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10529431-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G1P1 who presents to the ED with abdominal pain. The pain began approximately 5 days ago and has been increasing in intensity since then. She was seen yesterday at her PCPs office and was told that her pain was from "cramps". This morning, the pain became more intense and she presented to the ED. She denies fevers, chills, nausea, vomiting, dysuria, diarrhea. Does state that she may be constipated (has not had a bowel movement for ___. No recent sick contacts or unusual foods consumed. Denies history of STIs or multiple sexual partners. States she has not had intercourse for at least 3 months and always uses condoms with sexual contact. She did start to have some vaginal bleeding approx one week ago, which is different for her as she has been amenorrheic on Depo Provera for ___ years. <PAST MEDICAL HISTORY> ObHx: SVD x 1 GynHx: LMP last week. On Depo as above. No history STIs or abnormal Paps. Considers herself "celibate", no recent sexual intercourse. MedHx: Hypothyroidism SurgHx: Foot surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> VS 101.7 110 128/65 14 96% Gen: Curled up, lying on right side on stretcher. Appears uncomfortable with movement. CV: Tachycardic, RR, nl S1/S2 Lungs: CTAB Abd: Soft, nondistended. Diffuse tenderness to palpation, worst in LLQ. Voluntary guarding. No rebound. +BS. Ext: No C/C/E Bimanual: Nl external genitalia. +CMT. Uterus and left adnexa tender to palpation. No adnexal masses appreciated. <PERTINENT RESULTS> ___ 01: 35PM WBC-11.1*# RBC-4.27 HGB-13.0 HCT-40.3 MCV-94 MCH-30.6 MCHC-32.4 RDW-13.3 ___ 01: 35PM NEUTS-81.9* LYMPHS-14.8* MONOS-1.8* EOS-1.1 BASOS-0.2 ___ 01: 35PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01: 35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 01: 35PM URINE ___ BACTERIA-FEW YEAST-NONE ___ <MEDICATIONS ON ADMISSION> Levoxyl 125mcg, tums, vitamins <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *35 Tablet(s)* Refills: *1* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 5. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 13 days. Disp: *26 Capsule(s)* Refills: *0* 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 13 days. Disp: *26 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic inflammatory disease <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 * 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. * You may eat a regular diet.
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Pt was admitted to the GYN service for management of presumed pelvic inflammatory disease. She was treated with ampicillin, gentamycin, and clindamycin IV until she was afebrile for 36 hours. At this time she was switched to po doxycycline and flagyl. She was observed to be afebrile for 24 hours on this regimen and then discharged home. At the time of discharge she was comfortable with po pain control, ambulating, voiding, and taking good po's.
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10533013-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> post-op fever after low transverse c-section <MAJOR SURGICAL OR INVASIVE PROCEDURE> wound incision and drainage <HISTORY OF PRESENT ILLNESS> ___ G2P1 ___ s/p LTCS presents to Gyn triage with fever to 102.5 degrees. Patient reports feeling feverish last night and this morning. She took her temperature and noted it to be 102.5 degrees. She reports shaking chills. Reports abdominal pain, controlled with Percocet and Motrin. Reports persistent mild spotting, no foul smelling lochia. She reports mild nausea, now resolved. No emesis. She is tolerating PO. Denies diarrhea or urinary symptoms. Denies breast symptoms. Denies upper respiratory tract symptoms. Reports mild headache this morning, now resolved. Denies chest pain or shortness of breath. Denies neck pain or stiffness. <PAST MEDICAL HISTORY> OBHx: ___ LTCS for arrest of descent at 9cm, no complications ___ Ectopic GynHx: Dysmenorrhea Fibroid uterus PMH: GERD Depression Chronic low back pain PSH: ___ laparotomy left salpingectomy and cystotomy repair, for L ectopic pregnancy ___ ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> In GYN triage: PE: VS: T 98.8 BP 133/88 HR 121 RR 28 O2Sat 98% Repeat HR 115 NAD, appears comfortable Tachy, regular rhythm Breast no erythema, no induration, no evidence of mastitis CTAB Abd soft, ND, fundal tenderness; no CVAT Inc steri strips in place, erythema extending approx 3cm from incision in all directions, erythema extending over mons pubis, tender to palpation, warm, no induration, no fluctuance, no drainage Bimanual uterine tenderness, no adnexal tenderness, no palpable adnexal masses Ext NTNE <PERTINENT RESULTS> Labs: 20.0>26.1<562, left shift UCX no growth BCx no growth MRSA swab negative TAUS: Post-operative hematoma seen at the site of cesarean section wound just beneath the skin, with no focal drainable collection Abd wound Culture: ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 0.5 S PENICILLIN G---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 2 S <MEDICATIONS ON ADMISSION> Percocet Motrin <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *45 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *1* 3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Disp: *40 Capsule(s)* Refills: *0* 4. Reglan 10 mg Tablet Sig: One (1) Tablet PO day1 1tablet po qd: day2 1 tablet po bid day 3 to day 11 1 tablet po TID day 12 1 tablet po BID day 13 1 tablet po qd. Disp: *33 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> wound infection s/p cesarewan section requiring incision and drainage <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> f/u ___ for wound check. ___ for Daily dressing changes
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___ s/p LTCS (___) was readmitted ___ with fever. #) Fever: Endometritis and Cellulitis Initially exam was concerning for both endometritis and cellulitis and she was started on Gentamycin and Clindamycin for empiric treatment of postpartum endometritis, and Keflex for cellulitis. Her pain was treated with Percocet and Motrin. On admission her WBC was 26.1. On HD 2 she was still febrile to 100.4 but her fever curve was trending down and her fundal tenderness was improving. The erythema around her incision was noted to be stable but her mons was more edematous so an ultrasound was done which showed a 2.6 x 2.6 x 5.7 collection of fluid thought to be a post-operative hematoma on the anterior abdominal wall. Her white blood cell count had decreased to 22. On HD 3 she was afebrile for 24 hours on IV antibiotics and the Gentamycin and Clindamycin were discontinued. Her fundal tenderness was improved. She was continued on Keflex for cellulitis. Her incision was noted to have an area of fluctuance and it was probed with a sterile q-tip. It drained purulent material. A wound culture was sent and a bedside incision and drainage was completed. The fascia was found to be intact but the fluid collection was explored and drained 30cc's of purulent material. The wound was packed wet to dry. The wound nurse was consulted and agreed with the plan to pack incision wet to dry. She was continued on Keflex and the wound culture was c/w pan-sensitive staph aureus. She was discharged home on Keflex with ___ for BID dressing changes.
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10536763-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Nausea and vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G3P2 at 23w5d by 23w3d US and unknown LMP presents with persistent nausea, vomiting and inability to tolerate PO since ___. Was initially seen on ___ in ED for nausea/vomiting after a night of drinking alcohol and found to be 23w3d pregnant by US. Transferred to OB triage with reassuring evaluation. Today, presented to ED with persistent nausea/vomiting. Transferred to OB Triage for evaluation. States nausea and vomiting has persisted since last visit. Has vomited ___ times today and unable to tolerate PO. Denies abdominal pain, fever, chills, sick contacts, diarrhea. Reports constipation with last BM 5 days ago. Of note, patient had not yet had first prenatal visit. <PAST MEDICAL HISTORY> POBHx: G3P2 - G1: ___ SVD boy at 40wks, 7 lbs 14oz. No GDM. - G2: ___ SVD boy at 41wks. 8 lbs c/b GDMA1 PGynHx: Denies history of STD's, abnormal paps, uterine procedures or instrumentation. PMHx: depression, anxiety (self-dc'd meds prior to first pregnancy, denies depression/SI today). PSHx: none <SOCIAL HISTORY> ___ <FAMILY HISTORY> Not contributory <PHYSICAL EXAM> Upon arrival General: NAD, comfortable Cardiac: RRR Pulm: CTAB Abdomen: soft, nontender, nondistended, no rebound or guarding Extremities: No edema, nontender SVE: Deferred Upon discharge No acute distress RRR no m/r/g CTAB ABD S/NT/ND <PERTINENT RESULTS> ___ 01: 58PM PLT COUNT-166 ___ 01: 58PM NEUTS-78.3* LYMPHS-12.0* MONOS-9.4 EOS-0.1 BASOS-0.3 ___ 01: 58PM WBC-9.2 RBC-3.89* HGB-12.1 HCT-36.0 MCV-93 MCH-31.0 MCHC-33.5 RDW-13.1 ___ 01: 58PM CALCIUM-8.6 PHOSPHATE-2.8 ___ 01: 58PM LIPASE-24 ___ 01: 58PM ALT(SGPT)-49* AST(SGOT)-52* LD(LDH)-165 ALK PHOS-64 TOT BILI-1.1 ___ 01: 58PM GLUCOSE-84 UREA N-11 CREAT-0.5 SODIUM-140 POTASSIUM-2.8* CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 ___ 04: 35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 04: 35AM URINE HOURS-RANDOM ___ 05: 55AM ALBUMIN-3.4* CALCIUM-7.9* PHOSPHATE-1.5* MAGNESIUM-1.9 ___ 05: 55AM GLUCOSE-101* UREA N-8 CREAT-0.4 SODIUM-135 POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-24 ANION GAP-11 ___ 10: 35AM HCV Ab-NEGATIVE ___ 10: 35AM HIV Ab-NEGATIVE ___ 10: 35AM TSH-0.92 RUQ U/S showed cholelithiasis with no evidence of cholecystitis <MEDICATIONS ON ADMISSION> Prenatal vitamins <DISCHARGE MEDICATIONS> 1. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tablet by mouth q6hrs Disp #*30 Tablet Refills: *2 2. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth q6hrs Disp #*30 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> suspected viral transaminitis Blood work up still pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted into the ___ service for work up fo nausea, vomiting and transaminitis * You have been stable with no emesis and tolerating oral intake so the team feels that you are safe to discharge home
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Ms. ___ was admitted into the antepartum service for observation given evidence of transaminitis with no obvious source. Her RUQ showed cholelithiasis but no evidence of cholecystitis. She had normal Tbili and negative Hep C and HIV testing. Her liver enzymes were trended in house and became stable prior to discharge. She was given anti-emetics and placed on maintenance IV fluids until she was able to tolerate a regular diet. She had TORCH titers and bile acids ordered to evaluate for unusual causes of transaminitis. She was discharged in good condition and was asked to follow up at ___ for routine prenatal care.
