAL EXAM> GENERAL: She appears her stated age, in no apparent distress. HEENT: Normocephalic, atraumatic. Oral mucosa without evidence of thrush or mucositis. Eyes, sclerae are anicteric. NECK: Supple, no masses. No evidence of thyromegaly. LYMPH NODES: Survey negative. ABDOMEN: Soft, nontender, nondistended, no palpable masses. EXTREMITIES: No clubbing, cyanosis, or edema. PELVIC: Normal external genitalia. There is no vaginal mass or lesion. The inner labia minora is normal. The urethral meatus is normal. A speculum was placed and a normal vaginal canal was seen. The walls are smooth. It is normal in appearance. There is no mass or lesion. Bimanual exam reveals no mass or lesion. The uterus is mobile and slightly irregular in contour but otherwise normal. There is no parametrial nodularity or irregularity. RECTAL: Reveals good sphincter tone without mass or lesion. <PERTINENT RESULTS> CARDIOLOGY ========== ECGStudy Date of ___ 10: 41: 08 AM Sinus rhythm. Poor R wave progression. Non-diagnostic inferior Q waves. Compared to the previous tracing of ___ the Q wave is more prominent in lead V3. . PATHOLOGY ========= SPECIMEN SUBMITTED: ENDOMETRIAL BX...1 JAR. Procedure dateTissue receivedReport Date Diagnosed by ___. ___ Previous biopsies: ___ Endometrial Polyp And ___. ___ ENDOMETRIAL BIOPSY. ___ GI BX'S. Endometrial biopsy: 1. Scant inactive endometrium. 2. Minute fragment with gland crowding similar to previous biopsy (___). This focus is small and distorted precluding definitive diagnosis. Clinical: Post menopausal bleeding. Gross: The specimen is received in one formalin container labeled with the patient's name ___ and the medical record number. It consists of multiple mucus and soft tissue fragments measuring up to 0.8 x 0.4 x less than 0.1 cm in aggregate, entirely submitted in cassette A. . RADIOLOGY ========= PELVIS, NON-OBSTETRICStudy Date of ___ 8: 19 AM Uterine fibroids with no marked change since the prior ultrasound of ___. Endometrium not optimally visualized due to the fibroids but appears to measure approximately 5 mm. . CHEST (PRE-OP PA & LAT)Study Date of ___ 11: 55 AM FINDINGS: In comparison with the study of ___, there is no change or evidence of acute or chronic cardiopulmonary disease. <MEDICATIONS ON ADMISSION> none <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. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp: *60 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> postmenopausal bleeding <DISCHARGE CONDITION> stable <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 and no heavy lifting of objects >10lbs for 6 weeks. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * You may eat a regular diet. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit .
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Ms. ___ was admitted after undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, washings, and cystoscopy. Please see operative note for complete details. Her post-operative course was benign. Ms. ___ was eventually discharged on post-operative day 2 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty.
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10490045-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ___ <ATTENDING> ___. <CHIEF COMPLAINT> grade 3 endometrioid type endometrial adenocarcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and periaortic lymphadenectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G3P2 who presents for consultation regarding a new diagnosis of grade 3 endometrioid type endometrial adenocarcinoma. She initially presented in ___ with postmenopausal bleeding. Given her uterine tenderness on bimanual exam, she was given a course of doxycycline for presumed endometritis, and was scheduled for a transvaginal ultrasound and endometrial biopsy. Transvaginal ultrasound performed on ___ revealed a 30 x 18 x 22 mm solid mass with demarcated borders and color flow suspicious for an intracavitary fibroid obscuring the endometrial cavity, could not rule out endometrial mass. On ___, she underwent an endometrial biopsy which revealed grade 3 endometrioid type endometrial adenocarcinoma with extensive necrosis. Immunohistochemistry was negative for synaptophysin and rarely positive for chromogranin, as well as loss of nuclear expression of MLH1 and PMS2. CT torso on ___ showed no evidence of metastatic disease, and showed a 13mm exophytic right thyroid nodule, likely benign. <PAST MEDICAL HISTORY> PMH: - Migraine headache - Osteopenia - Bruxism - Sigmoid diverticulosis - Insomnia - GERD - Ventricular premature beats, s/p normal Holter (per pt) - Arthralgias of bilateral hands and knees - Sensorineural hearing loss - Cataracts - Denies history of heart disease, asthma, bleeding or clotting disorders PSH: - Tonsillectomy ___ - Open cholecystectomy ___ - Breast reduction POB: G2P2 PGYN: - Menses at 14, menopause at 56 - HRT x ___ years, OCPs x ___ years - No history of abnormal paps <SOCIAL HISTORY> ___ <FAMILY HISTORY> - No known family history of breast, uterine or ovarian cancer <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM --======== Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, nontender ___: nontender, nonedematous --======== PHYSICAL EXAM ON DISCHARGE: --======== Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 07: 24AM BLOOD WBC-11.1* RBC-3.88* Hgb-11.4 Hct-34.1 MCV-88 MCH-29.4 MCHC-33.4 RDW-13.0 RDWSD-41.3 Plt ___ ___ 07: 24AM BLOOD Glucose-114* UreaN-17 Creat-0.7 Na-142 K-4.4 Cl-106 HCO3-24 AnGap-12 ___ 07: 24AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0 <MEDICATIONS ON ADMISSION> - Multivitamin - Calcitonin - ASA 81mg <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild PACU ONLY do not take more than 4000mg in one day RX *acetaminophen 500 mg ___ tablet(s) by mouth q6hr Disp #*60 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID take if taking narcotics RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hr Disp #*60 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q6H: PRN Pain - Moderate PACU ONLY do not drive while taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___ * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service after undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and periaortic lymphadenectomy, and bilateral pelvic sentinel lymph node biopsy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV morphine and toradol. Her diet was advanced without difficulty and she was transitioned to oral oxycodone, ibuprofen, and acetaminophen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10492303-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Percocet / Tetracyclines / Ceftin / Aldactone / Cephalosporins / Gadolinium-Containing Agents <ATTENDING> ___. <CHIEF COMPLAINT> endometriosis/endometrioma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparotomy Excision of right ovarian remnant endometrioma Lysis of adhesions Incisional hernia repair with mesh <HISTORY OF PRESENT ILLNESS> ___ gravida 3 para ___ with long history of endometriosis who is being followed for right endometrioma and treated medically with norethindrone. She now desires definitive surgical therapy as patient also requires incisional hernia repair. If benign, patient desires to conserve left ovary and uterus. If borderline or malignant, she agrees to staging with hysterectomy and bilateral salpino-oopherectomy. She understands the recommendation of bilateral salpingo-oopherectomy and total abdominal hysterectomy and risks of conservative therapy. Her ventral hernia repair will be by Dr. ___. <PAST MEDICAL HISTORY> multiple sclerosis hypertension h/o DVT while on birth control pills at ___ asthma insulin resistance/obesity/PCOS endometriosis hyperlipidemia h/o cervical dysplasia ___ years ago ?___ tonsillectomy cryosurgery of cervix laparoscopic right salpingo-oopherectomy ventral hernia repair <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> obese white female in no acute distress HEENT wnl chest CTAB breast deferred cardiac S1 S2 normal abdomen obese, 15+cm right ventral wall hernia, nontender pelvic-rectal: deferred to OR extremities: no cords, cyanosis, edema <PERTINENT RESULTS> ___ 07: 15PM BLOOD Hct-38.3 ___ 06: 45AM BLOOD WBC-8.3 RBC-3.71* Hgb-10.8*# Hct-32.4* MCV-87 MCH-29.2 MCHC-33.5 RDW-12.3 Plt ___ ___ 12: 56PM BLOOD WBC-9.1 RBC-3.66* Hgb-10.8* Hct-32.1* MCV-88 MCH-29.4 MCHC-33.5 RDW-12.3 Plt ___ ___ 07: 40PM BLOOD WBC-12.4* RBC-3.61* Hgb-10.9* Hct-31.6* MCV-88 MCH-30.4 MCHC-34.7 RDW-12.3 Plt ___ ___ 06: 30AM BLOOD WBC-9.7 RBC-3.58* Hgb-10.6* Hct-31.2* MCV-87 MCH-29.5 MCHC-33.9 RDW-12.2 Plt ___ ___ 06: 30AM BLOOD Neuts-80.9* Lymphs-13.3* Monos-5.6 Eos-0.1 Baso-0.1 . ___ 07: 15PM BLOOD K-3.7 ___ 07: 15PM BLOOD Mg-1.5* ___ 06: 45AM BLOOD Glucose-118* UreaN-12 Creat-0.5 Na-137 K-3.8 Cl-104 HCO3-26 AnGap-11 ___ 06: 45AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.2 ___ 06: 00PM BLOOD Glucose-133* UreaN-11 Creat-0.6 Na-135 K-3.6 Cl-101 HCO3-28 AnGap-10 ___ 06: 00PM BLOOD Calcium-8.2* Phos-2.5* Mg-1.9 ___ 06: 30AM BLOOD Glucose-119* UreaN-7 Creat-0.5 Na-136 K-3.4 Cl-99 HCO3-30 AnGap-10 ___ 06: 30AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0 ___ 09: 25PM BLOOD Glucose-113* UreaN-10 Creat-0.6 Na-136 K-3.5 Cl-96 HCO3-28 AnGap-16 ___ 09: 25PM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0 . CHEST (PA & LAT) ___ 7: 08 ___ Lung volumes are quite low with a moderate degree of bibasilar atelectasis. Diaphragm contours are intact, stomach moderately dilated with air and fluid is in the left upper quadrant, and the mediastinum is not abnormally widened. Lateral view shows air in the entire length of the esophagus. Heart size is normal. No pneumothorax or appreciable pleural effusion. . LUNG SCAN ___ Low likelihood of pulmonary embolism. <MEDICATIONS ON ADMISSION> avonex ___ metformin lisinopril hydrochlorothiazide simvastatin flonase flovent albuterol klonopin lunesta baby aspirin calcium vitamin D fish oil <DISCHARGE MEDICATIONS> 1. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal BID (2 times a day) as needed. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *45 Capsule(s)* Refills: *1* 11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Endometrioma of right ovarian remnant Abdominal/Pelvic adhesions Incisional hernia <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your physician if you experience worsening or severe pain, fever > 100.4, nausea and vomiting, heavy vaginal bleeding, chest pain or trouble breathing, or if you have any other questions or concerns. - Please call if you have redness and warmth around your incision, if your incision is draining pus-like discharge, or if your incision reopens. - No heavy lifting or exercise for 6 weeks. - Please keep your follow-up appointments as scheduled below.
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Ms. ___ was admitted after her exploratory laparotomy, lysis of adhesions, resection of right ovarian remnant for endometrioma and large ventral hernia repair by Dr. ___ ___. Please see operative reports for complete details. She received one dose of clindamycin for prophylaxis as she had ___ drains placed by Dr. ___. Her post-operative course was characterized by the follow-ing issues: . *) fever Ms. ___ had a ___ of 100.9 on POD#1. Her WBC was initially elevated at 12.4 but this quickly normalized within 12 hours. Blood cultures and urine cultures were negative. . *) tachycardia In the setting of her fever, Ms. ___ was also tachycardic to the 110s-120s. EKG showed sinus tachycardia with no acute changes from previous EKG. Coupled with her acute desaturation (see below), however, she was evaluated for pneumonia, pulmonary edema, and pulmonary embolism. The tachycardia resolved by POD#2. . *) oxygen desaturation 84 -> 92% RA on deep inspiration w cough On POD#1, Ms. ___ also desaturated on room air to 88%. Chest x-ray showed low lung volumes, mod bibasilar atelectasis, and no evidence of pneumonia or pulmonary edema. Given her history of DVT on oral contraceptives and allergy to intravenous contrast, she underwent a ventilation-perfusion scan to determine risk for pulmonary embolism. Her scan was low risk. As per her history of asthma, she was on nebulizer treatments as needed during her hospitalization. . *) Low urine output She had low urine output the night after her surgery. This responded to 500cc boluses of LR x2. Her Hct stabilized at ~32, with a pre-operative Hct of 40.6. . *) Insulin resistance Ms. ___ was placed on an insulin sliding scale post-operatively. Her fingerstick glucoses ranged from 130-140s during her hospital course. She continued on her home metformin dose when she was able to tolerate hydration/food by mouth. . *) HTN She was continued on her home medications on POD#1. . She was discharged on POD#5 under adequate pain control, tolerating regular food, ambulating and urinating without difficulty, and afebrile. She was discharged with ___ to assist with her ___ drains which were still in place at the time of discharge.
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10492303-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Percocet / Tetracyclines / Ceftin / Aldactone / Cephalosporins / Gadolinium-Containing Agents / Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic mass, severe endometriosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, left salphingo-oopherectomy, omentectomy, lysis of adhesions <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___ G3, P3 with a gynecologic history notable for chronic menometrorrhagia, endometriosis, and previous surgeries for removal of endometriomas. She has had irregular menses throughout her life, which were previously controlled with progestins and more recently with metformin. She continues on metformin and was having more or less regular menses up to six months ago from which time she has had menometrorrhagia. A recent pelvic ultrasound was done. This showed a 9 cm uterus with a 17 mm endometrial stripe and a focal hypoechoic nodule measuring 9 mm. The right ovary was not seen; however, in the left adnexa 7.4 cm complex cystic lesion with multiple thick septations as well as internal echos was noted. Of note, she has had multiple previous surgeries in ___ and ___ for endometriomas. She has also had hernia repairs. I have reviewed her previous operative notes and she has had extensive pelvic adhesive disease as well as adhesions to the anterior abdominal wall. In fact, with her last surgery, Dr. ___ from GYN oncology was intraoperatively consulted due to the extensive pelvic adhesions and an initial laparoscopic surgery was converted to a laparotomy. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> 1. Asthma, mild-to-moderate: 2. Hypertension. 3. Multiple sclerosis for the last ___ years. She has some left upper extremity numbness and left lower extremity weakness occasionally as well as some symptoms of fatigue. 4. Insulin resistance. 5. Hypercholesterolemia. 6. Seasonal allergies. 7. She is up-to-date on mammograms and colonoscopy. Past Surgical History: 1. In ___, she had laparotomy, right salpingo-oophorectomy for endometrioma. 2. In ___, she had a laparoscopic repair of incisional hernia, laparoscopic drainage of an endometrioma. 3. In ___, she underwent laparoscopy with conversion to open laparotomy with repair of an incisional hernia with mesh by Dr. ___ as well as right salpingo-oophorectomy by Dr. ___ ___ Dr. ___. Pathology from that specimen showed a left paratubal cyst and right ovarian endometrioma and unremarkable fallopian tube. Past Ob/Gyn History: G3, P3 with three vaginal deliveries. Menstrual history as above. Had cryo procedure of her cervix in the distant past with normal Paps since then. She had been on progestin only birth control pills for many years in the past. No significant infections. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Breast cancer as per the HPI. Negative for ovarian or colon cancer. Her grandmother had uterine cancer. <PHYSICAL EXAM> General: On exam, she is a healthy-appearing woman who appears her stated age. She has an appropriate affect and is well engaging in conversation and asks appropriate questions and expresses good understanding of the clinical findings. HEENT: Her eyes are anicteric. Her mouth is moist. Neck: Supple. Heart: Regular rate and rhythm. Lungs: Clear without any rhonchi, rales, or wheezes. No CVA tenderness. No skin rashes. No cervical lymphadenopathy. Abdomen: Obese, soft, nontender. Vertical midline incision noted well healed. No hernias noted. No groin adenopathy. Extremities: No lower extremity edema. GU: External genitalia unremarkable. Vaginal mucosa is smooth. Blood is noted in the vaginal vault. Cervix is smooth. Rectovaginal Exam: Uterus is mobile and no adnexal masses appreciated, although exam is limited by habitus. No nodularity of the uterosacral ligaments is appreciated. <MEDICATIONS ON ADMISSION> Medications - Prescription ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled up to q ___ hrs prn as needed for cough and wheeze BISACODYL-PEG-ELECTROLYTE SOLN [HALFLYTELY-BISACODYL W-FLAV PK] - 5 mg x 2 (10 mg)-210 gram Kit - 1 Kit(s) by mouth once start noon on day prior to surgery. drink plenty of liquids. CLONAZEPAM - 0.125 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth maximum 3 times/week as needed for anxiety EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1: 1,000) Pen Injector - use in case of severe reaction and call ___ (use only once) FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 spray in each nostril daily FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs inhaled BID for ___ weeks, then decrease to 1 puff BID and then wean to 1 puff QD as tolerated FLUTICASONE-SALMETEROL [ADVAIR HFA] - 230 mcg-21 mcg/Actuation Aerosol - 2 inhalations(s) twice a day use only if fluticasone alone not effective HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a day INTERFERON BETA-1A [AVONEX ADMINISTRATION PACK] - 30 mcg/0.5 mL Kit - one dose once weekly LISINOPRIL - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day MASSAGE - - 1 every 6 weeks METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day SIMVASTATIN - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day in the evening Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D PETITES] - (OTC) - 200 mg (calcium)-250 unit Tablet - 2 Tablet(s) by mouth twice a day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (OTC) - 1,000 unit Tablet, Chewable - 3 Tablet(s) by mouth once a day FISH OIL-DHA-EPA - (OTC) - 1,200 mg-144 mg Capsule - 1 Capsule(s) by mouth twice a day <DISCHARGE MEDICATIONS> 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day) as needed for wheezing. 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *0* 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Motrin 600 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp: *50 Tablet(s)* Refills: *1* 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp: *60 Tablet(s)* Refills: *2* 14. Senna 8.6 mg Tablet Sig: ___ Tablets PO at bedtime as needed for constipation. Disp: *60 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometriosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or return to the hospital if you have: -Increased pain -Redness or unusual discharge from your incision -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -No intercourse, tampons, or douching for 6 weeks -No heavy lifting or vigorous activity for 6 weeks -You can shower and clean your wound, but do not use perfumed soaps or lotions. Be sure to pat completely dry after washing. -You may resume your regular diet and home medications.
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Ms. ___ was admitted to gyn oncology post-operatively. Please see OMR for full surgical details. Her post-operative course was overall uncomplicated. She had an ileus which resolved with a slow diet advance. She was discharged home on POD 6 in stable condition.
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10492303-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Percocet / Tetracyclines / Ceftin / Aldactone / Cephalosporins / Gadolinium-Containing Agents / Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> fever, incisional drainage <MAJOR SURGICAL OR INVASIVE PROCEDURE> Incision and drainage of abscesses <HISTORY OF PRESENT ILLNESS> Mrs ___ is a ___ year old woman who is status-post laparotomy, total abdominal hysterectomy, left salpingo-oophorectomy, lysis of adhesions for endometriomas on ___. She reports ___ days of increasing pain and redness at her incision with a fever at home on ___ to 101.5. On ___ her incision started draining thick purulent discharge. She was prescribed a z-pack last week which she completed for early cellulitis. She presented to Dr ___ ___ and was found to have 2 suprafascial abscesses with surrounding cellulitis which he drained and packed in clinic. She was afebrile at the time (Please see procedure note by Dr ___. She was directly admitted to the surgical floor for IV antibiotics and wound care. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> 1. Asthma, mild-to-moderate 2. Hypertension. 3. Multiple sclerosis for the last ___ years. She has some left upper extremity numbness and left lower extremity weakness occasionally as well as some symptoms of fatigue. Was on Avonex until surgery but has not yet resumed. 4. Insulin resistance on Metformin 5. Hypercholesterolemia. 6. Seasonal allergies. 7. She is up-to-date on mammograms and colonoscopy. Past Surgical History: 1. In ___, she had laparotomy, right salpingo-oophorectomy for endometrioma. 2. In ___, she had a laparoscopic repair of incisional hernia, laparoscopic drainage of an endometrioma. 3. In ___, she underwent laparoscopy with conversion to open laparotomy with repair of an incisional hernia with mesh by Dr. ___ as well as right salpingo-oophorectomy by Dr. ___ ___ Dr. ___. Pathology from that specimen showed a left paratubal cyst and right ovarian endometrioma and unremarkable fallopian tube. 4. ___ endometriosis TAH-LSO,LOA as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> Breast cancer as per the HPI. Negative for ovarian or colon cancer. Her grandmother had uterine cancer. <PHYSICAL EXAM> VS: T 99.3, HR 100, BP 110/68 RR 18 General: She appears well and in no apparent distress. S/HEENT: Skin and sclerae are anicteric. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, non-distended and without palpable masses. There is a midline vertical abdominal incision with two open areas which are packed with 4x4's and each are around 2 cm in diameter. There is a 2-3cm area of surrounding erythma but no fluctuance. Extremities: Without clubbing, cyanosis, or edema. No calf tenderness to palpation. <PERTINENT RESULTS> Labs: ___ 07: 15PM WBC-10.2 RBC-3.47* HGB-8.8* HCT-28.0* MCV-81* MCH-25.4* MCHC-31.6 RDW-15.0 ___ 07: 15PM NEUTS-66.6 ___ MONOS-5.7 EOS-3.0 BASOS-0.7 ___ 07: 15PM GLUCOSE-128* UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-26 ANION ___ Micro: ___ GRAM STAIN: 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. WOUND CULTURE (Final ___: mixed bacterial types (>=3) ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Imaging: abdominal ultrasound: In the subcutaneous tissues, a well-defined collection is present that measures 3.9 x 4.5 x 2.2 cm. The depth from the skin surface to the anterior border of the collection is a 3.1 cm and 5.2 cm to the posterior margin. <MEDICATIONS ON ADMISSION> Medications - Prescription ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled up to q ___ hrs prn as needed for cough and wheeze CLONAZEPAM - 0.125 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth maximum 3 times/week as needed for anxiety EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1: 1,000) Pen Injector - use in case of severe reaction and call ___ (use only once) FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 spray in each nostril daily FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs inhaled BID for ___ weeks, then decrease to 1 puff BID and then wean to 1 puff QD as tolerated FLUTICASONE-SALMETEROL [ADVAIR HFA] - 230 mcg-21 mcg/Actuation Aerosol - 2 inhalations(s) twice a day use only if fluticasone alone not effective HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a day INTERFERON BETA-1A [AVONEX ADMINISTRATION PACK] - 30 mcg/0.5 mL Kit - one dose once weekly LISINOPRIL - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day MASSAGE - - 1 every 6 weeks METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day SIMVASTATIN - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day in the evening Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D PETITES] - (OTC) - 200 mg (calcium)-250 unit Tablet - 2 Tablet(s) by mouth twice a day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (OTC) - 1,000 unit Tablet, Chewable - 3 Tablet(s) by mouth once a day FISH OIL-DHA-EPA - (OTC) - 1,200 mg <DISCHARGE MEDICATIONS> 1. Albuterol Sulfate Inhalation 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp: *30 Tablet(s)* Refills: *0* 11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp: *10 Tablet(s)* Refills: *0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. Disp: *60 Capsule(s)* Refills: *0* 13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Cellulitis Incisional abscesses s/p incision and drainage/washout <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Do not drive while taking narcotic pain medications - Visiting nurses ___ do dressing changes twice daily - Call Dr. ___ for any increasing redness, fever, chills, increasing pain, foul-smelling drainage from your incisions
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Ms. ___ was admitted to the Gyn Onc service on ___ for management of her fever and suprafascial postoperative wound infection. She was taken back to the operating room on ___ for incision and drainage and debridement. Her post-operative course was unremarkable. She remained afebrile while in house. She was discharged on ___, when she was tolerating a regular diet and her pain was well controlled with oral medications. #. Suprafascial postoperative wound infection: She received IV Levofloxacin and PO Metronidazole beginning on ___. Gram stain from ___ revealed Staphylococcus coagulase negative. The wound culture grew out mixed bacteria. While in house her cellulitis resolved. Her abdominal wound required three times daily wet to dry dressing changes. On discharge, she was sent home with Levofloxacin 750 mg PO, Metronidazole 500mg PO for a total of ___ ___ service will come to her house to help with wound care twice daily.
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10493251-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Right pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic bilateral salpingo-oophorectomy, mini-laparotomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G3P3, who initially presented to the ED on ___ with 24 hours of intermittent RLQ pain, that was sudden in onset and radiating to the midline. CT of abdomen and pelvis showed a 8.6 cm soft tissue density lesion within the left adnexa. Pelvic US showed a 6.7 cm heavily shadowing mass with internal vascularity and moderate surrounding free fluid. The pain resolved after receiving some pain medication in the ED. On ___, the pain returned, colicky and non-radiating in nature. She again presented to the ED for evaluation and received some morphine for pain control. A repeat pelvic US showed a solid and cystic right adnexal lesion, fibroid uterus with a 7cm exophytic fibroid projecting to the left of the midline, and stable free fluid. She denied any febrile episodes, nausea and vomiting or changes in bowel habits. <PAST MEDICAL HISTORY> OBGYN History Menopausal, last vaginal bleeding "years" ago Denies history of STI Past OCP use x ___ year No HRT SVD x3, term, uncomplicated PPTL for contraception PMH Depression Acoustic schwannoma Finger melanoma Denies HTN, asthma, diabetes, problems with anesthesia or bleeding/clotting diathesis Last ___ ___, BIRADS-2 Last Pap ___, NIL PSH PPTL, finger surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of breast, ovarian, uterine, cervical, or colon cancers. MGM with pancreatic vs liver cancer. No family history of problems with anesthesia, blood clots or bleeding disorders. <PHYSICAL EXAM> General: no acute distress, well appearing CV: RRR Lungs: CTAB Abdomen: soft, nontender, port site incisions and laparotomy incision c/d/i with steri strips in place Ext: nontender, nonedematous <PERTINENT RESULTS> ___ 06: 00AM BLOOD WBC-21.3*# RBC-3.71* Hgb-11.7* Hct-37.0 MCV-100* MCH-31.5 MCHC-31.5 RDW-13.7 Plt ___ ___ 06: 17AM BLOOD WBC-12.5* RBC-3.91* Hgb-12.4 Hct-37.8 MCV-97 MCH-31.7 MCHC-32.8 RDW-13.7 Plt ___ ___ 03: 40PM BLOOD WBC-10.3 RBC-3.76* Hgb-12.1 Hct-36.0 MCV-96 MCH-32.3* MCHC-33.7 RDW-13.6 Plt ___ ___ 06: 00AM BLOOD WBC-10.2 RBC-3.64* Hgb-11.4* Hct-36.0 MCV-99* MCH-31.3 MCHC-31.7 RDW-13.3 Plt ___ ___ 07: 05PM BLOOD WBC-10.4 RBC-4.18* Hgb-13.1 Hct-40.3 MCV-96 MCH-31.2 MCHC-32.4 RDW-13.4 Plt ___ ___ 06: 00AM BLOOD Glucose-144* UreaN-15 Creat-0.7 Na-136 K-4.6 Cl-101 HCO3-25 AnGap-15 ___ 06: 17AM BLOOD Glucose-93 UreaN-23* Creat-0.8 Na-140 K-4.5 Cl-105 HCO3-28 AnGap-12 ___ 06: 00AM BLOOD Glucose-81 UreaN-12 Creat-0.6 Na-141 K-3.8 Cl-107 HCO3-26 AnGap-12 ___ 07: 05PM BLOOD Glucose-113* UreaN-20 Creat-0.8 Na-143 K-4.2 Cl-103 HCO3-28 AnGap-16 Pelvic US ___ IMPRESSION: 1) Solid and cystic right adnexal lesion, probably an abnormal right ovary. Further evaluation with MRI is needed if surgical excision is not planned. No signs of ovarian torsion. 2) Moderate amount of free fluid, stable since 4 days prior 3) Fibroid uterus with a 7 cm exophytic fibroid projecting to the left of midline The study and the report were reviewed by the staff radiologist. CT/Abdomen Pelvis ___ FINDINGS: CT ABDOMEN WITHOUT CONTRAST: The imaged lung bases are clear without pleural or pericardial effusion. Please note assessment of solid organs in the abdomen is limited in the absence of intravenous contrast. The liver is normal in attenuation. The gallbladder, pancreas, spleen and bilateral adrenal glands are unremarkable. The kidneys are without hydronephrosis. The stomach, small and large bowel are grossly normal with normal appendix though portions of the bowel in the right lower quadrant are not well assessed due to surrounding heterogeneous free fluid. The aorta is normal in caliber. There is no free air, mesenteric or retroperitoneal adenopathy. CT PELVIS WITHOUT CONTRAST: The right lower quadrant and right adnexa are not well assessed with nonvisualization of the right ovary on this nonenhanced examination due to obscuration of this region by heterogeneous soft tissue density possibly complex fluid interspersed between multiple bowel loops and in the right adnexa. The left ovary is not discretely identified with an 8.6 x 7.5 cm (2: 68) soft tissue lesion within the region of the left adnexa, which may reflect a subserosal fibroid or ovarian pathology. The bladder and rectum are unremarkable. There is no pelvic or inguinal adenopathy is identified. OSSEOUS STRUCTURES: There is no suspicious lytic or blastic bony lesion to suggest osseous malignancy. IMPRESSION: No definitive explanation for the patient's symptoms on this noncontrast study noting several pelvic abnormalities. Specifically, a 8.6 cm soft tissue density lesion within the left adnexa which could reflect a fibroid or left ovarian lesion and heterogeneous mixed density fluid within the right adnexa with nonvisualization of the right ovary which could reflect right adnexal pathology. Normal appendix. Consider pelvic ultrasound for further assessment. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Venlafaxine XR 75 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Venlafaxine XR 75 mg PO DAILY 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 3. Ibuprofen 600 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 4. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN Pain Do not drive while taking this medication. RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 5. Acetaminophen ___ mg PO Q6H Do not exceed 4000 mg in 24 hours. RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> laparoscopic bilateral salpingo-oophorectomy, mini-laparotomy for right adenexal 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 for 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 2 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
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Ms. ___ was admitted to the gynecology oncology service after undergoing bilateral salpingo-oophorectomy and mini laparatomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled IV toradol and dilaudid. Her diet was advanced without difficulty and she was transitioned to PO Motrin and tylenol. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10494272-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lisinopril <ATTENDING> ___. <CHIEF COMPLAINT> abdominal distension and pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> explorative laparotomy, bilateral salpingoophorectomy <HISTORY OF PRESENT ILLNESS> ___ yo G3P3 ___ speaking woman who was transferred to ___ ED from ___ for increasing abdominal distension and abdominal pain. Symptoms began 3 months ago and have since been getting worse. She reports seeing a gynecologist when she initially developed lower abdominal pain 3 months ago, but based on exam her symptoms were attributed to GI etiology. Over the last 3 months she developed worsening abdominal pain and abdominal distension. She presented to ___ this morning for further management. At ___ she was afebrile with otherwise with normal vitals. An abdominal/pelvic CT showed "reproductive - large complex cystic mass in the pelvis with enhancing solid components measuring 16 x 16 x 9 cm. Suspect ovarian origin. Uterus is unremarkable." The CT also demonstrated "moderate right pleural effusion with atelectasis and small volume abdominopelvic ascites, no free air, no adenopathy." TVUS showed "within the right ovary there is a 16.2 x 10.8 x 11.9 cm solid mass with cystic components. The left ovary contains a 2.0 x 2.4 x 2.3 cm cyst. Additionally there is a solid component that measures 3.6 x 2.6 x 3.1 cm. Normal arterial and venous blood flow were identified. There is a small amount of free fluid." She did not require pain medication at ___ and was transferred to ___ for further management She reports only having pain when she palpates the mass. Otherwise she has no pain with ambulation or activity. On self palpation she reports a pain level of ___. She has noticed her abdomen getting larger and a 5 lb unintentional weight loss due to decreased appetite and early satiety. She has been having occasional dysuria, though no other voiding difficulties and on average has a BM every two days. Denies postmenopausal bleeding and vaginal discharge. Denies nausea and vomiting. Denies need for pain medication at home or now. Of note she is originally from ___ and had been abroad the first half of this year. She is accompanied by her son today in the ED. She was offered an interpreter, but declined and requested her son interpret for her. However, patient was able to answer all questions on her own and did not require any interpretation. <PAST MEDICAL HISTORY> OB: G3P3 - SVD x3 GYN: - LMP: menopause around age ___ or ___, denies any bleeding since then, took PO hormone replacement therapy for about ___ years, has since discontinued use - Sexually active: no - STIs: denies - Pap: denies abnormal Pap history - h/o endometriosis, fibroids, cysts: denies PMH: - HTN, on HCTZ, does not know dose - Insomnia, on trazodone - Hyperlipidemia, does not know name of medication she is on PSH: - Bilateral vein ligation and stripping <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of breast, ovarian, colon and uterine cancer. <PHYSICAL EXAM> Initial <PHYSICAL EXAM> Vitals: 97.2 105 145/79 17 100% RA General: NAD, comfortable, pleasant, well appearing Lymphatic: no neck or groin lymphadenopathy CV: RRR Resp: absent breath sounds right posterior lobe ___ way up, faint crackles left posterior lobe ___ way up Abd: soft, moderately distended, positive fluid wave sign, no rebound, mobile lower abdominal mass 1 cm inferior to umbilicus spanning 10 cm wide in lower pelvis, mildly tender, non-acute abdomen Pelvic: vulva notable for 1 cm pedunculated skin tag at 1 o'clock of mons pubis with black edges, non-tender, otherwise normal vulva, vaginal mucosa faint pink with moderate anterior wall prolapse/cystocele, normal cervix without lesions, no vaginal discharge or blood, on bimanual exam mobile pelvic mass mild to moderate tenderness with some guarding Rectal: normal recto-vaginal tissue without nodularity or fullness MSK: no CVA tenderness bilaterally Physical Exam on Day of Discharge: <PERTINENT RESULTS> ___ 06: 12PM PLT COUNT-275# ___ 06: 12PM WBC-14.2*# RBC-4.96 HGB-13.2 HCT-40.0 MCV-81* MCH-26.6 MCHC-33.0 RDW-13.5 RDWSD-39.2 ___ 06: 12PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-2.1 ___ 06: 12PM estGFR-Using this ___ 06: 12PM GLUCOSE-200* UREA N-6 CREAT-0.7 SODIUM-140 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15 ___ 10: 45PM PLT COUNT-267 ___ 10: 45PM WBC-13.1* RBC-4.96 HGB-13.2 HCT-39.0 MCV-79* MCH-26.6 MCHC-33.8 RDW-13.5 RDWSD-38.3 ___ 10: 45PM TSH-1.3 ___ 10: 45PM CALCIUM-9.1 PHOSPHATE-1.9* MAGNESIUM-1.8 ___ 10: 45PM CK-MB-1 cTropnT-<0.01 ___ 10: 45PM CK(CPK)-74 ___ 10: 45PM GLUCOSE-246* UREA N-6 CREAT-0.7 SODIUM-134* POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-19* ANION GAP-22* ___ 10: 58PM LACTATE-4.0* ___ 10: 58PM ___ COMMENTS-GREEN TOP <MEDICATIONS ON ADMISSION> - HCTZ - Trazodone - Cholesterol medication, not sure of name, received medication in ___ <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H do not exceed 4000mg in 24 hours RX *acetaminophen 650 mg 1 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. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe do not drink alcohol or drive while on this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*40 Tablet Refills: *0 4. Hydrochlorothiazide 12.5 mg PO DAILY HTN <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic mass <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. 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. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing explorative laparotomy, bilateral salpingoophorectomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with Dilaudid PCA with acetaminophen. On postoperative day zero, patient experienced tachycardia with HR 110-160s, increased anxiety, and "feeling of doom." Cardiology was consulted. EKG showed sinus tachycardia and patient was monitored on telemetry. Lactate was 4.0 and 1.8 when repeated. Hct was stable at 39 to 37.1, and troponins were negative. This episode was thought to be a panic attack, as symptoms quickly resolved and tachycardia improved. Her diet was advanced without difficulty and she was transitioned to ****(pain meds). On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10494796-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> spontaneous rupture of membranes <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p SVD Manual Removal of Placenta <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo who presented at term and underwent a spontaneous vaginal delivery. <PAST MEDICAL HISTORY> gestational hypertension <PERTINENT RESULTS> ___ 12: 52PM BLOOD WBC-23.5*# RBC-3.42* Hgb-10.9*# Hct-33.1* MCV-97 MCH-31.8 MCHC-32.8 RDW-13.3 Plt ___ ___ 01: 50PM BLOOD WBC-11.2* RBC-4.43 Hgb-14.2 Hct-41.2 MCV-93 MCH-32.1* MCHC-34.5 RDW-13.5 Plt ___ ___ 01: 50PM BLOOD Creat-0.7 ___ 01: 50PM BLOOD ALT-16 ___ 01: 50PM BLOOD UricAcd-4.7 ___ 02: 40PM URINE Color-Straw Appear-Clear Sp ___ ___ 02: 40PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 02: 40PM URINE Hours-RANDOM Creat-21 TotProt-LESS THAN <DISCHARGE INSTRUCTIONS> See Written Discharge Instructions
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On ___ Ms. ___ underwent a spontaneous vaginal delivery which was complicated by a retained placenta. This required a manual extraction, and an opertative dilation and curettage. She received 1 dose of ancef post partum for the instrumentation. Her total estimated blood loss was 1500cc and her hematocrit was noted to decrease from 41 to 33. Her pregnancy was also complicated by gestational hypertension. Her blood pressures were monitored and were non severe. Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Fluoxetine 60 mg PO DAILY 3. Ibuprofen 600 mg PO Q6H:PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 hours Disp #*60 Tablet Refills:*0 4. Doxepin HCl 40 mg PO HS Discharge Disposition: Home Discharge Diagnosis: s/p SVD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10498486-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> labor at term <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilatation and curretage <HISTORY OF PRESENT ILLNESS> CC: contractions HPI: ___ G2P1001 at 40w6d with in labor. + ctx, some blood show but no frank bleeding, - LOF. +FM. PNC: - ___ ___ by ___ and US - Labs Rh +/Abs pending/Rub I/RPR NR/HBsAg -/HIV -/GBS+ - Screening: CF carrier -, declined SMA. CFDNA low risk for trisomy 13,18,21 - FFS: ___ - GTT: nml - U/S: ___ - Issues: *) Headache: In triage ___ for ___ HA, felt similar to migraines. Treated with Compazine and fioricet. BPs normal, PIH labs wnl <PAST MEDICAL HISTORY> OBHx: G2P1001 - G1: ___ SVD at term, girl, 3545g GynHx: - Hx LEEP ___, no recurrence. PMH: - Migraines PSH: - Breast reduction (___) Meds: PNV All: NKDA SHx: ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, Vital signs stable Neuro/Psych: no acute distress, Oriented x3, Affect Normal Heart: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft, appropriately tender, fundus firm, incision clean/dry/intact Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 10: 52AM BLOOD WBC-11.3* RBC-4.77 Hgb-13.3 Hct-41.8 MCV-88 MCH-27.9 MCHC-31.8* RDW-13.5 RDWSD-42.7 Plt ___ ___ 11: 00PM BLOOD WBC-18.2* RBC-3.76* Hgb-10.8* Hct-32.7* MCV-87 MCH-28.7 MCHC-33.0 RDW-13.6 RDWSD-42.5 Plt ___ ___ 09: 40AM BLOOD WBC-13.1* RBC-3.71* Hgb-10.7* Hct-32.9* MCV-89 MCH-28.8 MCHC-32.5 RDW-13.8 RDWSD-44.8 Plt ___ ___ 11: 00PM BLOOD ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal delivery Postpartum hemorrhage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please see discharge packet
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Ms. ___ was admitted in labor and had a spontaneous vaginal delivery on ___. Her delivery was complicated by postpartum hemorrhage with a total EBL of 1100 cc (400cc at time of delivery and 900cc postpartum). She was treated with bimanual massage with IV Pitocin, PR cytotec, and IM methergine and continued to have persistent bleeding, and the decision was made to proceed to the OR for additional evaluation and D & C. A small amount of retained products were removed. Her bleeding improved and she was continued on oral methergine for the next ___ hours. Her lochia remained normal. She tolerated a regular diet, voided spontaneously without issue, and ambulated independently. On postpartum day 2 after vaginal delivery, she was appropriate for discharge and postpartum followup in ___ weeks or as needed.