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10540275-DS-6
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<SEX> M <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / Demerol / Penicillin V <ATTENDING> ___ <CHIEF COMPLAINT> gender identity disorder <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopy hysterectomy bilateral salpingo-ophorectomy extensive lysis of adhesions vaginal septum removal <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 0 transgender man, who presents requesting hysterectomy, removal of ovaries and fallopian tubes in order to continue his transition. The patient has been on testosterone for greater than a year. Last menstrual period was in ___. He denies any abnormal bleeding since beginning testosterone. He notes that he has known that he had wanted to transition for several years now. He is not interested in future childbearing or harvesting eggs. He notes that his mom, friends from school, and his partner are very supportive. Presently, he is in ___ school at ___. He also works outside of his home in ___. The patient had a history of abnormal bleeding and was placed on combination of birth control, Yaz. From this, he developed acute pancreatitis from elevated triglycerides which reached levels in the 900s at age ___. She had a history of PCOS that was diagnosed at age ___. <PAST MEDICAL HISTORY> OBSTETRICAL/GYNECOLOGICAL HISTORY: Menarche at ___. Prior to hormonal therapy, he had heavy menses and dysmenorrhea. Last Pap was in ___ and was normal. He tested negative for the high-risk HPV. The patient describes the sexual orientation as pansexual. He is not sexually active at present. First intercourse at age ___. He has never had a pregnancy or sexually transmitted infection. He was diagnosed as having a transverse vaginal septum at age ___. He has had issues in the past when he was bleeding, placing and removing tampons. He has never had a pregnancy. MEDICAL HISTORY: Acute pancreatitis that resulted in hospitalization, diabetes, GERD, history of recent pilonidal cyst that was recently incised. OPERATIVE HISTORY: Bilateral mastectomy in ___, appendectomy with removal of approximately 8 inches of intestine secondary to complications related to his appendicitis. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Positive for gestational diabetes, ___ syndrome. Negative for any female cancers <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <MEDICATIONS ON ADMISSION> metformin 1000 mg BID, depot testosterone 80 mg IM weekly <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 #*40 Tablet Refills: *1 2. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain may cause drowsiness. take with stool softener RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills: *1 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. GlipiZIDE 5 mg PO DAILY RX *glipizide 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills: *0 6. FreeStyle Lite Strips (blood sugar diagnostic) 1 miscellaneous prn RX *blood sugar diagnostic [FreeStyle Lite Strips] strips as needed Disp #*100 Strip Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> gender identity disorder <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear 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. While inpatient, you requested that your metformin be stopped due to gastrointestinal side effects you have been having while on it. Diabetes was consulted who recommended that you be switched to glipizide. Please check your fingersticks when you wake up and at night. 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. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Mr. ___ was admitted to the gynecology service after undergoing total laparoscopy hysterectomy, bilateral salpingo-ophorectomy, extensive lysis of adhesions, vaginal septum removal. 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 PO oxycodone, motrin and tylenol. Patient requested to stop metformin given the GI side effects he had been having. After curbsiding with ___ Diabetes, he was switched to Glipizide 5mg daily. By post-operative day 1, he was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. He was then discharged home in stable condition with outpatient follow-up scheduled.
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10540275-DS-7
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<SEX> M <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / Demerol / Penicillin V <ATTENDING> ___ <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> correction: the vaginal septum was removed on ___. he presented bleeding from the base of the removed septum PROCEDURE: EUA, suturing of the base of the vaginal septum <HISTORY OF PRESENT ILLNESS> ___ yo G0 transgender man now POD# 3 from TLH, BSO, LOA, and resection of vaginal septum for gender realignment surgery presenting c/o passing clots at home. States that he was straining on the toilet when he started to pass clots, heavily, which has continued since. Also intermittently feels lightheaded. Not dizzy, SOB, DOE, chest pain, or feeling faint. Some nausea, but tolerating small amounts of PO today. + flatus, no bowel movement <PAST MEDICAL HISTORY> GYN HISTORY: LMP: ___ MENARCHE: ___ yo Denies h/o abnl Pap, STI, other surgery OB HISTORY: G: 0 PAST MEDICAL HISTORY: - Diabetes - h/o Pancreatitis - GERD PAST SURGICAL HISTORY: - I&D pilonidal cyst - bilateral mastectomy - appendectomy c/b bowel resection - TLH, BSO, LOA, vaginal septum resection, cysto <SOCIAL HISTORY> ___ <FAMILY HISTORY> Positive for gestational diabetes, ___ syndrome. Negative for any female cancers <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> ___ 09: 20AM WBC-11.6* RBC-4.02* HGB-12.8 HCT-36.3 MCV-90# MCH-31.9# MCHC-35.2* RDW-12.8 ___ 09: 20AM PLT COUNT-285 ___ 10: 55PM WBC-8.3 RBC-4.91 HGB-13.8 HCT-37.8 MCV-77* MCH-28.1 MCHC-36.6* RDW-13.8 ___ 10: 55PM NEUTS-75.3* LYMPHS-15.5* MONOS-6.0 EOS-3.1 BASOS-0.2 ___ 10: 55PM PLT COUNT-203 ___ 10: 55PM ___ PTT-32.0 ___ ___ 10: 55PM ___ <MEDICATIONS ON ADMISSION> glypizide, oxycodone, colace, testosterone <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain 2. GlipiZIDE 5 mg PO DAILY 3. Ibuprofen 600 mg PO Q6H: PRN pain 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain not treated by tylenol/motrin may cause drowsiness. take with stool softener <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal septum bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You were admitted to the gynecology service after 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. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Mr. ___ was admitted to the gynecology service after presenting with vaginal bleeding and undergoing suturing of the base of the resected vaginal septum. Please see the operative report for full details. His post-operative course was uncomplicated. His diet was advanced without difficulty and his pain was controlled with tylenol, motrin and oxycodone. His foley was removed on POD#0 and he voided spontaneously. His HCT remained stable at around 36. By post-operative day 0, 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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10541011-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Retained products of conception <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilation and curettage, diagnostic laparoscopy converted to exploratory laparotomy <HISTORY OF PRESENT ILLNESS> This is a ___, G4, P ___, 7 weeks postpartum, status post SVD, who presented with continued vaginal bleeding at 6 weeks. An ultrasound was performed at an outside facility showing 4.5 cm of retained products of conception. The patient was counciled on her options including spontaneous passage, Misoprostol-induced passage, or ultrasound-guided D and C. After discussion of the risks and benefits, decision was made with the patient that success of removal was most likely through ultrasound-guided D and C. <PAST MEDICAL HISTORY> PMH: Hypothyroidism PSH: wisdom teeth removal <SOCIAL HISTORY> ___ <FAMILY HISTORY> N/A <PHYSICAL EXAM> PHYSICAL EXAM ON DISCHARGE: Vital signs: T 98.7 BP 92 / 58 HR 65 RR 16 SpO2 96% RA General: NAD, comfortable CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, incision/dressing clean/dry/intact GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 05: 50PM BLOOD WBC-3.9* RBC-2.90* Hgb-9.2* Hct-28.1* MCV-97 MCH-31.7 MCHC-32.7 RDW-12.8 RDWSD-44.9 Plt ___ ___ 09: 05PM BLOOD WBC-10.9*# RBC-3.34* Hgb-10.7* Hct-31.5* MCV-94 MCH-32.0 MCHC-34.0 RDW-14.5 RDWSD-49.6* Plt ___ ___ 10: 35PM BLOOD WBC-13.4* RBC-3.40* Hgb-10.7* Hct-32.1* MCV-94 MCH-31.5 MCHC-33.3 RDW-14.7 RDWSD-51.0* Plt ___ ___ 06: 15AM BLOOD WBC-9.6 RBC-2.90* Hgb-9.3* Hct-27.0* MCV-93 MCH-32.1* MCHC-34.4 RDW-15.2 RDWSD-52.0* Plt ___ ___ 01: 10PM BLOOD WBC-6.5 RBC-2.55* Hgb-8.0* Hct-23.8* MCV-93 MCH-31.4 MCHC-33.6 RDW-15.1 RDWSD-51.8* Plt ___ ___ 05: 35PM BLOOD WBC-5.1 RBC-2.37* Hgb-7.5* Hct-22.4* MCV-95 MCH-31.6 MCHC-33.5 RDW-15.1 RDWSD-52.1* Plt ___ ___ 09: 05PM BLOOD Glucose-130* UreaN-8 Creat-0.6 Na-139 K-4.2 Cl-107 HCO3-24 AnGap-8* ___ 09: 05PM BLOOD Calcium-7.3* Phos-3.6 Mg-1.4* ___ 06: 15AM BLOOD WBC-9.6 RBC-2.90* Hgb-9.3* Hct-27.0* MCV-93 MCH-32.1* MCHC-34.4 RDW-15.2 RDWSD-52.0* Plt ___ ___ 01: 10PM BLOOD WBC-6.5 RBC-2.55* Hgb-8.0* Hct-23.8* MCV-93 MCH-31.4 MCHC-33.6 RDW-15.1 RDWSD-51.8* Plt ___ ___ 05: 35PM BLOOD WBC-5.1 RBC-2.37* Hgb-7.5* Hct-22.4* MCV-95 MCH-31.6 MCHC-33.5 RDW-15.1 RDWSD-52.1* Plt ___ ___ 05: 25AM BLOOD WBC-4.7 RBC-3.09*# Hgb-9.7*# Hct-28.2*# MCV-91 MCH-31.4 MCHC-34.4 RDW-15.2 RDWSD-50.7* Plt ___ <MEDICATIONS ON ADMISSION> Levothyroxine 25 mcg <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4000 mg in a day 2. Docusate Sodium 100 mg PO BID constipation Take this medication while taking narcotics. Hold for loose stools. 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Do not exceed 2400 mg in a day. Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 hrs Disp #*40 Tablet Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Reason for PRN duplicate override: Alternating agents for similar severity Do not drink and drive. ___ cause sedation. Partial fill upon request RX *oxycodone 5 mg 1 tablet(s) by mouth q ___ hrs Disp #*10 Tablet Refills: *0 5. Levothyroxine Sodium 25 mcg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Retained products of conception, uterine perforation, acute blood loss anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 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 for two weeks * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the GYN service after undergoing a dilation and curettage for retained products of conception, diagnostic laparoscopy converted to exploratory laparotomy given surgical bleeding secondary to posterior wall perforation. Please see operative report for details of procedure. *)Postoperative course Immediately postoperatively her pain was controlled with a TAP block, IV dilaudid, and toradol. On postoperative day 1, her diet was advanced to regular and she was transitioned to PO oxycodone, ibuprofen, and acetaminophen for pain control. She had adequate urine output, so her foley was removed and she voided spontaneously on postoperative day 1. By postoperative day 2, she was tolerating a regular diet, ambulating, voiding, and her pain was controlled with PO pain medications. She was deemed stable for discharge. *)Acute Blood Loss Anemia Patient had a CBC drawn intraoperatively which returned with a hematocrit of 28.1. She received 2 units of packed red blood cells intraoperatively. Her hematocrit was then a 31.5 postoperatively in the PACU. On postoperative day 1, her hematocrit drifted down to 27->23->22. In the evening, she was complaining of lightheadedness and palpitations. Her hematocrit was a 22.4, and she received an additional 2 units of packed red blood cells. The next morning her hematocrit returned 28.2. She was normotensive and not tachycardic and was then discharged on postoperative day 2. *)Hypothyroidism Patients home dose of levothyroxine was continued *)Venous thromboembolism prophylaxis Patient had pneumoboots on during her hospital stay and use the incentive spirometer.
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10541950-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Painful ctx <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo G4P1 at 38+6 p/w painful Ucx q ___ min x past 2 hours. Previously contracting irregularly throughout the day, became more painful and intense in the afternoon. Pt had called in, was told to wait unitl Ucx q 5 min. Denies LOF. On wiping herself in the bathroom noted blooddy mucous. + FM PNC: 1. Dating: EDC: ___ by LMP = 6 wk u/s 2-Labs: B pos/Ab neg / RPRNR / RI / HBSAg neg / HIV neg / GC/CT neg / GBS neg 3-U/S: ant placenta, nl FFS 4- Fetal S<D - Last EFW ___ 2311 15% 5- routine: GLT 121, no genetic screening <PAST MEDICAL HISTORY> POBHx: SAB first trimester x 1 TAB first trimester x ___ at 35 wks gestation x 1 current GYNHx: LMP regular, distant abnl pap, colpo, most recent wnl PMH: - Asthma - PPD+, CXR neg, s/p INH x 7 mo SurgHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> PE: T98.6 HR 86 RR 18 BP 135/82 NAD CTA bilaterally RRR Abd soft, gravid, NT SVE: ___ / 75% / -2, + BOW FHT: 125 / mod / + Accel Toco: q ___ min <PERTINENT RESULTS> CBC 21.8>11.5/33.3<282 UA neg <MEDICATIONS ON ADMISSION> PNV, Zantac <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp: *60 Capsule(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4-6H () as needed. Disp: *30 Tablet(s)* Refills: *0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *60 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> spontaneous vaginal delivery <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your physician if you have bleeding > 1 pad per hour, severe pain, fevers, chills, or any other concerns. Do not place anything per vagina x 6 weeks Do not drive while taking narcotic pain medications Keep all your appointments
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___ G4P1 presented in labor. Pt had uncomplicated labor and vaginal delivery. Her postpartum course was also uncomplicated and she was discharged on PPD#1 in stable condition to follow up at ___.
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10542874-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Shellfish Derived <ATTENDING> ___ <CHIEF COMPLAINT> Menorrhagia, fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salphingo-oopherectomy, cytoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G0 with longstanding h/o fibroids and menorrhagia presents for pre-operative appt for TAH-BSO. She also complains of N/V and diarrhea with her periods. She has a h/o painful ovarian cysts and also wishes to have her ovaries removed. She notes some hot flashes on occasion. <PAST MEDICAL HISTORY> GYNHx: - LMP ___ - denies h/o abnl pap, last pap ___ neg - Denies h/o STI - not sexually active - female partners ___: GO PMH: Mild asthma, chronic back pain - disc degeneration, GERD, Depression, Insomnia PSH: Liposuction - stomach and thighs <SOCIAL HISTORY> ___ <FAMILY HISTORY> biological mother with colon CA, DM in ___, Stroke in ___. Sister with brain aneurysm. <PHYSICAL EXAM> At pre-op appt: BP 120/68, Wt 195 NAD, A&Ox3 no thyromegaly, no LAD RRR CTAB soft, NT, fibroid uterus palpable at 3cm above umb on right and at umb midline and on left, NT NT, NE <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> advair prn, albuterol prn, prilosec <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. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *3* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp: *60 Capsule, Delayed Release(E.C.)(s)* Refills: *2* 5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. Disp: *60 Tablet(s)* Refills: *2* 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath. 7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). <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), 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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Mrs. ___ underwent uncomplicated TAH/BSO and cystoscopy on ___. Full operative note available in OMR. She had a TAP block in the PACU. She did extremely well post-operatively. She walked on POD#0, her diet was advanced to regular, she passed her trial of void, and she was able to take oral pain medications. She was discharged home in good condition on POD#2.
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10542874-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Shellfish Derived <ATTENDING> ___. <CHIEF COMPLAINT> Incisional pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Scar injection <HISTORY OF PRESENT ILLNESS> ___ s/p TAH/BSO on ___ who presented to ED with abdominal pain x 10d. Pain started after having large BM 10d ago - she stood up from the toilet and was instantly doubled over in pain. It was the first BM since before her surgery. The pain at that time was deep abdominal in location and has overall improved since that time, turning into the what she describes as "gas pain". She has had 2 BM since that time, ___ ago and again 2 days ago. She has been taking colace BID. She started having burning pain on her ___ skin and "about 4 layers deep to the skin" in the same area roughly 8 days ago. "It feels like my skin is on fire." Touching her skin exacerbates the pain. She reports that even when sleeping, when her sheets touch the ___ skin, it wakes her from sleep. She is unable to wear underpants or pants ___ to pain. She has never experienced this before; she recovered well after her liposuction procedure. + nausea when pain is worst, denies emesis. Tolerating liquids, pudding, and yogurt. Passing flatus. Denies fevers, chills, abnormal vaginal discharge or bleeding. Has had occasional hot flashes and vaginal dryness. Not sexually active. In the ED, she received morphine 8mg IV, zofran 4mg IV, and dilaudid 0.5 IV. The dilaudid has had the best effect. She had 2L of NS. <PAST MEDICAL HISTORY> GYNHx: - denies h/o abnl pap, last pap ___ neg - Denies h/o STI - female partners ___: GO PMH: Mild asthma, chronic back pain - disc degeneration, GERD, Depression, Insomnia PSH: - TAH BSO as above - Liposuction x 2, ___ - stomach and thighs <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On admission: VS: 98.9 67 112/70 16 98RA uncomfortable appearing RRR CTAB abd - soft, mildly distended +tympany, esp in upper quadrants; mostly TTP in 5cm circumferential area around incision, from below umbilicus to the mons. no crepitus. no cutaneous numbness. inc: Pfannensteil, well healed, partially epithelialized, no erythema, exudates, or induration ext NT b/l pelvic: deferred <PERTINENT RESULTS> ___ 07: 15PM BLOOD WBC-6.3 RBC-4.60 Hgb-10.3* Hct-33.8* MCV-74* MCH-22.5* MCHC-30.6* RDW-14.1 Plt ___ ___ 06: 20AM BLOOD WBC-5.4 RBC-4.25 Hgb-9.8* Hct-32.3* MCV-76* MCH-23.0* MCHC-30.2* RDW-13.9 Plt ___ ___ 07: 15PM BLOOD Neuts-61.0 ___ Monos-3.5 Eos-3.5 Baso-0.5 ___ 07: 15PM BLOOD Glucose-101* UreaN-9 Creat-0.9 Na-137 K-4.3 Cl-102 HCO3-27 AnGap-12 ___ 06: 20AM BLOOD Glucose-90 UreaN-13 Creat-1.0 Na-137 K-4.4 Cl-100 HCO3-28 AnGap-13 ___ 06: 20AM BLOOD Calcium-9.8 Phos-4.0 Mg-2.2 ___ 02: 58AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR ___ 02: 58AM URINE RBC-2 WBC-0 Bacteri-NONE Yeast-NONE Epi-22 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. CT ___: IMPRESSION: No definite intra-abdominal abscess. There is a small amount of fluid at the operative site, not unanticipated. <MEDICATIONS ON ADMISSION> percocet prn, colace, prilosec <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. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp: *90 Capsule(s)* Refills: *2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp: *60 Tablet, Delayed Release (E.C.)(s)* Refills: *0* 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp: *90 Capsule(s)* Refills: *2* 7. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) patch Topical DAILY (Daily): Keep on for 12 hours, off for 12 hours . Disp: *20 patch* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cutaneous neuropathy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for nerve pain around your incision. You received an injection of an anesthetic and steroid which helped lessen the pain. We started you on a medication called gabapentin which should start to work in a few days. You also were given lidocaine patches to put on your skin and a narcotic called dilaudid to help lessen the pain until the steroid medication starts to work. You should also continue to take Ibuprofen and colace. It is important to drink lots of fluid to help keep your stools soft.
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Ms. ___ was admitted from the ED early on ___ with abdominal pain and incisional pain. CT had demonstrated no acute intraabdominal process. Her pain was felt to be consistent with post-operative neuropathy. She was started on tylenol, motrin, and dilaudid prn for pain. She was started on a bowel regimen. The chronic pain service saw her later that morning and performed an incisional injection with steroids and bupivicaine. She was also started on gabapentin. She had some immediate relief of her pain, however the majority of the benefit wore off after several hours. Lidocaine patches were applied with excellent relief. She reported a good decrease in her pain where she was able to tolerate some touch and the feel of clothing/blankets on her skin. She did remain constipated, but felt ready for discharge home on ___. Follow-up with the chronic pain clinic was arranged.