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10500420-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vertigo <MAJOR SURGICAL OR INVASIVE PROCEDURE> lumbar puncture attempted, unsuccessful <HISTORY OF PRESENT ILLNESS> HPI: ___ ___ at 25w5d GA referred to ___ for further work up of 4 day history of vertigo and headaches. Patient was in usual state of health until ___ when she woke up with a headache that she describes as starting in the back of her neck and spreading up to the top of her head. This headache is associated with photophobia and nausea, no phonophobia.This was also accompanied by vertigo that she describes as "room spinning." Vertigo is present regardless of what position she is in, but is better when she lies down with her eyes closed. She was seen at ___ on ___ night where she was given meclizine and IV fluids. Her vertigo improved after this, but was still persistent. <PAST MEDICAL HISTORY> PMH: Morbid obesity (BMI 43.5), T2DM vs gluc intolerance as above. Iron deficiency anemia. H Pylori (diagnosed in ___, no symptoms since then) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> <PHYSICAL EXAM> 98.3 77 94/54 16 97% RA Gen: NAD, lying down with eyes closed, opens eyes and able to respond to questions. CV: RRR Pulm: CTAB anteriorly Abd: soft, obese, ND, NT. No R/G, no fundal TTP Extr: NT/NE TAUS (performed after vasovagal episode): FHR 120bpm <PERTINENT RESULTS> ___ 06: 36PM BLOOD WBC-12.2* RBC-4.33 Hgb-11.8* Hct-35.8* MCV-83 MCH-27.2 MCHC-32.9 RDW-13.6 Plt ___ ___ 06: 36PM BLOOD Glucose-110* UreaN-7 Creat-0.6 Na-136 K-3.6 Cl-103 HCO3-21* AnGap-16 ___ 02: 05AM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-7 <MEDICATIONS ON ADMISSION> 1. NPH 20 Units Bedtime 2. Lorazepam 0.5 mg PO Q6H: PRN vertigo 3. Meclizine 25 mg PO Q8H: PRN vertigo 4. Ondansetron 4 mg PO Q6H: PRN nausea 5. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> no new meds- same as admission. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 25 weeks gestation vertigo <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for observation due to your symptoms of vertigo and headache. The neurology team followed you and felt that your symptoms and exam are most consistent with a condition called Benign Positional Vertigo, which is self-limited. You've been given medications to help your symptoms. It is important that you stay hydrated. Continue checking your fingersticks as you have been doing.
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Pt admitted ___ and seen by Neuro- benign positional vertigo dx. ASSESSMENT/PLAN: ___ year old woman, 5 months pregnant with a history of gestational diabetes who presents with 4 days of headache, vertigo, nausea and blurry vision. On reassessment in the morning the patient appears to have more of a muscular tension posterior headache without any signs concerning for meningitic pain as her eye pain has since resolved. MRI/V also demonstrated no enhancement of the meninges nor any sinus thrombosis. She demonstrates classic symptoms of benign vertigo, which include episodic vertigo to one side, worse with head movements and right head positioning, and right beating nystagmus. - Please continue hydration and anti-vertigo/emetic medication; recommend ativan/diazepam for acute management as this should treat both her tension headache from neck spasm, as well as treat her nausea. - No prophylactic medication should be necessary at this time to control the patient's headaches. Recommend that she stay adequately hydrated. Case discussed, patient seen, and plan formulated with ___, MD, Neurology Attending. Nl Nst ___ Stable and able to ambulate- did not take ativan D/c ___ afte nl fetal doptone f/u this week at ___
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10502794-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> "Symptomatic fibroid uterus" <MAJOR SURGICAL OR INVASIVE PROCEDURE> Supracervical Hysterectomy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 3, para ___ who has a history of heavy vaginal bleeding in the face of a known fibroid uterus. The patient was seen in the ___ ___ Emergency ___ on ___ with complaints of increased vaginal bleeding, lower abdominal cramping. At that time, her hematocrit was 28%. Her treatment options were reviewed. The patient was sent home on oxycodone and Motrin. It was recommended that she takes oral contraceptive pills in a tapering manner and daily iron supplementation. The patient is no longer taking her birth control pills. She is eating iron rich foods and taking her iron tablets. The patient denies any signs and symptoms of acute blood loss anemia. OB/GYN HISTORY: Menarche at 14. She cycles monthly and typically bleeds for ___ days. She passes small clots. During her heaviest bleeding period, she changes a pad or tampon every 30 minutes. She does have intermenstrual bleeding. She does have dysmenorrhea, dyspareunia. Denies postcoital bleeding. She denies any history of sexually transmitted infections. She has a remote history of abnormal Pap smears with several years of normal Paps since that time. She has never had a mammogram, colonoscopy, or bone density. She has had 3 pregnancies; 2 terminations of pregnancies without complications; and in ___, had a vaginal delivery at term. <PAST MEDICAL HISTORY> - Asthma <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for any female cancers. <PHYSICAL EXAM> Physical Examination was performed by Dr. ___ ___: This is a well-developed, well-nourished woman in no apparent distress. VITAL SIGNS: Blood pressure 122/82, weight 208. ABDOMEN: Soft, nondistended, nontender, negative hepatosplenomegaly. Fibroid uterus with 1 fingerbreadth above the umbilicus. PELVIC: There was normal female external genitalia. Bartholin, urethral, and Skene's glands were normal. Vaginal vault had normal appearing discharge. There were no lesions. Cervix appeared normal. There were no lesions. Pap smear was updated. Uterus is approximately 18 cm in maximal vertical dimension, irregularly contoured consistent with her known fibroid uterus, slightly mobile. Adnexa was impossible to evaluate secondary to her large pelvic abdominal mass. <PERTINENT RESULTS> Pelvic Ultrasound ___ Transabdominal ultrasound demonstrates an enlarged fibroid uterus measuring 16.9 x 10.1 x 10.4 cm. Transvaginal ultrasound examination was performed to better evaluate endometrial cavity. As mentioned, there are multiple masses consistent with fibroids. The dominant fibroid is located along the posterior aspect of the fundus and measures 8.6 x 7.8 x 7.8 cm which is significantly increased in size compared to prior measurement of 4.0 x 3.4 x 3.7 cm. Additional fibroids measure approximately 4 cm and 6 cm in the region of the lower uterine segment. The endometrium is distorted by the large fibroids and measures 9 mm. The ovaries are normal and only seen transabdominally. There is a minimal amount of free fluid seen in the cul-de-sac that is simple in appearance. <MEDICATIONS ON ADMISSION> - Proair - Flovent - Nebulizers <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *30 Tablet(s)* Refills: *1* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *30 Tablet(s)* Refills: *0* 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Uterine Fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Take your medications as prescribed -- do not drive while taking narcotics You may shower 24 hours after surgery -- do not scrub incisions, let water run over incisions and pat dry -- no tub baths/ hot tubs x 6 weeks No heavy lifting or strenuous activity x 6 weeks (or until cleared by Dr. ___. Otherwise, activity as tolerated. Nothing in your vagina x 6 weeks ( no sex, no tampons)
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Ms. ___ was admitted into the gynecology service for routine post-operative care following her surgery. She did very well and had no issues overnight. She was discharged on post-operative day 1 with adequate pain control, tolerating a regular diet, voiding and ambulating without difficulty.
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10503869-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ace Inhibitors / Beta-Blockers (Beta-Adrenergic Blocking Agts) / Lasix <ATTENDING> ___ <CHIEF COMPLAINT> "Pushing bladder in" <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Anterior colporrhaphy. 2. Posterior colporrhaphy. 3. Elevate hysteropexy. 4. Insertion of biologic graft in the anterior compartment. 5. Cystoscopy. <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 5 Para 5005 who presents for a consultation requested by Dr. ___ vaginal prolapse. She is in fact complaining of "having to push her bladder back in". She has wore a size 6 ring with support for years and has done fairly well until recently. She reports rare incontinence events per day characterized as urge. She voids ___ times per day and ___ times per night. She uses 0 pads per day. She admits to some urgency, she denies any dysuria and reports bladder emptying with normal flow. She denies any hematuria, kidney stones or pyelonephritis. She does report ?UTI's over the past 6 months. She also denies any constipation. She is not sexually active and does not experience dyspareunia. She denies any vaginal dryness and is using estrace cream. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY 1. Hypertension. 2. History of thoracic aortic dissection status post repair and known outpouching at anastomosis b/w graft and native aorta. 3. Mild hypertrophic cardiomyopathy. 4. H/o bladder cancer vs polyp on by treated with BCG and mitomycin per Dr. ___ 5. Hemorrhoids PAST OB GYN HISTORY SVD x 5 She denies having Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV She admits to using vaginal estrogen cream. She denies post-menopausal bleeding. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father died at ___ from MI; Mother: CVA in old age <PHYSICAL EXAM> INITIAL PHYSICAL EXAMINATION Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Normal sounds, no murmurs Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Ext: No edema or varicosities. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skin & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: no lesions, no discharge Uterus: small; non-tender Adnexa: no masses non tender. POP-Q Exam: Aa: 0 Ba: 0 TVL: 10 D: -6 C: -4 ___: 3.5 PB: 2 Ap: -1.5 Bp: -1.5 ___ Exam: Cystocele: 3 Uterus/Cervix: 2 Vault: Ant enterocele: Post enterocele: Rectocele: 1 Grade VAGINAL EXAM - There was severe vaginal atrophy: Small Ulceration (1cm) was present at mid posterior vaginal wall Hemostatic Size 6 ring pessary with support removed. Gellhorn #3 with long stem inserted. Patient ambulated and performed Valsalva maneuvers successfully. Well tolerated. Precautions reviewed with both patient and her daughter Empty ___ Test was: negative Her (PVR) post void residual was 110 ml assessed by straight catheterization <PERTINENT RESULTS> ___ 07: 25AM BLOOD WBC-11.0# RBC-3.96* Hgb-11.5* Hct-33.9* MCV-86 MCH-29.0 MCHC-33.9 RDW-13.5 Plt ___ <MEDICATIONS ON ADMISSION> amlodipine 10', atenolol 25', losartan 100', omeprazole 20', simvastatin 20', ASA 81' <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp: *50 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: *30 Capsule(s)* Refills: *0* 4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Macrobid ___ mg Capsule Sig: One (1) Capsule PO at bedtime for 7 days. Disp: *7 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Cystocele, Rectocele, Uterine prolapse, Weakened pubocervical fascia. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, you were admitted for post operative management after undergoing a anterior/posterior colporrhaphy, hysteropexy, graft placement, and cystoscopy. You were continued on all of your home medications. A foley catheter was placed becuase you did not pass a formal voiding trial (higher than expected amount of urine remaining in your bladder). You will have this catheter in place for approximately 1 week. Dr. ___ will call you tomorrow to set up an appointment to have the catheter removed. You will be taking an antibiotic for 1 week while the catheter is in place. 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.
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Ms. ___ is a ___ year old female who was admitted to the GYN service at ___ after undergoing an anterior colporrhaphy, posterior colporrhaphy, hysteropexy, insertion of biologic graft in the interior compartment and cystoscopy on ___. Please see Dr. ___ report for further details regarding the procedure. Initially Ms. ___ pain was controlled with IV dilaudid and low dose Toradol. She was transitioned to oral pain medication once tolerating a diet. Her pain remained well controlled. Her diet was advanced without difficulty to a regular diet on POD#1. Her foley catheter was removed on POD#1 and as she did not pass a formal voiding trial (void#1 175, PVR 200, Void#2 75, PVR 375) the decision was made to send the patient home with a foley catheter with plans to repeat the voiding trial in Dr. ___ office in ___ days. She was given prophylactic Macrobid to take while the foley remained in place. Ms. ___ was discharged home in stable condition on POD#1.
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10504589-DS-29
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Aspirin / Optiray 350 / Dilaudid / Gadofosveset <ATTENDING> ___ <CHIEF COMPLAINT> Back pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery code blue <HISTORY OF PRESENT ILLNESS> ___ yo G6 ___ who presented at 37/3 wks by LMP and no apparent clinical correlate/US correlate with complaint of ___ severity low back and neck pain that had worsened recently but has been chronically present. The patient initially called the OB resident on-call with the above complaints and was recommended to go to ___ due to the fact that her records and all care were held there. Despite verbally agreeing to go to the ___ emergency department for the best continuity of care, she presented to ___ ED. She was admitted with concern for acute sickle cell crisis. Records from a recent admission at ___ were obtained. The patient's records indicate that she was recently admitted for a sickle cell crisis where she received 1 Unit of PRBCs, was started on antibiotics for a presumed community acquired pneumonia, and was given IV narcotics. Multiple statements from this discharge summary indicate difficult behavioral issues surrounding IV access, prolonged periods where she locked herself in the restroom requiring security to get her out, and refusal of discharge. At time of presentation, the patient stated that she has been febrile nightly since that discharge, she occassionally is short of breath, and occassionally feels burning with urination. <PAST MEDICAL HISTORY> OB Hx: per other records for ___ G1 SVD 6.5 lbs term G2 SVD twins at 35 wks G3 SVD 6.2 lbs term G4 SVD after IOL for PEC 35 wks at ___ Uncertain timing of SAB vs TAB - Notably patient only admitted to one prior pregnancy at beginning of meeting, but ultimately admitted to having had more pregnancies. She pointed out that she gave up her previous children for "adoption" and no longer counts them among her pregnancies, although whether or not they were adopted or placed into foster care is unclear. GYN Hx: Unknown PMH: - Sickle cell disease: history of acute chest syndrome in past, but not recently. - ? Thalassemia (unable to verify with patient) - Mild asthma - She reports a ? history of a PE after her last pregnancy that was caused by DVTs. She says she received treatment at ___ rather than ___. She also got tx as an outpatient by her hematologist at ___, who she no longer has a relationship with. She also reports recent PE in ___ and is on Arixtra 10mg BID from ___ records. PSH: - LSC CCY ___ at ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Unknown <PHYSICAL EXAM> (on arrival) Vital Signs: 128/71 HR 125 RR 18 T 99.8 O2sat 100% on RA NAD, appears comfortable but somnolent. She does occasionally have episodes of tachypnea where she appears vaguely uncomfortable, but she is then able to talk in complete sentences without interruption Tachycardic but no m/r/g appreciated Lungs CTAB bilaterally Abdomen soft, gravid, nontender. No contractions palpated Back tender to palpation particularly right lower back ___ no edema, nontender bilaterally, WWP. FHT baseline 150, mod var, no accels, no decels but with occaasional loss of tracing Toco: rare contractions without any regularity <PERTINENT RESULTS> ___ WBC-15.7 RBC-2.12 Hgb-7.4 Hct-22.2 MCV-104 Plt-644 ___ Neuts-81 Bands-0 ___ Mono-4 Eos-0 Baso-0 Atyps-0 ___ Myelos-0 NRBC-36 Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-1+ Target-OCCASIONAL Burr-OCCASIONAL Ellipto-1+ ___ WBC-10.9 RBC-1.85 Hgb-6.4 Hct-19.9 MCV-107 Plt-681 ___ WBC-15.9 RBC-2.40 Hgb-8.3 Hct-25.7 MCV-107 Plt-681 ___ WBC-20.3 RBC-1.84 Hgb-6.5 Hct-19.3 MCV-104 Plt-586 ___ ___ PTT-22.6 ___ ___ Ret Man-16.0 ___ Glu-102 BUN-6 Cre-0.5 Na-141 K-4.0 Cl-107 HCO3-24 Gap-12 ___ Glu-116 BUN-5 Cre-0.5 Na-137 K-4.1 Cl-104 HCO3-24 Gap-13 ___ Glu-273 BUN-6 Cre-0.6 Na-152 K-7.7 Cl-112 HCO3-28 Gap-20 ___ ALT-35 AST-58 LDH-281 TBili-2.6 UrAcd-5.1 Iron-296 ___ Calcium-8.9 Phos-3.5 Mg-2.0 ___ Calcium-8.0 Phos-5.4 Osmolal-326 ___ calTIBC-335 Ferritn-1050 TRF-258 ___ BLOOD HBsAg-NEGATIVE HIV Ab-NEGATIVE ___ BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-POS marijua-NEGATIVE URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR NEISSERIA GONORRHOEAE, NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria Gonorrhoeae by PCR R/O GROUP B BETA STREP (Final ___: NEGATIVE RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE Rubella IgG/IgM Antibody (Final ___: POSITIVE by Latex Agglutination ___ CXR FINDINGS: There is mild unchanged cardiomegaly. There are no focal consolidations to suggest pneumonia. The mediastinal and hilar contours are otherwise unremarkable, besides an enlarged heart. There is no effusion or pneumothorax. The vasculature is unremarkable. Note that it is difficult to assess the lung bases secondary to the patient's increased breast mass at this stage of her pregnancy. IMPRESSION: 1. No radiologic evidence of acute cardiopulmonary process. ___ Chest MRI IMPRESSION: 1. No evidence of PE in pulmonary arteries up to the level of segmental pulmonary arteries. A subsegmental PE can not be excluded on the current study. 2. Wedge-shaped lesion with peripheral enhancement may represent a cavitated infarct secondary to acute chest syndrome in the setting of sickle cell disease; less likely this infiltrate represents a cavitated pneumonia. 3. Linear atelectasis is also seen in left lower lobe. 4. Hemosiderosis in the liver and spleen. 5. Large caliber of right and left main pulmonary arteries which may correspond to pulmonary artery hypertension. Please correlate with echo. <MEDICATIONS ON ADMISSION> Dilaudid Arixtra <DISCHARGE MEDICATIONS> N/A <DISCHARGE DISPOSITION> Expired <DISCHARGE DIAGNOSIS> N/A <DISCHARGE CONDITION> N/A <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> N/A
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The a patient is a ___ year old G6P2214 admitted to the ___ service at 37+3 weeks gestation with low back pain thought to be caused by a sickle cell crisis. She received the majority of her prenatal care at ___ and ___ she had not been seen at ___ in this pregnancy prior to this presentation. On arrival to labor and delivery, she had reassuring fetal testing and had no evidence of labor. Her cervix was closed. Given the complexity of her medical history, which was especially remarkable for significant narcotic dependence, multiple consults were obtained to assist in her care, including Heme/Onc, Maternal Fetal Medicine, NICU, Social Services, and Anesthesia. The patient acquiesced to having portions of her medical records from other institutions released, but refused to sign records release forms for others. . The ___ hospital course was complicated by the following issues. Of note, she expired on HD#7. . *) SICKLE CELL: It was unclear to the Heme/Onc team whether or not Ms ___ had an acute pain crisis. Although she had a low grade fever in the ED, there was no evidence of infection. Chest xray and urine culture was negative. Her hematocrit was initially 22, then dropped to 19 when repeated. Once appropriate intravenous access was obtained on HD#2, she was eventually transfused 2u pRBC prior to labor induction and her hct increased appropriately to 25. No further blood counts were checked and she remained asymptomatic. Her sickle cell pain was managed with exceptionally large doses of Dilaudid (10mg q2h), and the patient persistently reported that her pain was not well controlled despite this dosage, although she demonstrated no clinical signs of discomfort. . *) PREGNANCY: On admission, fetal testing was noted to be reassuring. On HD#2, an ultrasound performed by ___ revealed oligohydramnios and IUGR. BPP was ___, with points only given for movement. The patient was transferred to labor and delivery for induction of labor, but given her hct of 19 and consistently reassuring fetal heart tracing (as well as fetal movement that was appreciated maternally), the decision was made to stabilize her with blood transfusion as above. Obtaining IV access took many hours, as the peripheral IV placed by anesthesia under ultrasound guidance became dislodged (after pt was left unaccompanied for a short period of time). Eventually, a double lumen PICC line was placed for access. In addition, anesthesia was not comfortable using neuraxial anesthesia given her uncertain history of anticoagulation within the last 48h. . Labor was therefore induced on HD#3 with pitocin and placement of a foley bulb for cervical ripening. She had a spontaneous vaginal delivery of a liveborn male infant on HD#4. The delivery was overall uncomplicated. . The infant was tranferred to the NICU following delivery for closer monitoring due to evidence of narcotic withdrawal. The infant remained in the NICU throughout the ___ hospital stay. She was attentive to the infant, but insisted on breast feeding despite pediatrics recommendation for bottle feeding given narcotic use. A ___ was filed by social work and DCF was involved. . She had no complications unique to her postpartum state and was stable for discharge from this perspective on PPD#2. . *) SOCIAL ISSUES: Pt has a long history of social instability, with none of her five children in her custody. She had frequent difficult interactions with providers from all care teams in multiple hospitals. Because of this, social work and case management were involved very early in her hospitalization. On PPD#0, she had an altercation with the father of her infant, and he was subsequently removed from hospital premises by security. Although she initially spent significant time in the bathroom, she signed a care plan on HD#1 which limited her to <15mins in the bathroom and further clarified expectations for her behavior and interactions with staff. She did not exhibit any markedly different behaviors after periods of unsupervised time. . *) NARCOTIC ABUSE: As explained above, this patient had a significant narcotic requirement for back pain which she attributed to sickle cell disease. As elucidated through medical record review, this pt has filled prescriptions with multiple aliases in the past. She initially insisted upon IV dilaudid with benadryl, but a plan was made to only provide 10mg of PO dilaudid q2h with no IV pain medications given. Chronic pain consultation was obtained and this recommendation was upheld. This was significantly less than her reported home dosage. She was maintained on this regimen throughout her hospitalization and plan was for discharge with a one week's supply of dilaudid. She was to contact her primary hematologist for further prescriptions. She signed a narcotics contract with the supervising resident prior to discussion of discharge on HD#6. . *) HX PULMONARY EMBOLISM: Ms ___ had previously been taking Arixtra for anticoagulation per her ___ records. Heme/onc recommended starting Lovenox, but the pt declined this. Based on fetal testing, the decision was made on HD#2 to induce labor, therefore anticoagulation was held and restarted 24h after delivery. She was restarted on Arixtra 10mg daily. . On HD#6, she reported new onset of chest pain and shortness of breath upon preparation for discharge. She was mildly tachycardic (110), but had no other objective findings consistent with pulmonary embolism. Given her history of PE, the decision was made to obtain imaging to rule out a new embolism. As she is allergic to CT contrast dye, radiology recommended a chest MRI, which was performed in the afternoon on HD#6. Per the radiology preliminary read, this was remarkable only for a cavitary lesion in the left lower lobe, which was likely consistent with a small infarct from her prior PE. Recommendation was made for follow up CT scan and the decision was made to proceed with this as an outpatient, as there was no clinical concern for infection or any other acute process at the time of discharge. The pt was made aware of this finding and the need for follow up. She had no complaints. . *) CARDIOPULMONARY ARREST: As above, the patient was prepared for discharge on HD#6 by the supervising resident provider. This plan was finalized around 1800. The patient reported she was going to visit her infant, have dinner, and wait for her ride home. She left the postpartum floor and was noted to be absent from the NICU for approximately 45 minutes before returning to her room, despite RN's and security's attempts to locate her. Upon return, she refused to sign discharge paperwork and reported shortness of breath. O2 saturation was then noted to be 78% on room air, rising to 83-88% with deep inspiration, despite her very stable clinical appearance (she was carrying on conversations, appearing in no acute distress). She was evaluated by the resident physician and continuous pulse oximetry monitoring was initiated. ___ RN then remained with the patient, monitoring her closely. Her pulse ox did not rise >88%, but she continued to appear well. The pt then requested to be allowed to use the restroom independently. The door was closed, but left unlocked. After approximately 90 seconds, a loud noise was heard by the RN, who was waiting outside the door. When the door was opened, the patient was found to be unresponsive with multiple unmarked syringes surrounding her. Agonal breathing and a weak pulse were noted at this time. A code blue was called on ___ at 0049 and the team responded promptly. Resuscitation was attempted for approximately 40 minutes, but pulseless electrical activity was present and the code was eventually called. Time of death was ___ at 0131. . ___ Security and ___ Police were called to the scene. The medical examiner accepted the case.