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10543031-DS-11
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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 ___, last menstrual period, ___, who continues to have increased uterine cramping and heavy bleeding. Of note, her endometrial biopsy done on ___, showed Fragments of late secretory inactive endometrium with stromal breakdown. The patient has considered the options for her symptomatic fibroid uterus and wants definitive therapy in the form of a supracervical hysterectomy. We discussed the fact that her last Pap was negative for intraepithelial lesion or neoplasia and she also tested negative for the high-risk HPV. The patient does know, however, that this could change in the future and she may need treatment of her cervix. We also discussed the benefits versus risks of the removal of her fallopian tubes and the patient would like preservation of both the fallopian tubes and ovaries if they appear normal. There has been no change in this ___ medical, operative, social, family history since I saw her on ___. Of note, the two procedures that she had neither involved entering the intraperitoneal cavity. On ___, she had a cervical cerclage placed at ___ weeks of cervical insufficiency and on ___, she had a perineal vaginal fissure repair. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 13. She cycles monthly. She notes dysmenorrhea as well as dyspareunia, which has not resolved with nonsteroidal anti-inflammatories. Patient has remote history of abnormal Pap smears status post laser therapy and she has had normal Paps since that time. Patient has a history of chlamydia and warts. She has had three pregnancies. ___ premature birth at 29 weeks, ___, vaginal birth at 33 weeks, she had a first trimester termination of pregnancy. PMH: anemia, vitD def, sarcoidosis PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Diabetes, breast cancer in her great grandmother, maternal side, hypertension, glaucoma. <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> MVI, zyrtec <DISCHARGE MEDICATIONS> 1. Cetirizine 10 mg PO DAILY 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *1 3. 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 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing supracervical hysterectomy for symptomatic fibroid uterus. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO percocet and motrin. 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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10546928-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P1 at ___ transferred from ED to triage for eval of persistent HA ___ since ___ evening after altercation with family member on the phone. Has tried Tylenol x 1 last night with no relief. Denies any visual changes, RUQ or epigastric pain, CP/SOB. No other abdominal pain or vaginal bleeding. No fever/chills, dysuria, abnormal vaginal discharge. Denies any contractions or leakage of fluid. + active FM. Denies illicit drug use. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP - Labs Rh +/Abs -/Rub I/RPR NR/HBsAg -/HIV -/GBS unk - Screening LR ERA - FFS wnl, normal fetal echo - US ___ 56% ___ - Issues: T1DM Regimen 20 Levemir qhs / Novolog ___ with meals, followed by ___ ___: - G1 SVD 6 lbs 11 oz; Term. - G2 current GynHx: - h/o abnormal Pap s/p colpo - denies fibroids, Gyn surgery, STIs PMH: - T1DM s/p pancreatitis after first child, normal optho exam - denies HTN, Asthma PSH: - LSC cholecystectomy <SOCIAL HISTORY> denies tobacco/alcohol/illicit drug use <PHYSICAL EXAM> Admission: VS: 97.6 100 18 BP 125/85 -> 105/60 Gen: A&Ox3, uncomfortable with HA HEENT/Neuro: PERRL, CN ___ intact, strength ___ grossly in upper and lower extremities. sensations grossly intact. neg pronator drift test, normal finger nose test. CV: RRR PULM: CTAB Abd: soft, gravid, nontender, no RUQ TTP back: no CVAT Ext: no calf tenderness, no edema, no clonus, patellar reflexes 2+ TAUS: vtx, MVP 2.8 cm, + breathing, movement, tone SVE: deferred Toco occ ctx FHT 140/moderate variability/+accels/-decels <PERTINENT RESULTS> ___ 07: 24AM BLOOD WBC-15.0* RBC-3.96 Hgb-11.5 Hct-34.2 MCV-86 MCH-29.0 MCHC-33.6 RDW-13.3 RDWSD-41.2 Plt ___ ___ 06: 32AM BLOOD WBC-18.8* RBC-3.87* Hgb-11.0* Hct-33.7* MCV-87 MCH-28.4 MCHC-32.6 RDW-13.6 RDWSD-42.4 Plt ___ ___ 07: 24AM BLOOD Glucose-155* UreaN-5* Creat-0.4 Na-135 K-3.9 Cl-103 HCO3-19* AnGap-17 ___ 06: 32AM BLOOD UreaN-5* Creat-0.4 ___ 07: 24AM BLOOD ALT-12 AST-20 Amylase-112* ___ 06: 32AM BLOOD ALT-12 AST-19 ___ 06: 32AM BLOOD UricAcd-4.6 ___ 08: 34AM URINE Color-Straw Appear-Hazy Sp ___ ___ 08: 34AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD ___ 08: 34AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-1 ___ 10: 40AM URINE pH-6 Hours-24 Volume-4375 Creat-31 TotProt-6 Prot/Cr-0.2 ___ 08: 34AM URINE Hours-RANDOM Creat-22 TotProt-<6 Prot/Cr-<0.3 ___ 10: 40AM URINE 24Creat-___ 24Prot-263 . ___ 1: 08 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 sensitivity testing to clindamycin is required on this patient's isolate. <MEDICATIONS ON ADMISSION> PNV, 20 Levemir qhs / Novolog ___ with meals, iron, colace <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Humalog 12 Units Breakfast Humalog 12 Units Lunch Humalog 13 Units Dinner Levemir 26 Units Bedtime <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 34w1d type 1 diabetes <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum floor for observation after you presented with a severe headache. Your headache resolved and you had no evidence of preeclampsia. You received a course of betamethasone for fetal lung maturity which made your fingersticks elevated. ___ followed you while you were here and made changes in your insulin regimen. Fetal testing was reassuring during this admission. Your insulin plan at home: Take 12 units of Humalog at breakfast Take 12 units of Humalog at lunch Take 13 units of Humalog at dinner Take 26 units of Levemir at bedtime
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___ G2P1 at 33w3d with type 1 diabetes mellitus admitted to the ___ service on ___ with persistent severe headache and concern for pre-eclampsia. She remained normotensive other than occasional diastolic blood pressures of 90 with no clinical evidence of stroke or meningitis. She received magnesium for 24 hours for seizure prophylaxis. Her lab results were reassuring and her 24 hour urine protein was negative. She was given APAP, Compazine and IV hydration with improvement in headache severity and her headache resolved on hospital day 2. . She also has a history of pancreoprivic diabetes s/p severe pancreatitis and takes mealtime and bedtime insulin at home. Her blood glucose was monitored in the hospital and ___ followed her throughout her hospital stay with their recommendations for insulin regimen. She completed a course of betamethasone on ___ and had several insulin regimen adjustments during this process. Her blood glucose control improved prior to discharge and she was discharged with a new home insulin regimen as recommended by ___. . On admission, she had reassuring fetal status with reactive NST, modified BPP. However, on ___, she had a non-reactive NST and ___ BPP at bedside. She was rescanned at the ___ maternal-fetal medicine for a BPP of ___ and AFI 5.2, which was significantly decreased from her prior AFI. She did not have any evidence of rupture of membrane on exam. On ___, she again had a non-reactive NST with a bedside BPP of ___ for lack of fetal breathing. On ___, she again had non-reactive NST with BPP ___ at the ___ maternal fetal medicine and was sent to Labor & Delivery for prolonged monitoring. She had ___ BPP at bedside and returned to the antepartum floor. On ___, she had a BPP at the ___ maternal-fetal medicine with AFI of 12.2 cm. She was discharged home in stable condition with outpatient follow up.
| 1,303
| 406
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10548280-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> High bp medication / Percocet / codeine <ATTENDING> ___. <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> total vaginal hysterectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___ ___, ___ menopausal para 2, with a history of heavy irregular periods. Ultrasound showed a uterus with multiple small intramural fibroids ___ weeks size. Her bleeding became increasingly problematic over time, causing great disruption to activities of daily living and quality of life. She did actually undergo hysteroscopy and polypectomy with minimal improvement. She attempted daily progesterone with no improvement. She was not an estrogen candidate given hypertension and migraine history. She previously had an IUD and had complication with malposition. She has significant mood difficulties and further hormonal trials were suspected to be problematic with complication of her mood difficulties. After discussion of options including ablation and hysterectomy, she desired definitive surgical management in the form of hysterectomy. By exam and clinical history, she was deemed a candidate for a vaginal approach. <PAST MEDICAL HISTORY> OB/GynHx: SVD x2, fibroids PMH: anemia, depression, migraines, HTN PSH: TAB via D&C, tubal ligation, hysteroscopy and polypectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Gen: NAD, comfortable CV: RRR Lungs: CTAB Abd: soft, non-distended, +BS GU: voiding spontaneously, minimal spotting on pad Ext: non-tender <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. BuPROPion 300 mg PO DAILY 2. ClonazePAM 1 mg PO TID 3. Duloxetine 120 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO BID 5. Propranolol 80 mg PO DAILY 6. Sumatriptan Succinate 100 mg PO DAILY PRN migraines <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID Take with narcotics to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *3 2. 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 3. BuPROPion 300 mg PO DAILY 4. ClonazePAM 1 mg PO TID 5. Duloxetine 120 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO BID 7. Propranolol 80 mg PO DAILY 8. Sumatriptan Succinate 100 mg PO DAILY PRN migraines 9. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain Do not drive while taking. RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills: *0 10. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4000 mg acetaminophen in 24 hrs. RX *acetaminophen 500 mg ___ tablet(s) by mouth pain Disp #*30 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet * No bath tubs for 6 weeks, no restrictions on showering. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms ___ underwent an uncomplicated total vaginal hysterectomy; please see operative report for details. She had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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| 62
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10548397-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> weight loss and decreased appetite <MAJOR SURGICAL OR INVASIVE PROCEDURE> diagnostic laparoscopy, drainage of ascites (6L), peritoneal biopsy, concerning for possible recurrent breast CA <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ woman with a history of having had breast cancer ___ years ago. She reports that in ___, she began to feel bloated. A CT scan was performed, which revealed mild pancreatic inflammation but everything else was fine. Over the course of a four-month time period, she reports that she began losing weight and having a decrease in her appetite. In the past, she has had pancreatitis and was admitted for this back in ___. There was a concern for the possibility of this weight loss and this abdominal distention and so over the course of several-month period, she had a number of different imaging studies including CT scans, pelvic ultrasounds, head CTs, and bone scans. A PET CT scan performed in ___ revealed increased uptake in T11 the vertebral body. Also noted was a moderate amount of ascites. A CT scan reveals no evidence of any abnormality and pelvic ultrasounds have revealed a normal uterus and no adnexal masses have been visualized; however, the ovaries were not clearly seen, ascites was clearly demonstrated. A paracentesis was eventually performed, which initially did not reveal any malignant cells. Tumor markers revealed a normal CEA level and an elevated CA-125 level of 343, a ___ is elevated at 133. Pelvic fluid was sent for cytology at the end of ___ and this was positive for malignant cells. The immunohistochemistry supported diagnosis of metastatic cancer likely of breast origin. With that said, it is not exactly clear that this was the case. She again had five and half liters of ascites removed. She otherwise feels well. She has no complaints or concerns. She has no family history of breast or ovarian cancer beyond the fact that her mother at the age of ___ developed breast cancer and now is ___, is doing well and has no evidence of recurrent disease. With respect to the patient's own history of breast cancer, again, she was treated for stage 1 disease ___ years ago. She had a pea-sized lump on the right side and then calcifications are on the left, these were resected and she received bilateral radiotherapy followed by ___ years of tamoxifen. She denies any postmenopausal bleeding or problems since. REVIEW OF SYSTEMS: She denies fever, but does report a 15-pound weight loss over the course of six months. She reports weakness especially when she has a lot of fluid. HEENT: Denies headaches, visual or hearing changes, epistaxis, dysphasia. Cardiovascular: Denies chest pain, palpitations, or orthopnea. Respirations: Denies cough, dyspnea, or hemoptysis. GI: Does report abdominal discomfort with the ascites and when the ascites becomes tense, she has anorexia. She does deny nausea, vomiting, constipation, diarrhea, melena, change in bowel habits. GU: Denies dysuria, frequency, hematuria, abnormal vaginal bleeding. Musculoskeletal: Denies muscle, bone, or joint pain. Neuro: Denies syncope, paresthesia, or muscle weakness, and reports fatigue, but denies petechiae or spontaneous bleeding. <PAST MEDICAL HISTORY> She has a history of pancreatitis as noted above and breast cancer. She denied any history of asthma, mitral valve prolapse, hypertension, or thromboembolic disorder. She is up-to-date with respect to mammography. She had a tubal ligation after her daughter was born. She has never had any other surgeries. She is a gravida 3, para 2. She denies any history of pelvic infections or abnormal Pap smears. <SOCIAL HISTORY> ___ <FAMILY HISTORY> As above, no other family history of cancer. <PHYSICAL EXAM> GENERAL: The patient 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. LYMPHATICS: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. CHEST: Lungs clear bilaterally. HEART: Regular rate and rhythm. There are no appreciable murmurs. BACK: No spinal or CVA tenderness. ABDOMEN: Soft, nontender, nondistended. Port sites x2 clean dry and intact. EXTREMITIES: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. PELVIC: Normal external genitalia. There is no mass or lesion. The inner labia minora is normal. The urethral meatus is normal. Speculum was placed and normal vaginal canal is seen. There is no mass or lesion, the cervix is normal. The walls of the vagina are smooth. Bimanual exam reveals no submucosal abnormality to the cervix. The uterus feels well suspended and there is no palpable mass, but there is very little mobility, surprisingly little mobility to the uterus. Rectovaginal exam reveals again a little mobility or distensibility of the posterior cul-de-sac, however, I am unable to palpate any nodularity. I am concerned of the possibility that there may be a rind of tumor that is pulling the uterus onto the bladder and causing it to be adherent. There is no parametrial nodularity appreciated. <PERTINENT RESULTS> Peritoneal biopsy pathology pending <MEDICATIONS ON ADMISSION> Nexium <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *60 Tablet(s)* Refills: *2* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4-6H () as needed. Disp: *40 Tablet(s)* Refills: *0* 3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abdominal carcinomatosis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Take all medications as prescribed. No driving while taking narcotic pain medications. Call Dr. ___ if you have fever of 100.4 or higher, increasing abdominal pain, redness around or drainage from your incisions, nausea/vomiting preventing you from drinking fluids, or any other symptoms that worry you. Try to eat a soft diet with limited amounts of fiber/roughage.
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The patient underwent exploratory laparoscopy on ___ for details, please see the dictated operative note. Postoperative course was notable for low UOP ~10cc/hr. She was received IVF @125cc/hr and a 500cc NS bolus for UOP<10, after which she maintained UOP of about 10cc/h. Otherwise did well post-op, no pain nor nausea, and tolerated PO's. She voided spontaneously and was deemed stable for discharge home on POD#1.
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| 104
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10548397-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> nausea/vomiting, inability to keep food/fluids down <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo P2 with history of breast cancer with a recent diagnosis of diffuse peritoneal carcinomatosis from an exploratory laparoscopy on ___ who presents with progressive nausea/vomiting since her surgery on ___. The patient notes worsening nausea/bilious vomiting beginning ___ days ago. The patient has not been able to eat anything over the last ___ days. She has not vomited since last evening. She has been able to have small sips of water. Following her surgery on ___ she tolerated small amounts of jello and soft foods only. She notes that prior to her surgery she had a diet that was similar because she was unable to tolerate large amounts of food secondary to vomiting intermittently. The patient notes abdominal distention prior to and following her surgery. She denies abdominal pain. She has not required any pain medication. She denies fevers, chest pain, shortness of breath, dysuria. She denies headache, diarrhea. She has passed a small amount of medium consistency stool that was non-bloody. The patient's most recent diagnosis of metastatic adenocarcinoma, most likely from her breast cancer, was diagnosed on exploratory Laparoscopy ___. The patient noted increasing distention and noted to have large amount of ascites on a pelvic ultrasound in ___. A subsequent paracentesis of multiple liters of fluid revealed adenocarcinoma on ___. An exploratory laparotomy was performed because the possiblitity of an ovarian or peritoneal cancer could not be ruled out. During the exploratory laparoscopy on ___, diffuse carcinomatosis was found. Biopsies are pending. Per records, her highest Ca-125 was 343, most recently 100 on ___. ED Course: 1 Liter IVF NG tube placed <PAST MEDICAL HISTORY> PMHx: -Breast Cancer Stage 1 ___ years ago s/p lumpectomy and radiation with ___ years of Tamoxifen -Pancreatitis with admission ___ -Metastatic adenocarcinoma with final pathology pending PSHx: Lumpectomy Bilateral Tubal Ligation Exploratory laparoscopy ___ with ascites drainage Paracentesis x 4 with total of approx 22 Liters of fluid removed OBGynHx: Denies abnormal Pap smears, STI. 2 vaginal deliveries <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with history of breast cancer age ___ and living age ___ now. Denies other hx cancer. <PHYSICAL EXAM> Appears uncomfortable with NG tube in place. Breathing comfortably other wise in no acute distress, significant emaciation noted 97.4, 93, 102/73, 18, 100% room air 1Liter in; 1 void, not recorded RRR, Lungs clear anteriorly with decreased breath sounds posteriorly. Abd: distended moderately. Non-tender, no peritoneal signs. Port site Incisions at umbilicus and laterally dressed without erythema seen. Ext: non-tender, no edema Labs: Urine ___ WBC, ep ___, neg nitrites, 15 ketones 8.2 WBC (0 bands) HCT 40/.9, PLT 388 ALT 29 AST 35 Lipase 100 INR 1.0, ___ normal Lytes: ___ <MEDICATIONS ON ADMISSION> Nexium <DISCHARGE MEDICATIONS> 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp: *90 Tablet, Chewable(s)* Refills: *2* 2. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: ___ MLs PO QID (4 times a day) as needed. Disp: *1 bottle* Refills: *2* 3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> recurrent breast cancer <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. - Please call if you have any questions/concerns.
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The patient was admitted for possible SBO. She had an NGT placed in the ED, and a CT scan was performed that did not show any evidence of bowel obstruction. Over the course of HD#1 and 2, the patient felt much improved, and the NGT was removed. She was started on sips and advanced without problems to a regular diet to which she is accustomed at home prior to surgery on ___. She was passing gas and having loose, small bowel movements. She was discharged home on HD#3 without nausea/vomiting, and with follow up arrangements to start chemotherapy with Dr. ___ ___ for what the pathology shows to be metastatic breast cancer.
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10548792-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> decreased FM, fever of unknown origin, new onset rash <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ line <HISTORY OF PRESENT ILLNESS> ___ yo G4P1 at ___ GA who presents with complaints of decreased fetal movement, intermittent fevers, and new onset rash. Patient reports that she had not felt nearly as much fetal movement over the past day; this has resolved in ob triage. She also reports intermittent fevers to a maxiumum of 102.1 F at 1am today, for which she has been taking tylenol with relief of symptoms. She endorses some diarrhea, but otherwise denies URI sxs, n/v, or feeling ill. She also notes that this morning she had appearance of a large rash on her right buttocks and sacrum that is tender to palpation, preventing her from lying on that side. Denies vaginal bleeding or leaking of fluid. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ by LMP A+/Ab-/RPR NR/RI/HBsAg-/GBS unk - screening: GLT 60, SeqScr low risk - U/S: FFS nl, post plac - Issues: *) hx PEC last pregnancy *) right ovarian cyst 5.9 x 5.4 x 3.6 cm PAST OBSTETRIC HISTORY G4P1021 - TAB x1, SAB x1 - LTCS at 35wks, after failed IOL for gHTN, received PP Mag 4 days after delivery (no Mag during delivery) PAST GYNECOLOGIC HISTORY - denies STIs, abnl paps - ovarian cyst as above - s/p L partial oopherectomy ___ ovarian cyst PAST MEDICAL HISTORY as above + obesity PAST SURGICAL HISTORY - LTCS - R knee surgery s/p MVA - breast reduction - wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> T 96.7 GENERAL: awake, alert, comfortable, husband bedside ABDOMEN: soft, gravid, NT BPP ___, AFI 11cm, vtx ___ ULTRASOUND IMPRESSION: Single live intrauterine pregnancy at 36 weeks 4 days by LMP. Normal AFI. Biophysical profile is ___. S/D ratio of the umbilical artery within normal limits. ___ UPPER EXTREMITY ULTRASOUND IMPRESSION: Findings consistent with extensive cellulitis overlying the right buttock, hip, and thigh, without evidence of abscess. <PERTINENT RESULTS> ___ WBC-9.4 RBC-3.68 Hgb-10.6 Hct-31.7 MCV-86 Plt-211 ___ Neuts-85.1 ___ Monos-4.8 Eos-0.3 Baso-0.2 ___ ESR-97 ___ Glu-91 BUN-8 Cre-0.5 Na-136 K-4.0 Cl-102 HCO3-21 ___ Glu-87 BUN-9 Cre-0.5 Na-136 K-3.9 Cl-103 HCO3-20 ___ ALT-15 AST-15 LD(LDH)-157 AlkPhos-99 TotBili-0.3 ___ ALT-15 AST-15 LD(LDH)-148 AlkPhos-97 TotBili-0.3 ___ Calcium-8.8 Phos-3.3 Mg-2.1 UricAcd-5.8 ___ Calcium-8.6 Phos-3.2 Mg-2.0 ___ BLOOD Vanco-4.0 ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ URINE Hours-RANDOM Creat-170 TotProt-25 Prot/Cr-0.1 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Blood Culture, Routine (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH MRSA SCREEN (Final ___: No MRSA isolated <MEDICATIONS ON ADMISSION> prenatal vitamins iron supplement <DISCHARGE MEDICATIONS> prenatal vitamins iron supplement vancomycin 1.25 mg IV bid <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> pregnancy at 37+0 weeks gestation right thigh/buttock cellulitis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___ services will be available for administration of IV antibiotics for 5 days. Call your doctor with any fevers > 100.4, persistent nausea/vomiting, abdominal pain, leaking of fluid, vaginal bleeding, regular or painful contractions, or decreased fetal movement.
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___ yo G4P1 admitted at ___ GA with decreased fetal movement, fever, and rash; suspected cellulitis. . Ms ___ had reassuring fetal testing on arrival to labor and delivery. She was afebrile and without any abdominal tenderness. She had a normal white blood cell count and an elevated ESR (97). In regards to the suspected cellulitis on her right hip/buttock, ID was consulted and recommended IV Vancomycin to cover for MRSA. Ultrasound of the area showed no evidence of a collection or abscess. She was admitted to the antepartum floor for IV antibiotics and observation. Infectious disease continued to follow her closely. She was maintained on MRSA precautions. The cellulitis improved daily. A PICC line was placed on hospital day #4 and she was discharged home at that time. The Vancomycin trough was low, therefore, her dose was increased to 1.25mg bid prior to discharge. She will continue an additional 5 days of IV Vancomycin and will followup with ID as an outpatient. Of note, two sets of blood cultures were negative and her MRSA screen was negative. She remained afebrile throughout this admission. . Ms ___ has chronic hypertension and her blood pressures were occasional elevated during this admission, thought to be exacerbated by her anxiety. Preeclampsia labs were normal. She was continued on labetolol 100mg bid. . Fetal testing remained reassuring during this admission. She was monitored with daily NSTs. . Ms ___ was discharged home in stable condition on ___. She has ___ services set up and close outpatient followup with infectious disease within one week.