| 1,794
| 1,656
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10504672-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Egg <ATTENDING> ___. <CHIEF COMPLAINT> headache, increased BP <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Pt is a ___ yo G1P1 who is 14days PP s/p elective LTCS on ___ who presents with 5 day h/o headache and elevated BP's. Pt saw Dr. ___ in the office on tues for an incision check and at that time had an elevated BP of 140's/80'-90's. Labs showed trace protein and all other labs WNL. Pt was given precautions and told to call with persistent h/a and elevated BP's. states BP at home today was 160's/100's. Has ___ headache, took 600mg Motrin at 10 am with no relief. Reports some blurry vision at home, no RUQ abdominal pain. Has had ___ swelling since delivery. <PAST MEDICAL HISTORY> none <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> 97.5 78 149/92 150/92 137/77 Gen: holding hand against head, NAD RRR CTA B abd soft, NT ND incision c/d/i well-healed ext 2+ edema bilaterally, wearing TEDs <PERTINENT RESULTS> ___ 01: 03PM CREAT-0.6 ___ 01: 03PM ALT(SGPT)-38 ___ 01: 03PM URIC ACID-1.9* ___ 01: 03PM URINE HOURS-RANDOM CREAT-69 TOT PROT-11 PROT/CREA-0.2 ___ 01: 03PM WBC-8.0 RBC-3.57* HGB-9.5* HCT-27.8* MCV-78* MCH-26.7* MCHC-34.4 RDW-13.0 ___ 01: 03PM PLT COUNT-283 ___ 01: 03PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01: 03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ? postpartum PIH <DISCHARGE CONDITION> improved <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Given
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Ms. ___ was started on magnesium for seizure prophylaxis and labetalol 200mg BID during her hospitalization. She tolerated both well and her headache and blood pressures improved to within normal range. She was discharged home the day after admission on labetalol 200 mg BID and advised to f/u with Dr. ___ a BP check two days after discharge. She remained stable throughout her hospital stay without any complications.
| 638
| 88
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10508246-DS-20
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Augmentin / clindamycin <ATTENDING> ___ <CHIEF COMPLAINT> Symptomaic Fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Laparoscopic Hysterectomy, Cystoscopy <HISTORY OF PRESENT ILLNESS> ___ y.o. G0P0 with history of heavy menstrual bleeding, anemia and multiple uterine fibroids. Ultrasound on ___ showed an enlarged uterus measuring 10 X 6 X 8.5 cm. There were four masses consistent with fibroids, the largest of which was located intramurally on the left and measured 9 X 6.4 X 5.7cm. The other three fibroids were located intramurally on the right, exophytic on the right, and fundal with a 50% submucosal component. The endometrium was normal. See Dr. ___ note on ___ for full details. Pt initially opted for myomectomies but after discussion with Dr. ___ risks and benefits, chose to proceed with laparoscopic supracervical hysterectomy since she requested definitive surgery and desires no future childbearing. <PAST MEDICAL HISTORY> - G0P0 - Asthma - Recurrent major depression - Anxiety - Cystic breasts s/p biopsy - Uterine fibroids - Hyperprolactinemia - Optho surgery for "lazy eyes" <SOCIAL HISTORY> ___ <FAMILY HISTORY> Stroke, heart disease, hypertension, renal disease, thyroid disease, ___, Alzheimer's, breast cancer. <PHYSICAL EXAM> Exam on morning of discharge: Vitals: T 98.5, BP 119/65, HR 89, RR 18, SpO2 98% RA Gen: Comfortable, NAD Card: RRR Resp: CTAB anteriorly Abd: + TTP below R breast, + crepitus Ext: no calf TTP. pnuemoboots on and working <PERTINENT RESULTS> ___ 02: 53PM: WBC-16.0*# RBC-4.99 Hgb-12.6 Hct-37.9 MCV-76* MCH-25.2* MCHC-33.2 RDW-17.2* Plt ___ Glucose-132* UreaN-9 Creat-0.9 Na-138 K-4.7 Cl-104 HCO3-22 AnGap-17 Calcium-8.3* Phos-4.6* Mg-2.2 Pathology (Uterus/Cervix): Pnd at time of discharge <MEDICATIONS ON ADMISSION> 1. Lamotrigine 100 mg BID 2. Sertraline 100 mg BID 3. Adderall 20 mg BID 4. Lorazepam 1 mg ___ tabs PRN anxiety <DISCHARGE MEDICATIONS> 1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. sertraline 100 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Adderall 20 mg Tablet Sig: One (1) Tablet PO twice a day. 4. lorazepam 1 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as needed for anxiety. 5. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *1* 7. 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 Uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex)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.
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Ms. ___ was admitted to the gynecology service after undergoing a total laparoscopic hysterectomy. The patient had been scheduled for a supracervical hysterectomy and intraoperatively, the decision to convert to total laparoscopic hysterectomy was made due to obstructive paracervical fibroids. Please see Dr. ___ note for full details of the procedure. The procedure was otherwise uncomplicated, anesthesia was tolerated and blood loss was minimal. The patient recovered well and on POD#1 passed her voiding trial. Her diet was advanced to regular, and her pain was well controlled on oral medications. She was discharged home on POD#1 with follow up with Dr. ___ for ___.
| 1,126
| 143
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10510639-DS-3
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> hematuria <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, radical pelvic and para-aortic lymphnode disection and omental biopsy <HISTORY OF PRESENT ILLNESS> ___ G0 who was in her normal state of health until ___, when she woke up in the middle of the night with gross hematuria. She denied any other urinary symptoms at that time and presented to urgent care where a urinalysis did reveal gross hematuria. She was started on a course of antibiotics for presumed UTI. A second urinalysis was normal. She continued, however, to see blood with urination. She also began having intermittent stomach pains that were brief and throughout the abdomen. She had brief episodes of nausea associated with the pain. She thought perhaps this was due to norovirus. She followed up with her primary care doctor where referrals to both GYN as well as Urology were made. She met with the urologist and had normal urine cytology as well as a normal cystoscopy. She then had a day of vaginal spotting and was sent for a pelvic ultrasound. Pelvic ultrasound was performed on ___ and revealed 6.8 x 2.5 x 4.4 cm uterus with several small fibroids and an exophytic fundal fibroid measuring 4.1 x 2.7 x 3.0 cm. The endometrium was abnormally thickened at 15 mm with cystic and solid components. The ovaries were not definitively identified and there was no free fluid. She also was sent for a CT urogram the following day, which showed normal kidneys with no evidence of stones; however, there was left retroperitoneal adenopathy. This measured up to 1.6 x 1.2 cm. There was also adenopathy around the distal aorta and at the aortic bifurcation measuring 1.9 x 1.2 cm. There was also bilateral iliac adenopathy, larger on the left, measuring up to 2.2 cm. In the pelvis, there was a complex adnexal mass, again corresponding to what is thought to be an exophytic fibroid on pelvic ultrasound. The uterus was enlarged with an abnormal endometrium. She underwent an endometrial biopsy on ___. This returned as a high-grade serous adenocarcinoma, likely of the endometrium. Rereview of the pathology here suggests the same; however, an origin from the ovary or fallopian tube cannot be definitively excluded. Given these findings, she was referred here for further evaluation and consultation. She presents today accompanied by a good friend. She continues to have very minor fleeting abdominal pains. Her vaginal bleeding has stopped over the past few days. She has no changes in her weight, no problems with her bowels or bladder function other than what was thought to be hematuria. <PAST MEDICAL HISTORY> PMH: HTN, DM, HLD PSH: none ObGyn: G0. LMP ___ Pap with epithelial cell abnormality <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denies any family history of breast, ovarian, uterine, or colon cancers. Her mother did have stomach cancer and her brother and father have high blood pressure and cardiac disease <PHYSICAL EXAM> On day of discharge: Afebrile, vital signs stable Gen: well appearing, NAD CV: RRR Resp: CTAB Abd: soft, mildly distended, approprtiately tender without rebound or guarding, vertical midline incision c/d/i with steri strips Ext: non-tender, ___ pitting edema bilaterally <PERTINENT RESULTS> ___ 04: 10PM BLOOD WBC-8.3 RBC-3.78*# Hgb-10.0*# Hct-29.6*# MCV-78* MCH-26.4* MCHC-33.8 RDW-14.2 Plt ___ ___ 07: 48AM BLOOD WBC-9.4 RBC-4.43 Hgb-12.3 Hct-35.4* MCV-80* MCH-27.7 MCHC-34.7 RDW-14.9 Plt ___ ___ 08: 10AM BLOOD WBC-11.7* RBC-3.85* Hgb-10.6* Hct-30.4* MCV-79* MCH-27.6 MCHC-35.0 RDW-15.2 Plt ___ ___ 09: 10PM BLOOD WBC-11.5* RBC-3.53* Hgb-9.6* Hct-28.0* MCV-79* MCH-27.3 MCHC-34.5 RDW-15.3 Plt ___ ___ 07: 40AM BLOOD WBC-10.9 RBC-3.12* Hgb-8.7* Hct-24.9* MCV-80* MCH-28.0 MCHC-35.2* RDW-15.6* Plt ___ ___ 09: 30PM BLOOD WBC-13.5* RBC-3.75* Hgb-10.7* Hct-30.7* MCV-82 MCH-28.5 MCHC-34.8 RDW-15.7* Plt ___ ___ 06: 50AM BLOOD WBC-14.4* RBC-3.60* Hgb-10.3* Hct-30.0* MCV-83 MCH-28.5 MCHC-34.2 RDW-15.7* Plt ___ ___ 01: 00PM BLOOD WBC-13.1* RBC-3.15* Hgb-8.9* Hct-26.6* MCV-84 MCH-28.2 MCHC-33.4 RDW-16.9* Plt ___ ___ 09: 10PM BLOOD WBC-11.6* RBC-2.68* Hgb-7.8* Hct-21.7* MCV-81* MCH-29.1 MCHC-35.8* RDW-17.2* Plt ___ ___ 08: 05AM BLOOD WBC-13.3* RBC-3.74*# Hgb-11.3*# Hct-31.1*# MCV-83 MCH-30.1 MCHC-36.2* RDW-16.0* Plt ___ ___ 11: 45AM BLOOD WBC-13.1* RBC-3.77* Hgb-11.6* Hct-31.7* MCV-84 MCH-30.7 MCHC-36.5* RDW-16.2* Plt ___ ___ 06: 59AM BLOOD WBC-15.8* RBC-3.26* Hgb-9.7* Hct-27.4* MCV-84 MCH-29.7 MCHC-35.3* RDW-16.8* Plt ___ ___ 07: 52AM BLOOD WBC-17.4* RBC-3.35* Hgb-10.0* Hct-29.1* MCV-87 MCH-29.9 MCHC-34.5 RDW-17.1* Plt ___ ___ 07: 50AM BLOOD WBC-18.7* RBC-3.07* Hgb-9.2* Hct-26.5* MCV-87 MCH-29.9 MCHC-34.5 RDW-17.9* Plt ___ ___ 07: 35AM BLOOD WBC-25.6* RBC-3.00* Hgb-9.0* Hct-26.9* MCV-90 MCH-30.0 MCHC-33.4 RDW-17.8* Plt ___ ___ 07: 05AM BLOOD WBC-19.6* RBC-2.57* Hgb-7.4* Hct-23.0* MCV-90 MCH-28.9 MCHC-32.2 RDW-19.4* Plt ___ ___ 07: 30AM BLOOD WBC-13.3* RBC-2.53* Hgb-7.6* Hct-22.4* MCV-89 MCH-30.1 MCHC-34.0 RDW-18.8* Plt ___ ___ 08: 20AM BLOOD WBC-11.8* RBC-2.79* Hgb-8.3* Hct-25.1* MCV-90 MCH-29.7 MCHC-33.0 RDW-19.2* Plt ___ ___ 07: 41AM BLOOD ___ PTT-37.3* ___ ___ 04: 10PM BLOOD Glucose-113* UreaN-18 Creat-0.7 Na-138 K-3.8 Cl-106 HCO3-22 AnGap-14 ___ 06: 50AM BLOOD Glucose-138* UreaN-31* Creat-0.8 Na-137 K-4.4 Cl-104 HCO3-22 AnGap-15 ___ 07: 35AM BLOOD Glucose-134* UreaN-28* Creat-0.7 Na-132* K-4.2 Cl-99 HCO3-24 AnGap-13 ___ 07: 02AM BLOOD Glucose-102* UreaN-40* Creat-1.1 Na-131* K-4.0 Cl-97 HCO3-25 AnGap-13 ___ 07: 05AM BLOOD Glucose-103* UreaN-41* Creat-1.1 Na-135 K-4.1 Cl-99 HCO3-28 AnGap-12 ___ 07: 30AM BLOOD Glucose-109* UreaN-39* Creat-1.2* Na-135 K-4.2 Cl-100 HCO3-27 AnGap-12 ___ 08: 20AM BLOOD Glucose-117* UreaN-34* Creat-1.2* Na-135 K-3.9 Cl-99 HCO3-26 AnGap-14 ___ 06: 50AM BLOOD ALT-30 AST-61* AlkPhos-60 TotBili-1.1 ___ 06: 50AM BLOOD Lipase-34 ___ 04: 10PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 12: 20AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07: 48AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 08: 05AM BLOOD Triglyc-131 ___ 12: 54PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 09: 45PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12: 54PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM ___ 09: 45PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12: 54PM URINE RBC-11* WBC-13* Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 ___ 09: 45PM URINE RBC->182* WBC-26* Bacteri-FEW Yeast-NONE Epi-0 ___ 09: 45PM URINE Hours-RANDOM UreaN-1333 Creat-141 Na-<10 K-62 Cl-39 Microbiology: Urine culture ___ - no growth Stool C difficile ___ - negative Urine culture ___ - contaminated <MEDICATIONS ON ADMISSION> HTZ 12.5 mg, atenolol 50 mg, atorvastatin 40 mg, lisinopril 40 mg, aspirin 81 mg daily, multivitamin and vitamin D <DISCHARGE MEDICATIONS> 1. Atenolol 75 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg ___ capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 4. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *1 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 7. Lisinopril 40 mg PO DAILY 8. Metoclopramide 10 mg PO QIDACHS nausea RX *metoclopramide HCl 5 mg 5 mg by mouth every six (6) hours Disp #*50 Tablet Refills: *0 9. Senna 8.6 mg PO BID: PRN constipation RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #*30 Capsule Refills: *0 10. Acetaminophen (Liquid) 650 mg PO Q6H: PRN pain RX *acetaminophen 325 mg/10.15 mL 325-650 mg by mouth every six (6) hours Refills: *1 11. Bisacodyl 10 mg PO/PR DAILY: PRN constipation RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *1 12. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> endometrial cancer post-operative ileus pelvic hematoma 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 the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, radical pelvic and para-aortic lymphnode disection and omental biopsy. Please see the operative report for full details. Her post-operative course was complicated by immediate post-operative hypotension, blood loss anemia, interstitial edema with oliguria and post-operative ileus. Her course is outlined by problem below: #Post-operative hypotension: immediately post-op while in the PACU she was hypotensive in the setting of blood loss anemia and an epidural briefly requiring pressors. Her exam at this time was benign without evidence of ongoing bleeding and she was weaned off pressors shortly after this episode. During this an EKG was done which showed a very mild ST depression. She was asymptomatic and had negative troponins x 3. #Post-operative ileus: Her diet was slowly advanced however on post-operative day 3 she began having persistent nausea and vomiting and given concern for a post-op ileus she was made NPO and had a nasogastric tube placed on post-operative day 4. By post-operative day 6, her nausea had improved and she was passing flatus so the NG tube was removed and her diet was slowly advanced. Given her poor PO intake a nutrition consult was obtained and she was given partial peripherial nutrition for a total of 7 days after which her diet was supplemented with nutritional shakes. #Interstitial edema and oliguria: For the first few days post-op she was noted to be oliguric with a stable creatinine. She initially responded to IV fluid boluses however it was noted that she began having significant anasarca. Given her low urine output and low post-operative hematocrit she was given 1 unit of PRBCs with an inappropriate response in her urine output. In addition, she had a CT urogram performed which did not show any evidence of ureteral injury. At this point given her low urine output and evidence of fluid retention the decision was made to fluid restrict her and give her IV lasix for diuresis. She responded appropriately and by post-operative day 8 began to self diurese. By the day of discharge she was continuing to self-diurese with significant improvement in her anasarca. #Blood loss anemia and hematoma: Her initial estimated blood loss from surgery was 300cc. As routine post-operative care and as part of her evaluation for oliguria she had serial CBCs drawn throughout her stay and received a total of 5 units of PRBCs during her post-operative course. It was noted on a CT scan that she had a significant pelvic hematoma at the site of her hysterectomy. Given concern for possible ongoing bleeding her heparin prophlaxis was briefly held and restarted once her hematocrit was stable and the suspicion for ongoing bleeding was low. An ___ consult was obtained for possible drainage of her hematoma, however it was noted to be solid on ultrasound and thus was not amenable to ___ drainage. After her last transfusion on post-operative day 6 her hematocrit overall remained stable and she was asymptomatic. When she was able to tolerate PO she was started on iron supplementation. #Leukocytosis: On post-operative day 10 she was noted to have a worsening leukocytosis. She remained afebrile and no evidence on exam concerning for infection. A urine culture and C. difficile assay were both negative. She had a CT abdomen and pelvis performed which showed mild increase in size of her pelvic hematoma but no evidence of infection or absecesses. As above, given concern for superinfection of her hematoma an ultrasound was obtained to assess for possible ___ drainage however given no fluid components of her clot she was deemed to not be a candidate. She continued to be afebrile with no localizing features and her leukocytosis spontaneously resolved. #Care of chronic medical issues: She has a history of diabetes, hypertension and hypercholesterolemia. For her diabetes she had regular glucose checks and was written for an insulin sliding scale. She had good glucose control throughout her admission. For her hypertension she was initially continued only on her atenolol. She was then restarted on her home lisinopril and hydrochlorothiazide once taking PO. She had good blood pressure control throughout her stay. She was restarted on her home atorvastatin once taking PO. Post-operatively her pain was initially controlled with an epidural and tylenol. She was then transitioned to IV dilaudid and once able to tolerate PO she was transitioned to PO dilaudid and tylenol for pain. On post-operative day 10, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. On post-operative day 12 her staples were removed without issue and steri strips were placed over her incision which appeared to be well healing without erythema or drainage. She was seen by social work and physical therapy during her admission. By post-operative day 14, 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 ___ care and close outpatient follow-up scheduled.