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10548792-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> ovarian mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Total laparoscopic hysterectomy. 2. Bilateral salpingectomy. 3. Right salpingo-oophorectomy. 4. Cystoscopy. <HISTORY OF PRESENT ILLNESS> This is ___ with a history of a borderline tumor of the right ovary that was resected by right ovarian cystectomy at the time of repeat cesarean on ___. This cyst had been seen since ___ on her initial OB ultrasound and enlarged over the course of the pregnancy. The cyst ruptured at the time of cystectomy. Final pathology revealed a mucinous borderline tumor of the right ovary. She has a history of a LSO in ___ after presenting with ovarian torsion. She was last seen by our office ___. She has been lost to follow-up since that time due to insurance issues. She was doing well until ___ when she started having right lower quadrant abdominal pain which is intermittent, worse around her menses. She underwent an ultrasound on ___ revealing a multicystic right ovary with the ovary nearly completely replaced with cysts measuring up to 3.1 cm. The cysts were simple in appearance. The left ovary was not well seen, but there were no abnormalities. She presents to discuss management. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> hypertension. Last mammogram ___. She has never had a colonoscopy or BMD. Past Surgical History: - In ___, she had a right leg surgery with orthopedics. - In ___, she had removal of the hardware at ___. - In ___, she had an open LSO for ? ovarian torsion - In ___, she had a reconstruction of the ear drum at Mass Eye and Ear. - In ___, she had a breast reduction. - She has had 2 cesareans, in ___ and ___, the second with a right ovarian cystectomy (see above). OB/GYN History: G4P2, C/s x 2. Denies h/o STIs, abnl Paps. Last Pap ___ negative. Sexually active, not using contraception. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with breast cancer, living, dx at age ___. Denies family history of GYN cancer. Denies history of colon cancer, VTE. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 08: 10AM BLOOD WBC-7.7 RBC-3.25* Hgb-9.2* Hct-27.4* MCV-84 MCH-28.4 MCHC-33.8 RDW-13.6 Plt ___ ___ 08: 10AM BLOOD Glucose-124* UreaN-14 Creat-0.7 Na-139 K-3.6 Cl-105 HCO3-25 AnGap-13 ___ 08: 10AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.8 <MEDICATIONS ON ADMISSION> hydrochlorothiazide lisinopril <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*50 Capsule Refills: *2 2. Hydrochlorothiazide 25 mg PO DAILY 3. Ibuprofen 600 mg PO Q6H: PRN Pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. Lisinopril 10 mg PO DAILY 5. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking. RX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours Disp #*50 Capsule Refills: *0 6. Lorazepam 0.5 mg PO Q8H: PRN anxiety, muscle spasm Do not drive while taking. RX *lorazepam 0.5 mg 1 tablet(s) by mouth every 8 hours Disp #*20 Tablet Refills: *0 7. 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> benign mass of the ovary <DISCHARGE CONDITION> Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing total laparoscopic hysterectomy, bilateral salpingectomy, right salpingo-oophorectomy, cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and toradol. Her diet was advanced without difficulty and she was transitioned to oxycodone, tylenol, and motrin. She also received ativan for panic attack the evening following her surgery and for persistent anxiety. 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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10548792-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G4P2 POD ___ s/p total laparoscopic hysterectomy, bilateral salpingectomy and right salpingo-ophorectomy for right adenexal mass and history of borderline ovarian tumor presented with fever. Pt reports feeling well since discharge yesterday until this afternoon when she began feeling chills, fever and myalgias. She took her temperature multiple times at home with a Tmax of 102. She reports that overall her pain has been well controlled on oxycodone and tylenol though she was not tolerating ibuprofen well due to GI side effects. She endorses a cough since the surgery but denies any other upper respiratory or constitutional symptoms, SOB, CP. She endorses occasional nausea but has been able to take good PO, no emesis. Her last BM was today and she is passing flatus. She denies any urinary symptoms, vaginal bleeding or abnormal discharge. She does report feeling some pain on her buttocks which is similar to pain she had when she had cellulitis in ___. ROS: per HPI, otherwise negative <PAST MEDICAL HISTORY> OB/GYN Hx: G4P2, C/S x2, Denies h/o STIs, abnl Paps. Last Pap ___ negative, boarderline ovarian tumor PMH: hypertension, anxiety PSH: R leg surgery (___), hardware removal (___), open LSO for ?ovarian torsion (___), ear drum reconstruction (___), breast reduction (___), cesarean x 2, second of which with right ovarian cystectomy ___ and ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with breast cancer, living, dx at age ___. Denies family history of GYN cancer. Denies history of colon cancer, VTE. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, nontender, nondistended, incisions clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 10: 03PM PLT COUNT-239 ___ 10: 03PM NEUTS-68.3 ___ MONOS-5.6 EOS-5.0* BASOS-0.4 ___ 10: 03PM WBC-6.7 RBC-3.77* HGB-10.7* HCT-31.5* MCV-84 MCH-28.5 MCHC-34.1 RDW-13.4 ___ 10: 03PM CALCIUM-9.5 PHOSPHATE-4.1# MAGNESIUM-2.0 ___ 10: 03PM GLUCOSE-105* UREA N-14 CREAT-1.1 SODIUM-136 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 ___ 10: 49PM URINE MUCOUS-RARE ___ 10: 49PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE EPI-5 ___ 10: 49PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR ___ 10: 49PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10: 49 pm URINE Site: CLEAN CATCH Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- <=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 2 S <MEDICATIONS ON ADMISSION> HCTZ, lisinopril, colase, ativan, oxycodone, motrin <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN pain 2. Docusate Sodium 100 mg PO BID: PRN constipation 3. Hydrochlorothiazide 25 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Lorazepam 0.5 mg PO Q8H: PRN anxiety, insomnia 6. OxycoDONE (Immediate Release) ___ mg PO Q6H: PRN pain 7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice daily Disp #*8 Capsule Refills: *0 8. Climara (estradiol) 0.025 mg/24 hr transdermal weekly apply one patch weekly; avoid application to breasts RX *estradiol [Climara] 0.025 mg/24 hour apply one patch to skin weekly Disp #*12 Patch Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> urinary tract infection <DISCHARGE CONDITION> Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service for evaluation of fever, and you were found to have a urinary tract infection. We prescribed you an antibiotic (Macrobid) for this. 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 for 12 weeks after surgery. * No heavy lifting of objects >10 lbs for 4 weeks after surgery. * 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 for evaluation of postoperative fever. Upon admission to the service, she was febrile at 100.4 but defervesed and was subsequently afebrile throughout her course. Her white count was followed daily, and she never had a leukocytosis. Her wounds were intact without concern for cellulitis. Her vaginal cuff was intact without concern for cuff cellulitus. Her urinalysis was clean without evidence of infection. A CT abdomen/pelvis demonstrated normal post-surgical changes. A CXR revealed right lower lobe atelectasis. She also reported not having had a bowel movement since surgery. She was started on a stronger bowel regimen and had a bowel movement prior to discharge. On hospital day #3, her urine culture grew enterococcus and E. coli. She was started on macrobid ___ PO DIB x 5 days. She was discharged home on hospital day #4 in stable condition with appropriate follow up scheduled.
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10552386-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> Labor, macrosomia <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary low transverse cesarean section <HISTORY OF PRESENT ILLNESS> The patient is a ___ G1, who presented at 39 weeks 3 days gestation in labor. She had an ultrasound on ___ for advanced maternal age and was noted to have an EFW greater than 95th percentile at 4631 g. After discussion of the options, patient elected for primary cesarean section. <PAST MEDICAL HISTORY> Pregnancy History: G2 P1 SAB1 TAB0 PMH: hypothyroidism, HSV2, migraines, uterine septum resection, infertility <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Discharge: Gen: NAD, comfortable CV: RRR Resp: breathing comfortably Abd: incision c/d/I, appropriately tender, soft Ext: no TTP <PERTINENT RESULTS> ___ 09: 15AM BLOOD WBC-12.8*# RBC-3.99 Hgb-12.8 Hct-36.6 MCV-92 MCH-32.1* MCHC-35.0 RDW-13.0 RDWSD-43.0 Plt ___ ___ 08: 05PM BLOOD WBC-14.9* RBC-2.74*# Hgb-8.8*# Hct-25.0*# MCV-91 MCH-32.1* MCHC-35.2 RDW-13.1 RDWSD-42.5 Plt ___ <MEDICATIONS ON ADMISSION> levothyroxine, valacyclovir, vitamin D3, multivitamin <DISCHARGE MEDICATIONS> 1. 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 2. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> macrosomia pregnancy,delivered <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> call for increased pain, bleeding or fever
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Ms. ___ had a primary low transverse cesarean section for suspected macrosomia. Her hospital course was complicated by wound hematoma requiring take back to the OR for evacuation of 150cc of clot. No active bleeding was noted. Her hematocrit decreased from 36.6 on ___ to a hematocrit of 25 post-op. She remained hemodynamically stable throughout her hospital stay with incision remaining clean, dry, and intact. She was tolerating a regular diet, ambulating, voiding, pain well controlled on oral medications. She was discharged on ___ with follow up as scheduled.
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10553545-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> spontaneous vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 33+3 WGA with vaginal bleeding that started yesterday morning at 0400. She filled a pad quickly with bright red blood then, and then this morning she filled 4 regular sized pads very quickly again at 0400. She has noticed some cramping. Denies clearish watery discharge. +FM. ROS: denies CP and SOB <PAST MEDICAL HISTORY> PNC: *)Dating: EDC ___ *)Routine testing: O+, antibody neg, RPR NR, rubella immune, HbsAg NR, HIV neg, GBS sent ___ from triage *)Issues with this pregnancy: short cervix at ___ where she was started on vaginal progesterone. Low lying placenta at ___ as well but f/u US here on ___ showed placenta no longer low lying and CL37mm. Transferred care to ___ at ___ ___ b/c she didn't feel she was getting good care. PObHx: G1P0 PGynHx: - No hx abnormal pap smears - Denies hx STDs (on records hx +CT in ___ PMHx: denies PSHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Gen: NAD, coughing a little-has a cold VS: T 98.7 BP 108/64 HR 85 CV: rrr w/o m/g/r Chest: CTA B Abd: gravid, soft, nontender Back: - CVAT Ext: -edema B SVE: deferred SSE: two large walnut sized clots in vagina. Unable to get them out entirely and visualize cervix. EFM: 140 ___, mod variability, +accels, no decels, reactive. Toco: irreg contractions TAUS today: cephalic Discharge Exam: Gen: NAD CV: RRR R: No resp distress on RA Abd: soft, appropriately tender, non distended, fundus firm 2cm below the umbilicus GU: minimal vaginal bleeding MSK: WWP <PERTINENT RESULTS> ___ WBC-16.9 RBC-3.83 Hgb-10.6 Hct-32.2 MCV-84 Plt-396 ___ WBC-17.2 RBC-3.59 Hgb-10.3 Hct-30.7 MCV-86 Plt-391 ___ ___ PTT-29.5 ___ ___ URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE Epi-1 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG URINE CULTURE (Final ___: <10,000 organisms/ml. R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. 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 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Chronic abruption Spontaneous vaginal delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> no heavy lifting nothing in the vagina for 6 weeks
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___ yo G1P0 admitted at 33w3d with vaginal bleeding. On admission, she was hemodynamically stable with no active bleeding. Fetal testing was reassuring. Given the concern for abruption, she underwent close monitoring on labor and delivery. She received a course of betamethasone for fetal lung maturity and the NICU was consulted. She was contracting irregularly and was felt to make cervical change from 2cm/80% to 3cm/100%. She was not tocolyzed given the high suspicion for abruption. ___ was consulted and followed her. She remained stable and was transferred to the antepartum floor on HD#2. On HD#3, she went into active preterm labor and had an uncomplicated vaginal delivery on ___ (at 33w6d). She delivered a liveborn male infant with apgars of 8 and 8. Neonatology staff was present for delivery and transferred the neonate for prematurity. Of note, she was steroid complete at the time of delivery. . Ms ___ had an uncomplicated postpartum course and was discharged home on PPD#2.
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10553545-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cough, shortness of breath, contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G3P0111 at 35 weeks 4 days who was transferred from urgent care with cough and shortness of breath, also complaining of contractions. Cough and nasal congestion started 2 days ago; endorses chills but no fever. Lives at home with young son who is also sick with cold. Overnight/early this morning, felt short of breath and chest pressure with coughing. She has had decreased appetite, nausea, and one episode of post-tussive emesis. She presented to urgent care, where she was initially tachycardic to 128, T 99.1, RR 18, BP 127/70, and O2 sat 92% on room air. She was speaking in full sentences. CXR was normal. EKG was normal sinus. Rapid strep test was negative. Repeat O2 sat prior to transfer was 96-97% on room air. On arrival, she feels improved. No further shortness of breath or dizziness. Chest pressure lateral to the sternum on both sides occurs only in setting of cough. No pleuritic chest pain. Non-exhertional. In this setting she also complained of irregular, mild contractions, off and on for past 3 weeks, and increasing in frequency this morning. Denies VB, LOF. +FM. No recent abdominal trauma. ROS is also notable for cramping with urination and BMs. Endorses constipation. No hematuria or hematochezia. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ c/w 12w US - Labs Rh /+Abs neg/Rub ___ NR/HBsAg neg/HIV neg/GBS pos (___) - Screening: CF neg ___ records), SMA neg, low risk ERA - FFS normal - GLT 152 -> incomplete GTT, normal ___ monitoring for one week - S/p Tdap - Issues *) H/p PTD at 33 weeks, not on progesterone because patient declined; s/p MFM consult *) Low lying placenta, resolved OBHx: - G1: 33 week PTD after likely abruption, baby spent time in NICU but did well - G2: SAB - G3: current GynHx: - H/o abnormal Pap with positive HPV in ___ - Denies fibroids, Gyn surgery, STIs PMH: denies; no HTN, DM, ashtma PSH: none <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: ___ 20: 05MSpO2: 98% ___ 19: 30MSpO2: 97% ___ 19: 30Temp.: 99.8°F ___ 19: 15BP: 126/74 (85) ___ ___: 108 ___ 19: 15MSpO2: 98% Gen: A&O, comfortable CV: RRR, no m/r/g PULM: CTAB, resonant to percussion throughout Abd: soft, gravid, nontender EFW small by Leopolds Ext: mild muscular tenderness on the posterior thighs bilaterally; no edema or erythema SVE: ___ at ___ -> ___ at 2230 - negative pooling, negative fern, negative nitrizine TAUS: cephalic, anterior placenta, MVP 5.3 Toco q q2-4 min FHT baseline 150/moderate variability/+accels/-decels On discharge: Gen: appears comfortable, no evidence of resp distress VS: 98.1, 96/53, 104, 20, O2 95% Lungs: CTAB Heart: RRR, tachycardic Abd: soft, gravid, NT Ext: no calf tenderness Date: ___ Time: ___ FHT: 130s, mod var, +accels, no decels Reactive Toco: q4-6min <PERTINENT RESULTS> ___ WBC-16.2 RBC-3.70 Hgb-9.9 Hct-30.7 MCV-83 Plt-309 ___ Neuts-85.9 ___ Monos-6.2 Eos-0.9 Baso-0.2 Im ___ AbsNeut-13.93 AbsLymp-0.98 AbsMono-1.01 AbsEos-0.15 AbsBaso-0.04 ___ Glu-82 BUN-4 Cre-0.5 Na-137 K-4.2 Cl-104 HCO3-20 AnGap-13 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD* ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG ___ OTHER BODY FLUID CT-NEG NG-NEG ___ OTHER BODY FLUID Strep A-NEG URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. PRESUMPTIVE GARDNERELLA VAGINALIS. 10,000-100,000 CFU/mL R/O GROUP B BETA STREP (Pending): SMEAR FOR BACTERIAL VAGINOSIS (Final ___: Indeterminate. YEAST VAGINITIS CULTURE (Preliminary) <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Fluticasone Propionate NASAL 1 SPRY NU BID RX *fluticasone 50 mcg/actuation 1 spray IN twice a day Disp #*1 Bottle Refills: *0 2. MetroNIDAZOLE 500 mg PO BID RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 3. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 35w6d URI preterm contractions <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for observation due to respiratory symptoms and preterm contractions. Your respiratory symptoms were thought to be due to a viral infection and they improved while you were here. You were noted to have preterm contractions and were dilated 3cm, however, you had no evidence of preterm labor. Fetal testing was reassuring while you were here. You received a course of betamethasone for fetal lung maturity. Please maintain pelvic rest (nothing in the vagina) and avoid strenuous activity.
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___ yo G3P0111 admitted at 35 weeks 4 days with an upper respiratory tract infection and preterm contractions. In regards to her URI, she was afebrile and not ill-appearing. She had an unremarkable evaluation, including EKG, ___, and CXR. She was maintaining normal oxygen saturation and her symptoms improved with supportive care. Her contractions also improved while she was here and she had no evidence of ongoing preterm labor. She received a course of late preterm betamethasone (complete on ___ and fetal testing was reassuring. She was also treated with a seven day course of Flagyl for BV (vaginal swab indeterminate, +Gardnerella on urine cx). She was discharged to home on ___ and will have close outpatient follow up.
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10554387-DS-5
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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> Ms. ___ is a ___ s/p TAB at ___ ___ which was uncomplicated per her report who presented as a transfer from ___ with increasing abdominal pain and vaginal bleeding. Pelvic ultrasound at ___ showed 1.3cm thickened endometrial stripe and she was transferred with concern for RPOCs and ?PID/endometritis. She reported that initially after her procedure she had some cramping that was controlled with ibuprofen as well as light vaginal bleeding. Her pain worsened on ___ and felt like "gas pain" so she took gas-x. Her pain improved and then worsened again the evening of ___ for which she took aleve and tyelenol ___. This did not help so she went to the ED. Her pain improved after Dilaudid at ___ and Morphine here at ___ but then returned. She reported that her bleeding had been light. She had been tolerating PO and denies N/V. She had been passing gas and having bowel movements. She denied fevers and chills. This was her first pregnancy. She was approx. 8wks pregnant by LMP of ___. She denied a history of STIs. She was sexually active with one male partner x 9mo. She reported usually using condoms, but not always. <PAST MEDICAL HISTORY> Gyn: denies hx of STIs, sexually active as above, denies hx abnl Paps, regular monthly menses POb: G1P0 PMH: Fe deficiency anemia, mild asthma with no hospitalizations or intubations - has not taken albuterol in several years PSH: D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On presentation: T97.3 HR 82 BP 120/63 RR 16 O2 100%RA NAD, well-appearing RRR Ext without edema, NT Abd softly distended, tender to palpation across lower abdomen, no rebound or guarding Pelvic: SSS: discomfort with insertion of speculum, thin red blood in vault cleared with 5 scopettes, cervix closed with small amt of active bleeding from os, no cervical lesions other than healing tenaculum site at anterior lip on left, no cervicitis On bimanual, +uterine tenderness, no clear CMT, but tenderness with manipulation of uterus, no adnexal masses or 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 Ext: no c/c/e <PERTINENT RESULTS> ___ 03: 50AM GLUCOSE-95 UREA N-5* CREAT-0.7 SODIUM-136 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-22 ANION GAP-16 ___ 03: 50AM estGFR-Using this ___ 03: 50AM HCG-3256 ___ 03: 50AM WBC-11.2* RBC-4.63 HGB-8.1* HCT-29.6* MCV-64* MCH-17.5* MCHC-27.4* RDW-17.9* ___ 03: 50AM NEUTS-69.7 ___ MONOS-4.4 EOS-0.9 BASOS-0.5 ___ 03: 50AM PLT COUNT-296 ___ 03: 50AM ___ PTT-32.3 ___ <MEDICATIONS ON ADMISSION> aleve, tylenol ___, ibuprofen in the past week, Fe intermittently, no albuterol in the past year <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain do not take >12 tablets/24 hrs, do not drink or drive on this med RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every 4 hrs Disp #*5 Tablet Refills: *0 3. Doxycycline Hyclate 100 mg PO Q12H avoid sunlight RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*28 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometritis, possible pelvic inflammatory disease <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the Gynecology service at ___ ___ for the treatment of endometritis. You have received intravenous antibiotics, as well as oral antibiotics. You have tolerated the medications well, tolerated a regular diet, walked independently, and voided spontaneously. We have determined that you are in good condition to go home. Please take your medications as prescribed, and follow-up with us. Please call us if you have severe abdominal pain not controlled by pain medications, heavy vagnial bleeding, fevers or chills at home. The number to call is ___ to access the 24 hr service line for the ___ clinic. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your follow-up appointment * 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 * or anything that concerns you
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Ms. ___ was admitted to the gynecology service for treatment of endometritis after her surgical abortion on ___. It was not possible to completely rule-out a pelvic inflammatory disease, so she was also treated for that as well. Her pelvic US at ___ showed a 1.3 cm heterogenous stripe without vascularity and therefore there was low concern for retained products of conception. Her abdominal exam was benign, she was afebrile, and her WBC was 11.2. There was a low clinical suspicion for bowel injury. She had significant uterine tenderness on exam and was started on IV gent/clindamycin for 24 hours. She remained afebrile during her stay here, with an abdominal exam that improved. By HD #2, she was tolerating a regular diet, ambulating independently, voiding spontaneously and was in stable condition for discharge. She was discharged home with doxycycline 100mg BID for 14 days, with the first dose administered in the hospital. Her gonorrhea, chlamydia and STI results were still pending at the time of discharge, though the patient will be notified of the results as soon as they are available. The patient will use the combined hormonal contraceptive patch for birth control, and follow-up with the Resident-practice as scheduled.