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10511569-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Contrast dye <ATTENDING> ___. <CHIEF COMPLAINT> elevated blood pressures and headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <PHYSICAL EXAM> Admission: Gen NAD CV RRR Pulm CTAB, no crackles/wheezes Abd soft, NT/ND. no RUQ/epigastric TTP Neuro 2+ brachioradialis reflexes. no clonus Discharge: NAD, resting on left side in bed, moving extremities spontaneously CV: slightly tachycardia, regular rhythm Resp: CTAB Abd: soft, NTTP, no rebound no guarding Ext: symmetric, no edema, NTTP. Full strength and sensation in LLE and bilateral upper extremities. <PERTINENT RESULTS> ___ 08: 42PM URINE HOURS-RANDOM CREAT-88 albumin-2.0 alb/CREA-23 ___ 08: 42PM URINE UCG-NEGATIVE ___ 08: 42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 08: 42PM URINE RBC-0 WBC-1 BACTERIA-FEW* YEAST-NONE EPI-1 ___ 08: 14PM GLUCOSE-91 UREA N-9 CREAT-0.8 SODIUM-141 POTASSIUM-3.3* CHLORIDE-98 TOTAL CO2-23 ANION GAP-20* ___ 08: 14PM ALT(SGPT)-40 AST(SGOT)-29 ALK PHOS-110* TOT BILI-0.7 ___ 08: 14PM cTropnT-<0.01 ___ 08: 14PM ALBUMIN-4.5 ___ 04: 07PM K+-3.1* ___ 03: 56PM GLUCOSE-88 UREA N-7 CREAT-1.0 SODIUM-141 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-23 ANION GAP-20* ___ 03: 56PM LIPASE-15 ___ 03: 56PM cTropnT-<0.01 ___ 03: 56PM proBNP-112 ___ 03: 56PM WBC-4.5 RBC-4.84 HGB-13.4 HCT-41.2 MCV-85 MCH-27.7 MCHC-32.5 RDW-13.6 RDWSD-42.2 ___ 03: 56PM NEUTS-56.1 ___ MONOS-11.3 EOS-1.5 BASOS-0.7 IM ___ AbsNeut-2.54 AbsLymp-1.37 AbsMono-0.51 AbsEos-0.07 AbsBaso-0.03 <DISCHARGE INSTRUCTIONS> call for headache, visual changes, weakness/numbness, epigastric or RUQ pain, leg swelling or pain, dizziness, palpitations
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Ms. ___ was admitted with elevated blood pressures and a head at 2 months postpartum. On admission. She had severe range blood pressures that were treated with labetolol. Her labs were otherwise normal. She also had a normal EKG, normal troponins, and normal cardiac echo. She was discharged in stable condition on antihypertensives with appropriate follow up. Discharge Medications: 1. NIFEdipine (Extended Release) 30 mg PO DAILY RX *nifedipine 30 mg one tablet(s) by mouth once a day Disp #*90 Tablet Refills:*4 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 3. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10511947-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> nausea, vomitting <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparoscopy, partial (possible complete) right oophorectomy, lysis of adhesions, oversewing of bowel serosal defect, placement of right ureteral stent, proctoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ para 2 with a recent diagnosis of complex adnexal mass, who was seen by Dr. ___ for ___ planning. The patient indicated that she has had right sided abdominal pain since yesterday which improved with Tylenol. It was sharp and constant. Today on the way to the office the pain again returned and was exacerbated by the car ride. She had nausea and vomitted x 3. Initially vomitted clear fluid, then became billious. Of note, she is able to pass flatus. Had normal BM last night. Denied fevers / chills. Not hungry presently. Also reported minimal urine output since yesterday. Of ntoe, the patient reported several months h/o of similar abdominal pain associated with N/V, which led her to her local ED on ___. CT scan revealed a large pelvic mass, left hydronephrosis, and she was transferred to ___. CT scan performed here showed a large solid and cystic pelvic mass likely representing an ovarian tumor of epithelial origin, it appears to arise from the right ovary, based on provided surgical history. The mass itself measures 20 x 9 x 14 cm and has solid and cystic components to it. A CA-125 level was 17 on ___. <PAST MEDICAL HISTORY> PMHx is notable for a "noncancerous" adnexal mass removed at five months of pregnancy. She had this surgery through a vertical midline incision, and she thinks her left was ovary removed at that time. Her pregnancy continued until about 32 weeks, seven months and at that point because of placenta previa and accreta, she had a C-section and cesarean hysterectomy. The cervix was left in place. PSHx: cesarian section ___, ___ - hysterectomy ___ as above, resection of adnexal mass ___ as above PGYNhx: Denies abnl paps / STI's <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports that her grandmother had breast cancer. There is no other family history of cancer. <PHYSICAL EXAM> PE: T: 97.1 HR: 98 BP: 110/58 O2sat: 96%RA I/O: 125/hr / 100cc NAD A&O x 3 CTA bilaterally RRR Abd soft, + TTP without rebound or guarding most prominently in the RLQ and RUQ. No masses appreciated. Non-tympanic and non-distended. Pelvic deferred at this time <PERTINENT RESULTS> ___ 04: 12PM GLUCOSE-125* UREA N-15 CREAT-0.9 SODIUM-135 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17 ___ 04: 12PM ALT(SGPT)-14 AST(SGOT)-17 ALK PHOS-82 AMYLASE-56 TOT BILI-1.0 ___ 04: 12PM LIPASE-25 ___ 04: 12PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.8 ___ 04: 12PM WBC-16.1*# RBC-5.20 HGB-11.2* HCT-35.0* MCV-67* MCH-21.5* MCHC-31.9 RDW-15.2 ___ 04: 12PM NEUTS-92.3* LYMPHS-4.5* MONOS-2.9 EOS-0.1 BASOS-0.1 ___ 04: 12PM PLT COUNT-254 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *25 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp: *26 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrioma <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. Please call if you have redness and warmth around the incision, if your incision is draining pus-like or foul smelling discharge, 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.
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Ms. ___ was admitted for right complex adnexal mass, likely of ovarian origin, with nausea and vomitting, concerning for small bowel obstruction, given her extensive surgical history. She underwent an examination under anesthesia, extensive lysis of adhesions, right oophorectomy (likely complete), dissection of retroperitoneal space on the right side, ureteral stent placement and removal and proctoscopy on HD # 7. Please see operative note for complete details. Her hospital and post-operative course was remarkable for the following: * Nausea/vomiting She was admitted for nausea and vomiting, which were worked up with a KUB. The imaging study demonstrated no obstruction, and the symptoms resolved spontaneously. She remained on regular diet until the night prior to surgery, at which time she was made NPO. . * Infectious disease She was noted to have intermittent elevated temperatures, with a Tmax of 101.4 on ___. She was noted to have a urine analysis on arrival that was contaminated, but was suggestive of UTI, and was started on a three day course of ciprofloxacin. She continued to have elevated temperatures intermittently overnight, until levofloxacin was started on ___ after a CXR suggested a possible infectious process. She was started on a 7 days' course of levofloxacin, which was administered IV, given prior episode of nausea/vomiting. Cipro was discontinued at this time; urine culture was negative. The WBC had elevated to a max of 21.5 then normalized. Blood cultures from the hospital stay showed no growth. On POD #2 she had a mildly elevated temp to 100.9 with mild erythema and blanching over incision site and was started on keflex x7days po course. . * Hematology The patient was notably a difficult cross match for blood products, given history of massive transfusion (positive antibody screen, anti e, S antibodies). The difficulty in cross match delayed the surgical case. She was transfused one unit PRBC intraoperatively for a low hct preop (25.4). Postoperatively, her hct was noted to be appropriately elevated and stable. . Ms. ___ was discharged home on post-operative day 3 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty. She was discharged with keflex ___ po for a total of 7 days course.
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10513069-DS-3
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<SEX> M <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Citrus And Derivatives / latex <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exam under anesthesia, total laparoscopic hysterectomy, bilateral salpingo-oophoreectomy, and cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida ___ FTM with a history of chronic pelvic pain and intermittent vaginal staining/spotting. Workup prior to surgery included a CT of the pelvis done on ___, which showed no pathology in the pelvis. He underwent an ultrasound on ___, which was also normal. On ___, he had a Pap that was negative for intraepithelial neoplasia or malignancy. Endometrial biopsy showed atrophic endometrium. He is status post Top surgery at ___ and would like to proceed with his postponed operative procedure in a laparoscopic total hysterectomy with bilateral salpingo-oophorectomy and cystoscopy. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Last Pap was ___ and he stated this Pap was normal. He has never had an abnormal Pap smear. He has a history of chlamydia. Denies any pregnancies. PAST MEDICAL HISTORY: Significant for asthma, for which he takes an inhaler. He has never been hospitalized or intubated. He has decreased vision in his left eye secondary to Staph infection. OPERATIVE HISTORY: None. He has never been exposed to anesthesia. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Diabetes, hypertension and stroke. Negative for any female cancers. <PHYSICAL EXAM> On day of discharge VS: wnl Gen: well-appearing, NAD CV: RRR Pulm: CTAB Abd: soft, mildly tender to palpation, appropriate, no rebound or guarding, non-distended GU: pad with minimal spotting Ext: no calf tenderness, no edema <PERTINENT RESULTS> ___ 09: 56PM URINE UCG-NEGATIVE <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Sertraline 50 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H: PRN asthma 2. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 4. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain do not drink alcohol or drive while taking RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp #*30 Tablet Refills: *0 5. Sertraline 50 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Chronic pelvic pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, ___ was admitted to the gynecology service after undergoing examination under anesthesia, 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 1, his urine output was adequate so his foley was removed and he voided spontaneously. His diet was advanced without difficulty and he was transitioned to oral pain meds (oxycodone, ibuprofen). For his asthma, he was continued on his albuterol as needed. He was also continued on his home dose of sertraline. By the afternoon of 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.
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10515441-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Gadolinium-Containing Contrast Media / abalone / acetaminophen <ATTENDING> ___. <CHIEF COMPLAINT> ENDOMETRIAL CANCER <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, omental biopsy <HISTORY OF PRESENT ILLNESS> ___ with a history of diabetes and NASH, who developed some pink spotting in ___ and ___. This spotting subsequently increased in ___ and discussed with her endocrinologist who recommended a pelvic ultrasound, which revealed a uterus measuring 10.6 x 6.6 x 0.5 cm. The endometrial stripe was not visualized, but instead there was a large vascular mass in the fundus measuring 5.6 x 4.6 x 3.4 cm. This was concerning for an endometrial cancer. She had continued amounts of spotting, otherwise, she complained of some abdominal tenderness, though minimal as well some increased incontinence of urine. She denied any early satiety, nausea, vomiting, chest pain, shortness of breath, or change in bowel habits. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Significant for childhood asthma, diabetes, hypertension, hypercholesterolemia, breast cancer, status post lumpectomy and XRT, no chemo. She did not receive chemotherapy secondary to her NASH and also as another medical problem. PAST SURGICAL HISTORY: She had an appendectomy as a child, vein stripping in ___, bilateral knee replacement in ___, complete shoulder implant on the right in ___ and a left partial mastectomy in ___ as above. OB/GYN HISTORY: She is a gravida 5, para 5 with 4 SVD (1 twin), 1 SAB. Her last menstrual period was at age ___. She denies any history of abnormal Paps. Her last Pap was approximately ___ years ago. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: She has a maternal aunt with breast cancer, mother with a possible history of uterine cancer, a brother with metastatic colon cancer, and a maternal uncle with lung cancer, otherwise, no other GYN related malignancies. <PHYSICAL EXAM> On day of discharge: Afebrile, vital signs stable gen: no acute distress CV: RRR Pulm: CTAB Abd: soft, nt,nd, incisions c/d/i ___: nt, no edema <PERTINENT RESULTS> ___ 06: 10AM BLOOD WBC-4.6 RBC-3.28* Hgb-9.7* Hct-29.2* MCV-89 MCH-29.6 MCHC-33.3 RDW-12.7 Plt ___ ___ 05: 00AM BLOOD WBC-5.8 RBC-3.42* Hgb-10.1* Hct-30.5* MCV-89 MCH-29.6 MCHC-33.2 RDW-12.8 Plt ___ ___ 06: 40AM BLOOD WBC-6.5# RBC-3.77* Hgb-10.9* Hct-33.3* MCV-88 MCH-29.0 MCHC-32.9 RDW-13.3 Plt ___ ___ 07: 08PM BLOOD WBC-17.2*# RBC-4.33 Hgb-12.8 Hct-39.4 MCV-91 MCH-29.6 MCHC-32.5 RDW-12.8 Plt ___ ___ 05: 00AM BLOOD Neuts-75.9* Lymphs-16.1* Monos-7.0 Eos-0.8 Baso-0.2 ___ 06: 10AM BLOOD Glucose-90 UreaN-12 Creat-0.7 Na-140 K-3.7 Cl-104 HCO3-31 AnGap-9 ___ 05: 00AM BLOOD Glucose-127* UreaN-16 Creat-0.8 Na-142 K-3.9 Cl-107 HCO3-26 AnGap-13 ___ 06: 40AM BLOOD Glucose-103* UreaN-19 Creat-1.0 Na-144 K-4.3 Cl-107 HCO3-27 AnGap-14 ___ 07: 08PM BLOOD Glucose-170* UreaN-21* Creat-0.9 Na-144 K-4.2 Cl-108 HCO3-24 AnGap-16 ___ 06: 10AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0 ___ 05: 00AM BLOOD Calcium-8.2* Phos-2.0*# Mg-2.1 ___ 06: 40AM BLOOD Calcium-8.7 Phos-4.9* Mg-2.2 ___ 07: 08PM BLOOD Calcium-8.9 Phos-4.9* Mg-2.3 <MEDICATIONS ON ADMISSION> atorvastatin 20; insulin aspart [Novolog] 5 TID with meals; Lantus 25 QHS, Lisinopril 5, Metformin 500 daily <DISCHARGE MEDICATIONS> 1. TraMADOL (Ultram) 50 mg PO Q4H: PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID constipation take to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*50 Capsule Refills: *0 3. Glargine 25 Units Bedtime novolog 5 Units Breakfast novolog 5 Units Lunch novolog 5 Units Dinner 4. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> presumptive endometrial cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 8 weeks * No heavy lifting of objects >10lbs for 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
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Ms. ___ was admitted to the gynecology oncology service after undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, omental biopsy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dialudid. Her diet was advanced without difficulty and she was transitioned to oral tramadol. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Once she was tolerating an regular diet, her diabetes was controlled with her home insulin regimen and her hypertension was controlled with her home dyazide. On post-operative day 2 she was noted to be febrile to 100.6 and developed resting hypoxemia to 90% on room air. She had bilateral crackles at the bases and a chest Xray showed bilateral lower lobe volume loss/infiltrate. Labs were drawn which showed a normal white blood count. She was given one dose of IV lasix with good response, and her hypoxemia resolved with incentive spirometry. Her temperature spontaneously defervesced and she had no further fever throughout the course of her admission. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10519094-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> urosepsis, obstructed nephrolithiasis, DVT, pregnancy at 36 weeks gestation, pneumonia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Right percutaneous nephrostomy ___ Endotracheal intubation ___ <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ year old woman, G2P1001, currently 35 weeks pregnant, with history of DVT in her previous pregnancy, nephrolithiasis, pyelonephritis due to obstructing right ureteral stone, who presented ___ with sepsis due to recurrent pyelonephritis. She was transferred to the FICU due to hypoxemic respiratory failure requiring intubation. She was diagnosed with pyelonephritis due to E.coli/staph epidermidis in ___, with CT showing 5mm stone and renal ultrasound showing marked hydronephrosis. She had a ureteral stent placed ___, removed ___. She had been on Keflex for suppression but stopped this 2 weeks prior to admission. On the night prior to admission she developed abdominal and low back pain, and presented to ___ for evaluation. At ___, she was febrile on arrival, as well as tachycardic and tachypneic. Additionally she was having intermittent contractions, but was C/L/high on serial cervical exams. FHT revealed fetal tachycardia to the 180s. On exam she had supra-pubic and right flank pain. CBC was notable for a ___ count of 18 and UA positive for leukocytes and nitrites. She received 2 liters of IVF, 1 g ceftriaxone and then transferred to ___. On evaluation here, EMS reported hypotension to the ___ as well as a tmax of 104.7. She reports persistent suprapubic pain. Denies VB, LOF, reports +FM and intermittent ctxs. <PAST MEDICAL HISTORY> -G2P1, s/p C-section at full term in ___ -DVT in RLE during first pregnancy -Breast augmentation <SOCIAL HISTORY> ___ <FAMILY HISTORY> Unable to obtain <PHYSICAL EXAM> ICU ADMISSION PHYSICAL EXAM: -======= VITALS: T 100.8 HR 121, BP 116/64, RR 23, SPO2 100% on CMV FIO2 100%, PEEP 10, RR 15, TV 300 GENERAL: intubated, sedated on propofol. Moves all extremities, opens eyes spontaneously HEENT: Sclera anicteric. PERRL NECK: supple, JVP not elevated, no LAD LUNGS: Diffuse rales and rhonchi CV: Tachycardic, regular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, gravid, EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: dry, no rashes NEURO: PERRL, moves all extremities ACCESS: left radial A-line, peripheral IVs DISCHARGE PHYSICAL EXAM: <PERTINENT RESULTS> ADMISSION LABS: -== ___ 04: 25PM ___ ___ 04: 25PM ___ PTT-24.4* ___ ___ 04: 25PM PLT COUNT-154 ___ 04: 25PM NEUTS-85.4* LYMPHS-5.7* MONOS-7.6 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-14.10* AbsLymp-0.94* AbsMono-1.25* AbsEos-0.00* AbsBaso-0.04 ___ 04: 25PM WBC-16.5* RBC-3.12* HGB-9.9* HCT-28.7* MCV-92 MCH-31.7 MCHC-34.5 RDW-13.0 RDWSD-43.3 ___ 04: 25PM ALBUMIN-3.3* CALCIUM-8.5 PHOSPHATE-2.1* MAGNESIUM-1.4* ___ 04: 25PM ALT(SGPT)-7 AST(SGOT)-14 ___ 04: 25PM estGFR-Using this ___ 04: 25PM GLUCOSE-79 UREA N-6 CREAT-0.7 SODIUM-136 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-19* ANION GAP-18 ___ 04: 53PM LACTATE-2.1* ___ 05: 00PM URINE MUCOUS-RARE ___ 05: 00PM URINE RBC-16* WBC->182* BACTERIA-MOD YEAST-NONE EPI-0 RENAL EPI-<1 ___ 05: 00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG ___ 05: 00PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 05: 33PM LACTATE-1.6 ___ 05: 33PM TYPE-ART PO2-90 PCO2-23* PH-7.52* TOTAL CO2-19* BASE XS--1 ___ 10: 30PM GLUCOSE-96 UREA N-6 CREAT-0.8 SODIUM-137 POTASSIUM-3.2* CHLORIDE-106 TOTAL CO2-16* ANION GAP-18 ___ 10: 51PM LACTATE-1.1 MICROBIOLOGY: - ___ URINE Legionella Urinary Antigen -FINAL INPATIENT ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT ___ URINE,KIDNEY FLUID CULTURE-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT IMAGING: ======== <MEDICATIONS ON ADMISSION> PNV, Lovenox, keflex <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild Do not exceed 4,000m gin 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 2. Cefpodoxime Proxetil 200 mg PO/NG Q12H RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice daily Disp #*18 Tablet Refills: *0 3. Cephalexin 250 mg PO Q24H Start after cefpodoxime course finishes. Continue for remainder of pregnancy. RX *cephalexin 250 mg 1 capsule(s) by mouth daily Disp #*14 Capsule Refills: *0 4. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 5. ___ ___ UNIT SC BID RX *heparin (porcine) 10,000 unit/mL 1 mL SC twice daily Disp #*50 Vial Refills: *0 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Severe Do not drink alcohol or drive. RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp #*25 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> urosepsis, obstructed nephrolithiasis, DVT, pregnancy at 36 weeks gestation, pneumonia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital for kidney stone, kidney infection, urosepsis, and pneumonia. You have recovered well and the team feels you are ready to be discharged home. Please follow the instructions below. - Please take cefpodoxime twice a day for the next 9 days, and then take Keflex once a day for the rest of the pregnancy. You will have visiting nurses who will help with dressing changes for your nephrostomy tube. Please present to your follow-up visit with Urology, which is detailed below. - Attend all appointments with your obstetrician and all fetal scans - Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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On arrival Ms. ___ was fevrile, tachycardic, and tachypneic. FHT showed fetal tachycardia to the 180s. Labs showed leukocytosis to 18, pyuria, urine nitrites. Prior to transfer to ___ she received ceftriaxone 1g and 2L of IVF. On transfer she was hypotensive to 80/40, with Tmax 104.7, HR 130-140s, satting 95% on RA. With further resuscitation, her blood pressure improved, however she remained tachycardic. She was treated with vancomycin and zosyn. Renal ultrasound showed severe right hydroureteronephrosis, and so she underwent placement of right percutaneous nephrostomy on ___. Due to sustained tachycardia, she had a CTA to evaluate for pulmonary embolism. Shortly after completion of the scan, while patient was still in radiology department, she became tachypneic, hypotensive, with more rapid HR to 140-150s, and hypoxemic to SPO2 in the ___ on room air. She was placed on non-rebreather and transferred back to the L&D unit. There she rapidly developed worsening respiratory distress. On exam, she remained tachycardic but was normotensive; she was tachypneic, and auscultation showed bilateral rales and rhonchi. Unclear if patient had other complaints at this time. Due to severe distress, she was intubated (received propofol and succinylcholine). She was also given Lasix 20mg IV, with brisk urine output following administration. She was transferred to the ___ ICU for further care. ICU COURSE: # Acute hypoxemic respiratory failure: Patient developed acute hypoxemia shortly after CTA, done for suspicion of PE because of unexplained tachycardia. Prior to CTA patient had been on room air. Exam demonstrated diffuse rales and wheezing. CTA motion degraded, but negative for significant PE, does show potential pneumonia. Initially considered ARDS due to pyelonephritis in pregnancy, although the rapid onset of hypoxemia would be unusual for this; P/F ratio 190. Also considered bronchospastic reaction to iodinated contrast (although did not have angioedema, hives, hypotension, that may be expected with anaphylaxis). Patient was given IV Lasix and had a very rapid response to diuresis raising a question of acute pulmonary edema due to fluid overload, although this was not reflected on exam or imaging. Patient was also started on broad spectrum antibiotics and was subsequently extubated within 24 hours. She was de-escalated to ceftriaxone and azithromycin for treatment of CAP. ECHO with normal LVEF and no e/o systolic dysfunction. #Hypotension/Sepsis due to pyelonephritis: Cultures from CHA growing pan-sensitive E. Coli. Hydronephrosis seen on ultrasound this admission has been present on ultrasound in ___ and ___ at ___. Has no imaging demonstrating presence of obstructing stone this admission, and with questionable chronic pyelo, unable to ensure she has new obstruction. Due to potential new obstruction, however, she had placement of right perc nephrostomy, currently in place. Initially on vanc/zosyn then de-escalated to ceftriaxone and azithromycin as above to cover both urine and pulmonary pathogens. POST-ICU COURSE / ANTEPARTUM COURSE: She was transferred out of the ICU in stable condition. She was monitored on telemetry and her pain was controlled initially with IV pain medications. She was transitioned to PO pain medications and her respiratory status continued to improve. She was initially continued on supplemental oxygen and was then transitioned to room air with normal O2 saturations. She ambulated on her own and her pain continued to be well-controlled with oral pain medications. She remained afebrile with normal vital signs. Her foley catheter was removed, and she had adequate urine output through voids as well as through her nephrostomy tube. She received a full course of antibiotics (IV azithromycin for 5 days) for her pneumonia and received ceftriaxone for her urosepsis. On the day of discharge, she was transitioned to oral cefpodoxime for a planned total 14 day course. Fetal status was monitored twice daily with non-stress tests, which were reassuring. By hospital day 8, her pain was well controlled with oral medication, and she was discharged home in stable condition with outpatient follow-up as scheduled.
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| 1,001
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10519094-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right flank pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat low transverse C-section, bilateral tubal ligation <HISTORY OF PRESENT ILLNESS> ___ G2P1 at ___ w/ history significant for DVT in previous pregnancy, nephrolithiasis, pyelonephritis due to obstructing right ureteral stone, and recent admission for urosepsis from ___ due to recurrent pyelonephritis requiring an admission to the FICU due to hypoxemic respiratory failure requiring intubation, presenting today for right flank pain. She reported that the pain began on ___ and has been increasingly worsening until this evening when her typical pain medications of Dilaudid were no longer treating her pain. She denies any fevers. She endorses active fetal movement and denies any vaginal bleeding or loss of fluid. She is having intermittent contractions that occur approximately every 10 minutes. Patient presented to triage on ___ with a similar presentation to today's. Labs were done were notable for a leukocytosis of 11.6, urine culture was growing prelim gram negative rods she was restarted on cefpodoxime and told to discontinue macrobid. However, the patient has yet to pick up the prescription. She was evaluated by urology during this visit. Perc nephrostomy tubes were found to be draining adequately with no concerns. In brief her prior h/s is significant for a diagnosis of pyelonephritis secondary to E. coli/staph epidermidis in ___. She had a CT scan showing a 5 mm stone and renal ultrasound unremarkable for hydronephrosis. She had ureteral stents placed on ___ and removed on ___. She was on Keflex for suppression but stopped this medication 2 weeks prior to her admission for urosepsis. On admission she was noted to be febrile, tachycardic, and tachypneic. Fetal heart rate was significant for tachycardia in the 180s. She had a renal ultrasound that showed severe right hydroureteronephrosis she underwent a placement of a right percutaneous nephrostomy tube on ___. During this admission she developed increased tachypnea and rapidly worsening respiratory distress. She was intubated and transferred to the ICU for acute hypoxemic respiratory failure. She had a CTA negative for pulmonary embolism. This episode was thought to be secondary to ARDS due to pyelonephritis in the pregnancy. There was also concern for acute pulmonary edema secondary to fluid overload since the patient improved with a dose of IV Lasix. She was treated with vancomycin and Zosyn and then narrowed to ceftriaxone and aggressively resuscitated in the ICU. She was treated for pneumonia with IV azithromycin for 5 days. She was discharged home on oral cefpodoxime for a planned ___fter completing her course she was given Macrobid for prophylaxis. <PAST MEDICAL HISTORY> PNC: - ___: ___ - Labs: Rh+/Abs-/RI/RPR NR/HBsAg-/HIV-/GBS unknown - Screening: LR NIPT - FFS: velementous marginal cord insertion, echogenic focus in the left ventricle - GTT: passed - U/S: ___ for marginal cord 1314 g 41% - Issues: *) h/o DVT: Diagnosed in last pregnancy at 6 months, was on anticoagulation the rest of pregnancy and 40 days of post-partum course. Is on lovenox. *) Pyelonephritis, h/o urosepsis w/ perc neph tubes in place: see above *) Zika exposure: Patient from ___. Negative serum testing. *) History of LTCS: Full-term. Operative note not available. *) Velamentous marginal cord: Noted on FFS. Normal EFW on ___ 41% OBHx: G2P1 - G1: LTCS full-term in ___ (operative note not available) - G2: Current GynHx: - Denies abnormal Pap or cervical procedures - Denies fibroids/endometriosis/cysts - Denies STIs PMH: - h/o pyelonephritis due to right ureteral stone - h/o right ___ DVT during first pregnancy, see above PSH: - LTCS - Breast augmentation <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Lungs: breathing comfortably on room air Abdomen: soft, appropriately tender, fundus firm, incision c/d/I Back: bilateral CVA tenderness, right percutaneous nephrostomy tube in place Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 07: 00AM BLOOD Hct-26.0* ___ 03: 21AM BLOOD WBC-11.0* RBC-3.49* Hgb-10.7* Hct-32.3* MCV-93 MCH-30.7 MCHC-33.1 RDW-13.3 RDWSD-44.9 Plt ___ ___ 03: 21AM BLOOD Neuts-51.8 ___ Monos-9.5 Eos-1.5 Baso-0.5 Im ___ AbsNeut-5.70 AbsLymp-3.88* AbsMono-1.05* AbsEos-0.17 AbsBaso-0.05 ___ 03: 21AM BLOOD Glucose-72 UreaN-8 Creat-0.6 Na-136 K-4.1 Cl-102 HCO3-22 AnGap-16 ___ 03: 21AM BLOOD Calcium-9.8 Phos-4.4 Mg-2.0 ___ 03: 21AM URINE Color-Straw Appear-Clear Sp ___ ___ 03: 21AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every four (4) hours Disp #*40 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 #*60 Capsule Refills: *0 3. Enoxaparin Sodium 40 mg SC Q24H Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin [Lovenox] 40 mg/0.4 mL 1 injection IM DAILY Disp #*42 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *1 5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO QHS RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth daily Disp #*42 Capsule Refills: *0 6. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> 39 week gestation, history of C-section, history of urosepsis, nephrolithiasis, desired sterilization <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 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 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. You will be set up with a visiting home nurse to help you take care of the nephrostomy tube. If you start developing pain or a fever, you should connect the tube back to a bag to help drain your urine from your kidney. You should then call the interventional radiology office at ___ if you feel worsening fevers, chills, and right flank pain.
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Ms. ___ is a ___ s/p rLTCS on ___ with a history of nephrolithiasis and pyelonephritis requiring prior ICU admission in this pregnancy, also with a history of deep venous thrombosis during pregnancy. Her course is as follows: *) Nephrolithiasis/ h/o Pyelonephritis Urine cultures from ___ grew pseudomonas. With regards to antibiotics, she was started on ceftriaxone 1g Q24 hours. She was transitioned to ceftazidime (___) and then to cephalexin (___-). She received Tylenol, ibuprofen, oxycodone, and IV dilaudid for pain. She was followed by urology. She had a CT abdomen/pelvis on ___ that showed 2 non obstructing stones within the lower pole of the left kidney, measuring up to 4 mm. She also had an anterograde nephrostogram with moderate hydromephrosis with proximal dilatation and also dilatation in the mid segments of the right ureter. She was discharged home with plans to continue a cap trial of her right percutaneous nephrostomy tube at home with a visiting nurse. She will plan to follow up with interventional radiology in 2 weeks. She will also have outpatient follow up with urology for a ureteroscopy. For her history of DVT, she was continued on heparin for prophylaxis. Her postpartum course was otherwise uncomplicated. By ___, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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10519519-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic-assisted laparoscopic myomectomy converted to mini laparotomy, left paratubal 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: ___ 10: 55AM BLOOD WBC-13.2* RBC-3.56* Hgb-10.5* Hct-31.4* MCV-88 MCH-29.5 MCHC-33.4 RDW-11.9 RDWSD-38.5 Plt ___ Relevant Labs: ___ 06: 55AM BLOOD WBC-11.3* RBC-3.48* Hgb-10.1* Hct-30.9* MCV-89 MCH-29.0 MCHC-32.7 RDW-11.9 RDWSD-38.5 Plt ___ ___ 06: 55AM BLOOD Glucose-86 UreaN-7 Creat-0.6 Na-135 K-3.7 Cl-100 HCO3-23 AnGap-12 ___ 06: 55AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.8 <MEDICATIONS ON ADMISSION> - sprintec (takes pills continuously, no placebos) - iron <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Enoxaparin Sodium 40 mg SC DAILY Start: Tomorrow - ___, First Dose: First Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg daily Disp #*10 Syringe Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity please take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe do not drink or drive while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic 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 your procedure. You have recovered well and the team believes you are ready to be discharged home. We are discharging you home with Lovenox for anti-coagulation for the next ___ days. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing robotic-assisted laparoscopic myomectomy converted to mini laparotomy and left paratubal cystectomy for symptomatic fibroids. Please see the operative report for full details. EBL was 800cc. Pre-operative HCT was 31.4 and post-operative HCT was 30.9. Patient with known ___ ___ disease. She received TXA TID while in the hospital post-operatively with SC Heparin prophylaxis. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and Toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, ibuprofen, and acetaminophen. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharged home with 10-days of prophylactic Lovenox.
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10520371-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Amoxicillin / clindamycin <ATTENDING> ___. <CHIEF COMPLAINT> induction of labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> Low transverse cesarean section <HISTORY OF PRESENT ILLNESS> ___ G1P0 presenting for IOL at ___ GA for chronic HTN. PNC: ___ ___ by LMP c/w first tri US O+/ab neg/RI/RPRNR/HBsag neg/HIV neg/GBS neg LR ERA Normal FFS Normal GLT Issues: 1) Chronic HTN: no medications. Baseline 24 hour urine 220mg ___ PEC labs wnl Last EFW ___ 70% <PAST MEDICAL HISTORY> OB-GYN Hx: G1. No hx of abnormal pap or STI PMH: - Chilblain lupus (only cutaneous manifestation as diagnosed by dermatology, no evidence of systemic lupus)- negative ___, negative anti Rho and ___ in ___, and again in this pregnancy. - History of SVT in childhood requiring ablation - Obesity (BMI 46) PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On admission; <PHYSICAL EXAM> VSS Gen: NAD Abd: soft, obese, NT, ND SVE: ___ On discharge VSS Gen: NAD CV: RRR Abd: soft, nontender <PERTINENT RESULTS> On admission: ___ 09: 58AM BLOOD WBC-12.8* RBC-3.46* Hgb-9.6* Hct-29.9* MCV-86 MCH-27.7 MCHC-32.1 RDW-13.5 RDWSD-41.3 Plt ___ ___ 09: 58AM BLOOD UreaN-9 Creat-0.5 ___ 09: 58AM BLOOD UricAcd-5.1 <MEDICATIONS ON ADMISSION> Prenatal vitamins Iron <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 4. norethindrone (contraceptive) 0.35 mg oral DAILY Take at exactly the same time everyday RX *norethindrone (contraceptive) [___] 0.35 mg 1 tablet(s) by mouth once a day Disp #*3 Packet Refills: *4 5. Ranitidine 150 mg PO BID available over the counter 6. NIFEdipine CR 30 mg PO BID RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> S/p cesarean section <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Congratulations on the birth of your baby! Please follow these instructions following dicharge from the hospital: . 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 . Your staples will be removed at your appointment ___ at 1: 30 ___ . Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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The patient is a ___, G1, who presented for induction of labor at 39 weeks 2 days gestation for chronic hypertension. Her induction was begun on ___. She received 3 Cytotec's initially, but due to minimal response and acuity on the labor floor, was briefly admitted to antepartum for rest. On ___ her induction was restarted with placement of a single cytotec. She was felt to be favorable at that time and was thus started on Pitocin on ___ progressed to 5 cm of dilation. However, could not increase the Pitocin above 6 due to category 2 fetal heart tracing. An IUPC and amnioinfusion was started, and contractions were found to be incrementally adequate; however over 4 hours the patient had no progression past 5 cm of dilation and developed fetal tachycardia to the 170s. After discussion of options with the patient, the decision was made to proceed with primary low transverse cesarean section, which happened on ___, late in the evening. Please see operative report for details. Her postpartum course was complicated by the following: 1) Chronic hypertension: While she was not on medications during pregnancy, she was started on nifedipine 30mg CR on ___, and this was increased to 30mg twice daily on ___. Her blood pressures remained in an acceptable range. 2) Anxiety: She was closely monitored postpartum for depression and did receive a social work consult. She also required several doses of ativan during her stay. 3) Chorioamnionitis: She received 24 hours of antibiotics postpartum without any other complications. Her postpartum course was otherwise uncomplicated and she was discharged home on postpartum day 6, a prolonged stay due to blood pressure monitoring.
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10524448-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: preterm contractions leakage of fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> Repeat cesarean section by low vertical incision with post-placental mirena IUD insertion <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G4P3 at ___ w h/o 3 prior CD who presents with leakage of fluid since 2pm. Denies vaginal bleeding. In triage endorses intermittent abdominal pain. Active fetal movement. Denies fevers, abdominal trauma, dysuria, abnormal vaginal discharge. <PAST MEDICAL HISTORY> ___ by first trimester US - Labs Rh pos/ abs neg (anti-A1 reported)/ Hep B and C neg/HIV neg - GLT 243 - Declined aneuploidy screening - FFS: male, anterior placenta - US ___ EFW 1668 g, 75%, AC is 95%. - S/p Tdap and Flu - Issues: *) Fibroids: not reported on ultrasounds *) H/o GDM, GDM OBHx: G4P3003, cesarean x 3; first CD for arrest of dilation, then elective repeat CDs PMH: no chronic medical conditions PSH: cesarean x 3, knee surgery; denies anesthesia complications Meds: PNV <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> On admission Gen: well appearing, tearful, NAD CV: RRR Pulm: normal work of breathing Abd: soft, gravid, no fundal tenderness SSE: + pooling, + nitrizine, + ferning SVE: ___ FHT 155/mod var/+accels/+variabl deels Toco q3-4 min, irritable TAUS: cephalic, no fluid pocket On discharge: 24 HR Data (last updated ___ @ 859) Temp: 98 (Tm 99.3), BP: 120/73 (118-122/73-79), HR: 62 (62-83), RR: 16 (___), O2 sat: 97% (97-99), O2 delivery: RA General: NAD Lungs: Nonlabored breathing Abd: soft, fundus firm at umbilicus, appropriate fundal tenderness, + BS Incision: incision C/D/I, no erythema/induration Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 04: 50PM BLOOD WBC-7.8 RBC-3.62* Hgb-10.1* Hct-31.9* MCV-88 MCH-27.9 MCHC-31.7* RDW-13.6 RDWSD-44.4 Plt ___ ___ 09: 05AM BLOOD WBC-15.6* RBC-4.15 Hgb-11.7 Hct-37.3 MCV-90 MCH-28.2 MCHC-31.4* RDW-13.9 RDWSD-45.2 Plt ___ ___ 05: 07PM BLOOD WBC-11.8* RBC-4.85 Hgb-13.5 Hct-42.3 MCV-87 MCH-27.8 MCHC-31.9* RDW-13.3 RDWSD-42.2 Plt ___ ___ 04: 50PM BLOOD UreaN-8 Creat-0.6 ___ 05: 24PM URINE Color-Straw Appear-Hazy* Sp ___ ___ 05: 24PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.5 Leuks-LG* ___ 05: 24PM URINE RBC-3* WBC-13* Bacteri-FEW* Yeast-NONE Epi-8 TransE-<1 ___ 4: 57 pm ANORECTAL/VAGINAL Source: Anorectal/Vaginal. R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREPTOCOCCI. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___: CT Abdomen and Pelvis IMPRESSION: 1. Status post cesarean section. Along the Caesarean incision is a 8.3 cm collection with hemorrhagic components and air. This is nonspecific although the imaging appearance is within the realm of what can be expected after uncomplicated Caesarean section. Short-term reimaging could be considered, however, if there is clinical concern regarding the possibility of any developing infection. There is no evidence of active extravasation. 2. Dilated colon without evidence of obstruction suggestive of postoperative ileus. 3. Mild bilateral hydronephrosis very likely due to mass effect from enlarged postpartum uterus. 4. Equivocal filling defect in the right lower lobe subsegmental pulmonary arterial branch which may represent a pulmonary embolism. It may be helpful to consider dedicated CT angiography of the chest to help confirm or refute if needed clinically. ___ CTA IMPRESSION: 1. Evaluation for pulmonary embolism is limited secondary to suboptimal contrast opacification despite two attempts at injection, as well as respiratory motion. No central pulmonary embolism through the lobar level. There is persistent heterogeneous opacification of segmental branches in the right lower lobe, favored to reflect volume averaging. Given the technical limitations, consider ultrasound of the bilateral lower extremities to evaluate for DVT. 2. Mild subsegmental atelectasis in the bilateral lower lobes. 3. 3 mm perifissural nodule in the right lower lobe. See below for recommendations. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild don't take more than 4000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 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: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity don't drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean section at 30 weeks due to category II tracing and preterm labor Gestational diabetes insulin controlled <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Congratulations on the birth of your baby! 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) - 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 (Motrin) in 24 hrs
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Ms. ___ is a ___ year old ___ admitted with PPROM (1400 ___ and preterm contractions on ___. On sterile speculum exam, patient had confirmed PPROM. She was started on magnesium and tocolysis. Overnight her vaginal exam remained at ___. She was transitioned off tocolysis and started on latency antibiotics, receiving azithromycin x 1 dose and IV ampicillin for 48 hours. Given her history of three prior cesareans, she was kept NPO during fetal monitoring. She was started on betamethasone for fetal lung maturity and was seen by the neonatologists for consultation . For her gestational diabetes, her fingersticks were monitored and she was started on an insulin sliding scale given elevated glucose readings in the setting of betamethasone. On ___, patient was admitted to the antepartum service for further monitoring. On ___, patient reported painful contractions and was found to have cervical change. FHT was notable for a Cat II tracing. Given these findings, patient underwent a repeat low vertical cesarean delivery with insertion of post-placental Mirena IUD. Her surgery was complicated by an EBL of 1325mL and multiple dense adhesions. Please see operative report for full details. Her postpartum course was complicated by postpartum hemorrhage, however, her Hct remained stable and she did not require any blood transfusions. Her pain was treated with oral pain medications. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced, however, on PPD 4, she developed ___ abdominal pain. A CTA a/p was done which was consistent w/ ileus and showed an equivocal filling defect in right lower lobe. In regards to her ileum, her diet was advance slowly over the next few days. For her small pulmonary right lower lobe filling defect, given she had a CTA (___) that was nondiagnostic; potential filling defect in R posterior basilar subsegmental pulmonary artery, no large central PE, no R heart strain, no pulmonary infarct . She was on telemetry for the following 12 hours and given she was completely asymptomatic with stable findings and with reassuring vital signs therapeutic anticoagulation was deferred. This was discussed with pulmonary service, with recommendation for bilateral ___. This ahs since been done and was negative bilaterally therefore no indication for anti-coagulation with consideration of repeat CTA ___ months from last CTA to reevaluate filling defect. During her stay she received prophylactic anticoagulation with lovenox. Social work followed the patient and she received lactation consultations. By postpartum day 7, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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| 609
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10524663-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Keflex <ATTENDING> ___. <CHIEF COMPLAINT> CC: n/v <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> HPI: ___ yo G3P0 at 6w4d by LMP presents with nausea and vomiting since ___. Patient initially presented to OSH (___) with N/V and episgastric pain where she was found to have early, unplanned pregnancy. She had pelvic u/s there which showed CRL c/w LMP. She has been unable to tolerate regular diet. She did not try anything for the nausea and vomiting. She was transferred to ___ for further evaluation. In the ED she received 4 mg IV morphine x2, 0.5 mg IV ativan, 8 mg IV zofran, 10 mg IV reglan and 20 mg IV pepcid with some relief of her nausea and vomiting but was unable to tolerate and oral intake. She currently feels relief of her epigastric pain which is "much better" and ___. She also only has mild nausea and no longer having emesis. She denies fever, chills, chest pain, SOB, diarrhea, dysuria, ctx, vaginal bleeding, LOF. +FM. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ c/w 6 week u/s OBHx: - TAb/D+C x2, both first trimester GynHx: - hx of abnormal Pap 1 mos ago, denies colpo - hx of chlamydia ___ years ago - Regular monthly menses - Contraception: was using condoms and withdrawal method PMH: Denies PSH: Denies Meds: PNV All: Keflex -> n/v <SOCIAL HISTORY> ___ <FAMILY HISTORY> lives with her father, parents divorced. <PHYSICAL EXAM> Physical Exam VS: T-97.9 HR-53 BP-116/65 RR-16 Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness Labs- ___ 6 ----------- < 104 3.3 20 0.5 ALT/AST- ___, Tbili-0.2, Lipase 4.4 UA: sm bld, neg nit, neg leuk, 40 ket, no bact, 3 epis <PERTINENT RESULTS> ___ 07: 50PM GLUCOSE-104* UREA N-6 CREAT-0.5 SODIUM-138 POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-20* ANION GAP-13 ___ 07: 50PM ALT(SGPT)-13 AST(SGOT)-18 ALK PHOS-34* TOT BILI-0.2 ___ 07: 50PM LIPASE-44 ___ 07: 50PM WBC-9.2 RBC-3.61* HGB-11.0* HCT-32.1* MCV-89 MCH-30.5 MCHC-34.2 RDW-12.2 ___ 07: 50PM NEUTS-86.4* LYMPHS-10.1* MONOS-3.1 EOS-0.2 BASOS-0.3 ___ 07: 50PM PLT COUNT-222 ___ 06: 30PM URINE UCG-POSITIVE ___ 06: 30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG ___ 06: 30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG <DISCHARGE INSTRUCTIONS> call if you have persistent nausea and vomiting, dizziness, chest pain, shortness of breath, worsening abdominal pain, vaginal bleeding, feelings like you want to harm yourself or someone else
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Patient was admitted to antepartum service for IV antiemetics and IVF. Received nutrition consult. She spent many hours in the shower because it made her abdominal pain feel better. She had a psychiatric consult for her very complicated psych history, including diagnoses of ADHD, depression, anxiety, prodromal schizophrenia and borderline personality disorder. She was given zyprexa to help her sleep as per psych recommendations, and that seemed to work. She has seroquel at home, and did not feel that was helpful. She had pulled out her IV, so IVF and medications were unable to be given. She was seen by psych again on HD#2. Per Dr. ___ ___ attending): there were no clear signs of a full major depressive syndrome, (hypo-)mania, psychosis, or gross congnitive impairment. He felt that psychiatric admission is unlikely to alter her symptoms, although she does need long term mental health care on an outpatient basis. She was given ___ contact information so that she can arrange follow up on ___. She was offered by declined psyschiatric admission and did not meet the criteria for involuntary hospitalization. She denied vaginal bleeding. She was able to tolerate liquids and denied dizziness or lightheadedness. She was discharged home to f/u as outpatient on ___. Discharge Disposition: Home Discharge Diagnosis: nausea and vomiting in pregnancy complex psychiatric history, including diagnoses of ADHS, depression, anxiety, prodromal schizophrenia, and borderline personality disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10525140-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Latex <ATTENDING> ___. <CHIEF COMPLAINT> heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy bilateral salpingo-oophorectomy partial omentectomy ___ lymph node dissection repair of gonadal vein laceration cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G3P2 with a history of irregular and heavy bleeding lasting approximately eight months, which she had attributed to menopause. In ___, she experienced an episode of very heavy bleeding with large clots for which she presented to the ED. Subsequent work up with ultrasound and endometrial biopsy revealed fibroids as well as endometrial adenocarcinoma, favoring serous type. Her bleeding has decreased but persists, and she denies abdominal pain or bloating, weight loss, urinary symptoms or changes in bowel habits. <PAST MEDICAL HISTORY> PMH: borderline DMII, mild hypercholesterolemia, both controlled with diet. PSH: c/s x2, one via vertical midline incision, the second via Pfannensteil incision OB: G3P2, c/s x2 as above, SAB x1, preeclampsia x2 GYN: Menarche age ___. Pap containing endometrial cells one year ago per patient, no follow up. Periods regular until eight months ago, lasting four days <SOCIAL HISTORY> ___ <FAMILY HISTORY> history significant for HTN, DMII. Denies history of ovarian, endometrial, colon or breast cancer. <PHYSICAL EXAM> on discharge: afebrile, vital signs stable Gen: NAD, AxO CV: RRR Resp: CTAB Abd: +BS, soft, nondistended, minimally tender to palpation, no rebound or guarding, midline vertical incision c/d/i with staples and no erythema/induration Ext: calves nontender <PERTINENT RESULTS> ___ 08: 05AM BLOOD WBC-7.9 RBC-4.07* Hgb-9.8* Hct-30.6* MCV-75* MCH-24.0* MCHC-31.9 RDW-18.8* Plt ___ ___ 07: 15AM BLOOD WBC-12.1* RBC-4.54 Hgb-10.9* Hct-33.7* MCV-74* MCH-24.0* MCHC-32.3 RDW-19.4* Plt ___ ___ 07: 50AM BLOOD WBC-9.1 RBC-4.43 Hgb-10.8* Hct-33.5* MCV-76* MCH-24.4* MCHC-32.3 RDW-18.2* Plt ___ ___ 01: 30AM BLOOD WBC-9.7 RBC-4.66 Hgb-11.5* Hct-35.3* MCV-76* MCH-24.8* MCHC-32.7 RDW-18.2* Plt ___ ___ 07: 20PM BLOOD WBC-10.8# RBC-5.03# Hgb-12.3# Hct-38.2 MCV-76* MCH-24.5* MCHC-32.2 RDW-18.8* Plt ___ ___ 07: 15AM BLOOD ___ PTT-25.2 ___ ___ 07: 50AM BLOOD ___ PTT-27.1 ___ ___ 08: 05AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-140 K-4.1 Cl-105 HCO3-28 AnGap-11 ___ 07: 15AM BLOOD Glucose-111* UreaN-11 Creat-1.1 Na-138 K-4.1 Cl-103 HCO3-26 AnGap-13 ___ 04: 15PM BLOOD Glucose-113* UreaN-11 Creat-1.0 Na-137 K-4.3 Cl-104 HCO3-27 AnGap-10 ___ 07: 50AM BLOOD Glucose-84 UreaN-11 Creat-1.1 Na-141 K-4.6 Cl-107 HCO3-25 AnGap-14 ___ 07: 20PM BLOOD Glucose-133* UreaN-10 Creat-0.8 Na-138 K-4.7 Cl-108 HCO3-23 AnGap-12 ___ 08: 05AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9 ___ 07: 15AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1 ___ 04: 15PM BLOOD Calcium-8.7 Phos-4.4 Mg-2.3 ___ 07: 50AM BLOOD Calcium-8.9 Phos-5.8* Mg-1.7 ___ 07: 20PM BLOOD Calcium-8.1* Phos-4.7* Mg-1.8 Final pathology pending <MEDICATIONS ON ADMISSION> denies <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on percocet to prevent constipation. Disp: *60 Capsule(s)* Refills: *2* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *80 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial cancer, final pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well, and the team feels that you are ready to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will be removed at your visit next week on ___, ___, as listed below. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ G3P2 who was admitted to the gynecologic oncology service after undergoing exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral periaortic lymph node dissection, partial omentectomy, washings, and cystoscopy for endometrial cancer. Intra-operative frozen section of a 1.5 cm left left-sided ___ lymph node was consistent with metastatic adenocarcinoma; final pathology is pending at the time of this discharge summary. The case was notable for an intraoperative consultation to Vascular Surgery for repair of injury to the left gonadal vein. Please refer to Dr. ___ Dr. ___ reports for details of the operation. Her pre-op HCT was 30.6, EBL was 600cc, and she received 2units of pRBCs intraoperatively. Her post-operative course was uncomplicated. On post-operative day 1, her HCT was stable at 33 although her creatinine was slightly elevated at 1.1 Repeat creatinine was 1.0, and her vital signs were stable with good urine output, so her foley was removed and she voided spontaneously. Her pain was managed with a dilaudid PCA and she was transitioned to oral pain medications with good pain control. By the morning of post-operative day 3, she was tolerating a regular diet, ambulating independently, voiding spontaneously, and pain was controlled with oral medications. Her vital signs continued to be stable with good urine output, and her creatinine returned to her baseline of 0.7. She was then discharged home in good condition with outpatient follow-up with Dr. ___.
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10526948-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abdominal mass s/p resection, TAH, BSO <MAJOR SURGICAL OR INVASIVE PROCEDURE> - Exploratory laparotomy, lysis of adhesions, radical abdominal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy. - ICU admission for respiratory distress and hypotension - blood transfusions <HISTORY OF PRESENT ILLNESS> ___ year old female with morbid obesity (BMI 60) and 50cm pelvic mass s/p ex-lap TAH/BSO with post op hypotension and fluid shifts requiring phenylephrine and intubation admitted for FICU for further monitoring. Per notes, patient has a history of abnormal uterine bleeding secondary to fibroids. She had a CT A/P on ___ which showed a 45x38x26cm uterine mass thought to be consistent with fibroids (increased from 28cm in ___ per pt). She was also noted to have enlarged retrocrural and retroperitoneal lymph nodes. She also had an MRI torso in ___ which showed large mass replacing the uterus with nodularity in pelvis and renal mass measuring ~3.7cm. No ascites or disease in the chest was seen. She underwent biopsy of the renal mass which showed oncocytoma. She saw urology and was told that no further work-up was needed. She saw Dr. ___ second opinion and was scheduled for ex-lap, TAH, BSO on ___. Preoperatively patient received Tylenol ___, pregabalin 75mg, heparin SC, phenazopyridine 100 mg, scopolamine patch. Primary surgeon was Dr. ___ anesthesiologist was Dr. ___. Mass was found to be 50cm and 50lbs requiring 50cm supraumbilical incision. EBL was 2000cc. She received 3upRBCs, 750cc 5% albumin, and 3000mL LR. She had 100cc UOP. Frozen sections were negative x 3 but showed smooth spindle cells. Size of mass is concerning for malignancy. Anesthesia did not feel that patient could be extubated given her size. Post operatively she required phenylephrine for hypotension. She had an epidural placed for pain control. Per OBGYN team, anticipate patient will have significant pain, nausea, vomiting. She may need more blood. OBGYN overnight resident will check on her. Okay with Tylenol, dilaudid PCA, foley, pneumoboots, SCH 5000 BID, and mIVF at 125mL LR overnight. If extubated sips overnight then ADAT. On arrival to the MICU, patient is intubated and sedated. She awakens to voice and responds to commands. <PAST MEDICAL HISTORY> Asthma Abnormal uterine bleeding Morbid obesity Ear tubes as a child <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father: bone cancer Mother: T2DM, CAD Denies history of gyn or colon cancer, bleeding or clotting disorder. <PHYSICAL EXAM> MICU ADMISSION EXAM: VITALS: T 98.8 BP 122/76 HR 117 intubated GENERAL: sedated but awakens to voice, responds to commands HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, over breathing vent use ABDOMEN: midline incision above umbilicus with dressing C/D/I, soft nondistended EXTREMITIES: 2+ pitting edema of legs, no cyanosis, moving all 4 extremities with purpose PULSES: DP pulses dopplerable bilaterally NEURO: responding to commands, moving all 4 extremities to command 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 ___: nontender, nonedematous <PERTINENT RESULTS> ___ 04: 36PM BLOOD WBC-25.6*# RBC-4.23 Hgb-12.3 Hct-37.4# MCV-88 MCH-29.1 MCHC-32.9 RDW-14.5 RDWSD-45.8 Plt ___ ___ 05: 32PM BLOOD Hct-UNABLE TO ___ 12: 13AM BLOOD WBC-20.9* RBC-3.90 Hgb-11.3 Hct-34.6 MCV-89 MCH-29.0 MCHC-32.7 RDW-14.6 RDWSD-46.5* Plt ___ ___ 04: 51AM BLOOD WBC-14.8* RBC-3.65* Hgb-10.5* Hct-32.0* MCV-88 MCH-28.8 MCHC-32.8 RDW-14.6 RDWSD-46.9* Plt ___ ___ 10: 58AM BLOOD WBC-11.5* RBC-3.18* Hgb-9.3* Hct-28.3* MCV-89 MCH-29.2 MCHC-32.9 RDW-14.3 RDWSD-46.7* Plt ___ ___ 05: 42PM BLOOD WBC-15.0* RBC-2.96* Hgb-8.5* Hct-26.6* MCV-90 MCH-28.7 MCHC-32.0 RDW-14.6 RDWSD-47.5* Plt ___ ___ 11: 19PM BLOOD WBC-15.2* RBC-3.13* Hgb-9.1* Hct-28.5* MCV-91 MCH-29.1 MCHC-31.9* RDW-14.6 RDWSD-48.6* Plt ___ ___ 05: 14AM BLOOD WBC-14.1* RBC-3.08* Hgb-9.0* Hct-28.1* MCV-91 MCH-29.2 MCHC-32.0 RDW-14.4 RDWSD-47.8* Plt ___ ___ 05: 01AM BLOOD WBC-7.2 RBC-2.82* Hgb-8.2* Hct-25.9* MCV-92 MCH-29.1 MCHC-31.7* RDW-13.8 RDWSD-47.1* Plt ___ ___ 05: 21AM BLOOD WBC-4.5 RBC-2.93* Hgb-8.5* Hct-26.5* MCV-90 MCH-29.0 MCHC-32.1 RDW-13.2 RDWSD-44.4 Plt ___ ___ 04: 36PM BLOOD Neuts-85.2* Lymphs-4.9* Monos-8.9 Eos-0.1* Baso-0.2 Im ___ AbsNeut-21.81* AbsLymp-1.25 AbsMono-2.27* AbsEos-0.02* AbsBaso-0.06 ___ 04: 36PM BLOOD ___ PTT-29.0 ___ ___ 04: 36PM BLOOD Plt Smr-NORMAL Plt ___ ___ 12: 13AM BLOOD Plt ___ ___ 04: 51AM BLOOD Plt ___ ___ 10: 58AM BLOOD ___ PTT-31.4 ___ ___ 10: 58AM BLOOD Plt ___ ___ 05: 42PM BLOOD Plt ___ ___ 11: 19PM BLOOD Plt ___ ___ 05: 14AM BLOOD ___ PTT-32.0 ___ ___ 05: 14AM BLOOD Plt ___ ___ 05: 01AM BLOOD ___ PTT-27.6 ___ ___ 05: 01AM BLOOD Plt ___ ___ 05: 21AM BLOOD Plt ___ ___ 04: 36PM BLOOD ___ ___ 10: 58AM BLOOD ___ ___ 04: 36PM BLOOD Glucose-143* UreaN-10 Creat-0.6 Na-137 K-4.6 Cl-102 HCO3-20* AnGap-20 ___ 04: 51AM BLOOD Glucose-131* UreaN-8 Creat-0.4 Na-136 K-4.0 Cl-102 HCO3-25 AnGap-13 ___ 05: 14AM BLOOD Glucose-110* UreaN-6 Creat-0.3* Na-137 K-3.3 Cl-102 HCO3-25 AnGap-13 ___ 05: 01AM BLOOD Glucose-106* UreaN-6 Creat-0.3* Na-138 K-3.3 Cl-103 HCO3-26 AnGap-12 ___ 05: 21AM BLOOD Glucose-103* UreaN-5* Creat-0.3* Na-137 K-3.6 Cl-101 HCO3-27 AnGap-13 ___ 04: 36PM BLOOD Phos-4.7* Mg-1.5* ___ 04: 51AM BLOOD Calcium-7.5* Phos-4.4 Mg-1.5* ___ 05: 14AM BLOOD Albumin-2.7* Calcium-6.9* Phos-2.4* Mg-1.8 ___ 05: 01AM BLOOD Calcium-7.2* Phos-2.3* Mg-1.7 ___ 05: 21AM BLOOD Calcium-7.1* Phos-2.6* Mg-1.9 ___ 09: 09PM BLOOD ___ pO2-67* pCO2-56* pH-7.29* calTCO2-28 Base XS-0 ___ 12: 36AM BLOOD ___ Temp-37.9 pO2-52* pCO2-55* pH-7.31* calTCO2-29 Base XS-0 Intubat-INTUBATED ___ 05: 00AM BLOOD ___ pO2-64* pCO2-50* pH-7.37 calTCO2-30 Base XS-1 ___ 09: 09PM BLOOD Lactate-3.0* ___ 12: 36AM BLOOD Lactate-2.6* ___ 09: 09PM BLOOD freeCa-1.15 ___ 05: 00AM BLOOD freeCa-1.09* Blood cultures pending <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID Take this medication with narcotics RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 2. Enoxaparin Sodium 60 mg SC Q12H RX *enoxaparin 60 mg/0.6 mL 60 mg SC twice a day Disp #*56 Syringe Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Take medication with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Reason for PRN duplicate override: Alternating agents for similar severity Do not drive or operate heavy machinery when on this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 5. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ Diagnosis: uterine 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 were admitted to the ICU for issues with breathing and low blood pressure. Your blood pressure improved after transfusion with blood and fluid. Your breathing improved and you were successfully extubated. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * You will take a blood thinner called Lovenox twice a day to help prevent blood clots. A visiting nurse ___ help you with administration. * 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. * Your staples will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
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Ms. ___ was admitted to the gynecologic oncology service after undergoing an exploratory laparotomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy for a 50cm fibroid uterus. Please see the operative report for full details. Her postoperative course was complicated by respiratory distress requiring ICU admission for respiratory monitoring after aggressive intraoperative volume resuscitation. Intraoperative findings were notable for a 50cm fibroid uterus that extended into the retroperitoneal space. Given the patients morbid obesity with a BMI of approximately 60 a supraumbilical incision was made. EBL in the case was 2000cc. She was resuscitated with 3000cc crystalloid, 3 units of packed red blood cells, and 750 cc of albumin. Given the aggressive fluid resuscitation there was concern from anesthesia about her respiratory status and inability to extubate. She was therefore transferred to the ICU intubated for close monitoring. In the ICU her course was notable for continued pressor requirement. Her hematocrit was trended and showed an initial drop to 28 from 32, remaining stable from there. Given an unremarkable exam and adequate urine output, there was low concern for ongoing bleeding. The patient was successfully extubated on the morning of ___. She initially had a 4L oxygen requirement but then was successfully weaned off of O2. Her blood pressures subsequently stabilized ranging in the 100-120/38-50. She was weaned off of pressors on ___. Her pain was controlled with an epidural and Dilaudid PCA. Given her successful intubation and her improving blood pressure the patient was called out to the floor on ___. Once transferred to the floor the remainder of her postoperative course was uncomplicated. The epidural and the PCA were discontinued and the patient was successfully transitioned to oral pain medications of Tylenol, oxycodone, and ibuprofen. Her diet was advanced without incident. Her Foley was removed and she voided spontaneously. During her hospitalization she was maintained on DVT prophylaxis initially with heparin while the epidural was in place and then transitioned to Lovenox. She was continued on her home medications By post-operative day 5, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10527031-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> painful contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> SVD <HISTORY OF PRESENT ILLNESS> ___ G4P2 at ___ with painful ctx without VB or LOF. +FM. PNC: - ___ ___ by ___ - Labs Rh +/Abs -/Rub I/RPR NR/HBsAg -/HIV -/GBS + for PCN - Screening: low risk - FFS: wnl - GTT: 148-> passed 3 hr GTT - U/S - Issues: PEC in prior pregnancy *) elevated BPs on admission - likely in the setting of pain and CSE placement [ ] PIH labs, P: C <PAST MEDICAL HISTORY> OBHx: - G1- SAB - G2- SVD - G3- SVD - G4- Current GynHx: - abnormal Pap, fibroids, Gyn surgery, STIs PMH: hypothyroidism PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VS: Afebrile, Vital signs stable Neuro/Psych: no acute distress, Oriented x3, Affect Normal Heart: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 08: 55AM URINE HOURS-RANDOM CREAT-41 TOT PROT-7 PROT/CREA-0.2 ___ 08: 55AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08: 55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 06: 15AM CREAT-0.6 ___ 06: 15AM estGFR-Using this ___ 06: 15AM ALT(SGPT)-31 AST(SGOT)-24 ___ 06: 15AM URIC ACID-5.2 ___ 05: 17AM WBC-8.1 RBC-4.91 HGB-12.9 HCT-40.4 MCV-82 MCH-26.3 MCHC-31.9* RDW-14.6 RDWSD-43.2 ___ 05: 17AM PLT COUNT-140* <MEDICATIONS ON ADMISSION> levothyroxine 100mcg <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID 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 Pain - Mild/Fever NOT relieved by Acetaminophen take with food RX *ibuprofen 600 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 3. NIFEdipine (Extended Release) 30 mg PO DAILY RX *nifedipine 30 mg 1 (One) tablet(s) by mouth once a day Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy resulting in vaginal birth gestational hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <DISCHARGE INSTRUCTIONS> per written instructions reviewed by nursing and OB providers ___: ___
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Ms. ___ had a spontaneous vaginal delivery on ___. She ruled in for gestational hypertension intrapartum. Her PIH labs were within normal limits (apart from a slightly decreased platelet count). Her blood pressures were monitored closely in the postpartum period. Given persistently elevated blood pressures, she was started on nifedipine on ___ and required titration to BID dosing on ___. The remainder of her postpartum course was uncomplicated. Her vaginal bleeding was within normal limits. She tolerated a regular diet, voided spontaneously without issue, and ambulated independently. By postpartum day 4 after vaginal delivery, she was deemed stable for discharge with a plan set for postpartum follow up.
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10528828-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> left leg swelling and pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G4P3 @ ___ presents with increasing left leg swelling and pain. Pt was seen on ___ and had ___ which was negative for DVT. The swelling has increased and she now has even more pain with ambulation. No personal or family hx of DVT. Denies chest pain, shortness of breath. Feels irregular mild ctx, especially at night. No VB, LOF. +AFM. Pt reports poor control of blood glucose over past few days. Has had to give extra humalog postmeals to bring ___ down from as high as 280, but also has had lows overnight and premeal. <PAST MEDICAL HISTORY> OBHx: 3 SVD ___ Term, ___ 32 weeks, ___ Term MedHx: T1DM SurgHx: Open appendectomy <SOCIAL HISTORY> Late transfer of care from ___. No T/E/D. <PHYSICAL EXAM> VS 96.8 87 18 120/72 NAD RRR, nl S1/S2 CTAB Abd soft, gravid, NT Ext LLE with 1+ pitting edema from ankle to inguinal region. Slight erythema appreciated; no palpable cords, but diffusely painful to palpation. RLE soft, nontender, nonedematous, no erythema. SVE 1/long/posterior/medium consistently (multiparous) Toco q2-5mins, irregular FHT 140/mod var/+accels/no decels <PERTINENT RESULTS> BLOOD ___ 06: 20PM BLOOD WBC-13.1* RBC-3.78* Hgb-11.0* Hct-32.5* MCV-86 MCH-29.1 MCHC-33.8 RDW-12.7 Plt ___ ___ 06: 20PM BLOOD Plt ___ ___ 06: 20PM BLOOD ___ PTT-27.4 ___ ___ 06: 20PM BLOOD ___ ___ 10: 56PM BLOOD LMWH-0.65 ___ 06: 20PM BLOOD Glucose-189* UreaN-10 Creat-0.7 Na-135 K-3.8 Cl-103 HCO3-23 AnGap-13 ___ 06: 20PM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9 URINE ___ 05: 50PM URINE Color-Straw Appear-Clear Sp ___ ___ 05: 50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RADIOLOGY BILAT LOWER EXT VEINS Study Date of ___ 3: 15 ___ INDICATION: Left inguinal and thigh pain. COMPARISON: Ultrasound from ___. FINDINGS: Waveforms at the common femoral veins show appropriate respiratory variability and response to Valsalva maneuvers on the right, and absent flow on the left. Echogenic material is visualized within the vein on the left and there is no evidence of flow on color Doppler analysis. Similar echogenic material is seen along the length of the superficial femoral vein which is noncompressible. Additionally, material seen in the popliteal vein, which is also non-compressible, which has no evidence of flow on color Doppler analysis. Echogenic material is also seen within the posterior tibial and peroneal vein on the left. In the right lower extremity, the common femoral, proximal greater saphenous, superficial femoral, and popliteal veins are all appropriately compatible. Note is made however of slightly isoechoic appearance to the internal contents, which was seen in real time to represent slow moving blood. Wall-to-wall flow is also noted in the posterior tibial and peroneal veins in the calf. IMPRESSION: 1. Extensive deep venous thrombosis in the left lower extremity extending from the common femoral vein into the posterior tibial and peroneal veins in the calf. 2. No evidence of deep venous thrombosis in the right lower extremity, however note is made of slow flow. SOFT TISSUE US Study Date of ___ 3: 15 ___ INDICATION: Left leg and buttock pain. COMPARISON: None available. FINDINGS: Spot sonographic images obtained over the left buttock at the site of insulin injection revealed no subjacent abnormality, specifically no evidence of subjacent abscess. IMPRESSION: Normal ultrasound. <MEDICATIONS ON ADMISSION> Novolog ___ humalin ___ PNV <DISCHARGE MEDICATIONS> 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp: *60 syringes* Refills: *2* 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain: do not exceed 4g of acetaminophen in 24hours. Disp: *20 Tablet(s)* Refills: *0* 4. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: see separate sheet Subcutaneous ASDIR (AS DIRECTED). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> left lower extremity deep vein thrombus type 1 diabetes <DISCHARGE CONDITION> Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your obstetric doctor, if you have regular, painful contractions, leak of fluid, vaginal bleeding, do not feel the baby move. Please call your Please keep all your follow up appointments.
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Ms. ___ was admitted for extensive left lower extremity DVT (please see radiology report) and was started on enoxaparin 80mg BID subcutaneous injections. A Factor Xa was checked at the appropriate time and its result was noted to be in therapeutic range. She was evaluated by vascular surgery and physical therapy, who agreed with medical therapy as initiated, and provided crutches and recommended ambulation respectively. Of note, she has type 1 diabetes, for which the endocrine service was consulted. Her insulin regimen was titrated to improve her blood glucose control. Fetal well being was affirmed with BPP ___ and AFI 20. Fetal monitoring was continued with NST twice daily, which were all reassuring. She was discharged home on HD#2 in good condition with follow up appointments with primary obstetrician and endocrinologist. She will have postpartum appointments with vascular surgery and hematologist.
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10528828-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> induction of labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G4P3 at 38+ week for induction of labor so as to allow her to be off her anticoagulation for delivery and Type 1 Diabetes <PAST MEDICAL HISTORY> OBHx: 3 SVD ___ Term, ___ 32 weeks, ___ Term MedHx: T1DM SurgHx: Open appendectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/c <PHYSICAL EXAM> PE AFVSS Pulm: CTA Cor: RRR, no M/R/G Abd: gravid, EFW ___ pounds SVE ___ Ext Left extremilty mildly edematous but non tender <PERTINENT RESULTS> ___ 10: 06AM ___ PTT-27.9 ___ ___ 10: 06AM ___ ___ 09: 00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09: 00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR ___ 08: 59AM WBC-8.2 RBC-3.76* HGB-11.0* HCT-32.4* MCV-86 MCH-29.4 MCHC-34.1 RDW-13.2 ___ 08: 59AM PLT COUNT-163 <MEDICATIONS ON ADMISSION> INsulin NPH and H PNV Lovenox 80 bid <DISCHARGE MEDICATIONS> 1. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: Take at 4pm each day., to start on ___ Disp: *60 Tablet(s)* Refills: *2* 2. tylenol as needed 3. Lovenox 80 bid <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal delivery Type 1 diabetes DVT in the left leg <DISCHARGE CONDITION> Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> given NO MOTRIN NEED follow up with hematology in 6 months after off coumadin NEED vascular surgery follow up if any change in leg swelling NEED ___ clinic follow up
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She was admitted, started on pitocon, AROM and had a SVD on ___ in the late afternoon about 20 hours after last dose of lovenox and no bleeding was noted She had an uneventful PP course and her bleeding was within the expected range. She was to start coumadin with lovenox as a bridge and she wanted essure for contraception which was all arranged.
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10529115-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> stage III cystocele <MAJOR SURGICAL OR INVASIVE PROCEDURE> anterior repair, hysteropexy, and cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G14P10 (SVDx10) who presented with vaginal bulge and urinary urgency. Patient speaks ___ this visit was conducted with the assistance of a hospital interpreter. She first noticed the vaginal bulge ___ years ago, and notes worsening with straining, coughing, and lifting things. She often has trouble voiding due to the prolapse, and sometimes feels as though she incompletely empties her bladder. She denies issues with bowel movements and has never had to reduce the bulge in order to void or defecate. She briefly tried a pessary in the past but discontinued use due to vaginal irritation. She has had urinary urgency over the last ___ years, and reports incontinent episodes with almost every void. She voids ___ times per day and 3 times per night. She wears pads daily, and changes them ___ times per day (she does not think that she is constantly leaking urine). When she leaves her house, she makes sure to limit fluid intake and periodically empties her bladder to avoid incontinent episodes. She finds her prolapse and urinary symptoms very distressing as she is unable to leave her house for long periods of time and has trouble lifting and carrying bags (ex. at the grocery store). She denies leakage of urine with coughing, sneezing, or straining. Although she has a history of frequent UTIs in the past (approx. 3x per year), she has not had any dysuria, hematuria, or pain/discomfort with voids over the last year. She denies a history of nephrolithiasis. She denies changes in her bowel habits. No pain with BMs, constipation, diarrhea, fecal incontinence. She presented to ___ clinic in ___ and underwent placement of a #5 ring pessary. She used the pessary briefly, but discontinued use due to vaginal irritation and discomfort. She is not interested in another pessary trial. She re-presented to Dr. ___ 2 months ago and was started on oxybutynin. She reports improvement in her symptoms since starting oxybutynin. <PAST MEDICAL HISTORY> PMH: T2DM, HTN, HLD PSH: laprascopic cholecystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Vital signs: ___ Temp: 99.1 PO BP: 137/75 R Lying HR: 77 RR: 16 O2 sat: 95% O2 delivery: RA ___ 2327 Temp: 99.0 PO BP: 102/69 HR: 78 RR: 18 O2 sat: 95% O2 delivery: ra ___ 0330 Temp: 98.1 PO BP: 155/80 HR: 70 RR: 18 O2 sat: 95% O2 delivery: ra Ins: > Last day: ___ Total Intake: 2697ml PO Amt: 700ml IV Amt Infused: 1997ml > Since ___ Total Intake: 1240ml PO Amt: 240ml IV Amt Infused: 1000ml Outs: > Last day: ___ Total Output: 1610ml Urine Amt: 1610ml ___ pad: 0ml > Since ___ Total Output: 625ml Urine Amt: 625ml General: NAD, comfortable CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, nontender to palpation without rebound or guarding GU: vaginal packing in place with moderate amount of thin, serosanguinous discharge on pad; foley in place draining clear yellow urine Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 06: 29AM BLOOD WBC-11.4* RBC-3.53* Hgb-10.9* Hct-32.5* MCV-92 MCH-30.9 MCHC-33.5 RDW-11.8 RDWSD-39.3 Plt ___ ___ 06: 29AM BLOOD Plt ___ <MEDICATIONS ON ADMISSION> - glipizide 10mg QD - HCTZ 25mg QD - metformin 1000mg BID - oxybutynin 5mg QD - simvastatin 40mg QD - Tylenol prn - calcium - eye drops <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID RX *acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills: *1 3. Ibuprofen 400 mg PO Q8H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *1 4. Artificial Tears GEL 1% 1 DROP BOTH EYES TID 5. GlipiZIDE 10 mg PO BID 6. Hydrochlorothiazide 25 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> stage III cystocele <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. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing anterior repair, hysteropexy, and cystoscopy for stage III cystocele. Please see the operative report for full details. Immediately post-op, her pain was controlled with IV Dilaudid and Toradol. During pre-operative, she was hypertensive to 200-210s, asymptomatic, with no signs of end-organ failure. Following the procedure, she was hypertensive to the 200s in the PACU and received hydral 10 mg IV. Since then, she has remained mildly hypertensive. She was restarted on her home hydrochlorothiazide on post-op day 0. On post-operative day 1, her urine output was adequate and she was able to spontaneously void after a formal trial of void. Her diet was advanced without difficulty and she was transitioned to oral ibuprofen, and acetaminophen. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was restarted on her home metformin and glipizide for diabetes management. She was then discharged home in stable condition with outpatient follow-up scheduled.
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