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10554387-DS-6
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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> ___ yo ___ s/p ___ trimester TAB at ___ ___ complicated by postprocedure endometritis requiring hospital admission from ___ presents with recurrent lower abd cramping and pain. Initially was improved at discharge but then presented to ___ for pain on ___ where she was discharged home with Percocet. She represents to ___ ___ for continued lower abdomina pain that is ___. It radiates to her back. Not relieved with Percocet. Has not taken ibuprofen. She reports that initially after her procedure she had some cramping that was controlled with ibuprofen as well as light vaginal bleeding. Her pain worsened ___ and felt like "gas pain" so she took gas-x. Her pain improved and then worsened again the evening of ___ for which she took Aleve and Tylenol ___. This did not help so she went to the ___. Her pain improved after Dilaudid at ___ and Morphine here at ___ but is now returning. She reports that her bleeding has been light. She has been tolerating PO and denies N/V. She has been passing gas and having bowel movements. She denies fevers and chills. <PAST MEDICAL HISTORY> Gyn: denies hx of STIs, sexually active as above, denies hx abnl Paps, regular monthly menses POb: G1P0 PMH: Fe deficiency anemia, mild asthma with no hospitalizations or intubations - has not taken albuterol in several years PSH: D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> PE VS: T-97.8 HR-72 BP-120/68 RR-16 O2-100%ra RA Gen: NAD CV: RRR Pulm: CTAB Abd: soft, mild suprapubic tenderness, no rebound or guarding, nondistended Ext: nontender Pelvic: Difficult due to patient discomfort. Normal appearing external genitalia, inner labial folds, urethral meatus. Bimanual exam with pos CMT, pos uterine tenderness. No adnexal masses or adnexal tenderness appreciated. 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 Ext: no c/c/e <PERTINENT RESULTS> ___ 06: 15AM WBC-7.6 RBC-3.77* HGB-6.7* HCT-23.9* MCV-63* MCH-17.7* MCHC-27.9* RDW-18.7* ___ 06: 15AM NEUTS-54.0 ___ MONOS-7.2 EOS-1.4 BASOS-0.5 ___ 06: 15AM PLT COUNT-250 ___ 06: 33PM URINE HOURS-RANDOM ___ 06: 33PM URINE HOURS-RANDOM ___ 06: 33PM URINE UCG-POS ___ 06: 33PM URINE GR HOLD-HOLD ___ 06: 33PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06: 33PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06: 33PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 06: 33PM URINE RBC-16* WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 ___ 06: 33PM URINE MUCOUS-RARE ___ 06: 00PM GLUCOSE-90 UREA N-7 CREAT-0.7 SODIUM-141 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13 ___ 06: 00PM WBC-7.5 RBC-4.15* HGB-7.5* HCT-26.5* MCV-64* MCH-17.9* MCHC-28.2* RDW-18.2* ___ 06: 00PM NEUTS-67.5 ___ MONOS-6.7 EOS-0.6 BASOS-0.7 ___ 06: 00PM PLT COUNT-298 <MEDICATIONS ON ADMISSION> percocets, ibuprofen, tylenol, doxycycline <DISCHARGE MEDICATIONS> 1. MetRONIDAZOLE (FLagyl) 500 mg PO BID Duration: 10 Days do not drink while on this medication RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 2. Levofloxacin 500 mg PO Q24H Duration: 10 Days RX *levofloxacin 500 mg 1 tablet(s) by mouth every day Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometritis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the Gynecology service at ___ ___ for your abdominal pain. You have received antiobiotics with much improvement. Specifically, your pain is controlled with medications, you are walking independently, urinating spontaneously and tolerating a regular diet. We have determined that you are in a stable condition to go home. Please 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 * 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 Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service for post-procedural antibiotics. Please refer to the H&P for full details. The patient was started on IV gentamycin and clindamycin. She remained afebrile and her pain was controlled with ibuprofen and acetaminophen. 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. Her discharge medications include levofloxacin and metronidazole for 10 days. She will follow-up at the ___ ___ in ___.
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10559181-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Morphine <ATTENDING> ___. <CHIEF COMPLAINT> Symptomatic fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy Bilateral salpingectomy <HISTORY OF PRESENT ILLNESS> ___ G3P3 woman with LMP ___ returns for ___ visit. Her bleeding and cramping are under much better control now, and she has not been using any pain medications recently in last 2 weeks, no spotting or bleeding since last period concluded 5 days ago. The patient continues to decline pelvic exam and would like to forgo any invasive testing as she has had a difficult time with these exams since ___. Pt initially seen in ___ when she came in after an emergency room visit at ___. Patient states that she was in her usual state of health until her period began in ___, at which time she had first episode of heavy bleeding accompanied by severe pelvic and back pain. The pain became so intense that her fiancé took her to the emergency room at ___. Pain was described as throbbing and located deep in the abdomen and pelvis radiating to the back. She had no associated symptoms of fever, chills, shortness of breath, chest pain, bowel or bladder symptoms. She has never had anything like this happen before. Her menstrual periods are usually every 28 days very regular all of her life and with no intermenstrual or postcoital bleeding. She has not been recently sexually active. The patient underwent multiple vaginal exams and CT scan which left her quite traumatized. She has not been comfortable with exams since. She and her partner were quite concerned because she was diagnosed with fibroids. At that time the patient was trying to conceive, but over the last 2 months has arrived at the conclusion she is done with childbearing. She has decided that she would prefer to have definitive surgery to remove the fibroids, and after extensive discussions on several occasions, she has decided hysterectomy is the right decision. She remains undecided about removal of fallopian tubes, and would like to decide on this over the next few days. The patient has not been seen by her PCP yet for ___. <PAST MEDICAL HISTORY> 1. Anemia: Life long. 2. Sickle cell trait: fiance negative. 3. pt has a h/o of EToH in OMR, however denies this history 4. h/o pancreatitis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Reports a history of breast cancer in her family <PHYSICAL EXAM> Physical Exam Initial: General: Comfortable, NAD. CV: RRR, no murmurs. Pulm: RRR, no wheezes or crackles. Abd: Soft, non-distended, appropriately TTP. ___ dressing clean, dry and intact. LSC port dressings clean. GU: Pad with no spotting. Foley in place draining yellow urine. Extremities: Warm, well-perfused. No edema or tenderness. Pneumoboots on. Physical Exam on Day of Discharge: ___ 0723 Temp: 98.8 PO BP: 117/71 L Lying HR: 81 RR: 17 O2 sat: 98% O2 delivery: RA Abd: no guarding or rebound, no CVAT incisions: clean, dry, intact, with no erythema, induration, d/c or bleeding <PERTINENT RESULTS> ___ 12: 43PM PLT COUNT-244 ___ 12: 43PM WBC-8.0 RBC-3.19* HGB-7.5* HCT-22.4* MCV-70* MCH-23.5* MCHC-33.5 RDW-19.8* RDWSD-50.0* ___ 12: 43PM estGFR-Using this ___ 12: 43PM CREAT-0.5 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H do not exceed 4000mg in 24 hrs RX *acetaminophen 500 mg ___ tablets 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 Disp #*60 Capsule Refills: *1 3. 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 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity do not drink alcohol or drive while taking this medication; causes sedation 5. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild take with food to prevent upset stomach RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 6. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity do not drink alcohol 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 7. Simethicone 80 mg PO QID RX *simethicone 125 mg 1 tab by mouth q 6 hour Disp #*40 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns (___). Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your follow-up visit. 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 ___. It was a pleasure caring for you. We wish you all the best. Sincerely, Your GYN team at ___
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a laparoscopy, attempted laparoscopic hysterectomy that was converted to open laparotomy, total abdominal hysterectomy, bilateral salpingectomy for symptomatic fibroid uterus. Conversion was made due to bleeding from feeder vessels arising from the left infundibulopelvic pedicle and redundant vasculature of the right uterine vessels. Please see the operative report for full details. Her postoperative course was complicated by acute on chronic anemia. On post-operative day 1, her hematocrit returned at 17.6, which was decreased from 29.2 preoperatively. She was transfused 2 units of packed RBCs and started on oral iron pills, her hematocrit rose appropriately to 24.4 on post-operative day 2. Immediately post-op, her pain was controlled with a TAP block in recovery room, Dilaudid PCA, and IV Toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to oral oxycodone and Tylenol. Given her significant daily alcohol intake, patient was monitored on CIWA protocol and given 1L IVF with thiamine, folic acid, and a multivitamin. 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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10562137-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy right oophorectomy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 4, para 3 who has had crampy uterine pain, has had several cervical evaluations due to her history of cervical stenosis, last surgical evaluation being ___. She has had multiple emergency room visits for chronic pain. Her last ultrasound on ___ showed a uterus, which measured 11 x 4.3 x 4.9 cm. There was an irregular wax-like fluid collection within the uterine cavity measuring up to 2.5 cm in maximal transverse diameter. The ovaries were normal in appearance. There was no free pelvic fluid. These results were reviewed with the patient. I have performed an endometrial biopsy on ___. The cervix to allowed passage of a small dilator quite easily. The endometrial sampler was placed in the endometrial cavity and a biopsy was performed. Pathology was negative. A brown slightly cystic fluid extruded from uterus consistent with old blood at the time of the endometrial biopsy. The patient states that she is having increased pain with her uterus, particularly around the time of menses and declines any additional medical therapy. The patient at this time is requesting hysterectomy and thorough pelvic evaluation. <PAST MEDICAL HISTORY> OB/GYN HISTORY: She has had three previous cesarean sections without complications. One first trimester abortion without complication. Again, she has a long history of chronic pelvic pain, menorrhagia, fibroids, abnormal Pap in ___, negative colposcopy, no treatment was necessary. She denies any history of sexually transmitted infections. PAST MEDICAL HISTORY: Significant for the above complaint. In addition, she has migraine headaches, back pain secondary to degenerative disc disease and sickle cell trait. SURGICAL HISTORY: Again, cesarean section x3, bilateral tubal ligation, D&C x1, ___, she had a diagnostic/operative hysteroscopy D&C, NovaSure endometrial ablation, diagnostic laparoscopy, aspiration of ovarian cyst and lysis of adhesions. In ___, she had a left L5-S1 microdiscectomy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast, uterine, ovarian, or cervical cancer. <PHYSICAL EXAM> GENERAL: This is a well-developed, obese woman, in no apparent distress. VITAL SIGNS: Weight 220. She plans on having gastric banding at ___. Blood pressure 126/82. HEENT: Normocephalic, atraumatic. Sclerae anicteric, conjunctivae pink. Oropharynx clear. NECK: Supple, without increased thyroid. LYMPH SYSTEM: Negative. LUNGS: Clear to auscultation bilaterally. COR: Regular rate. ABDOMEN: Obese, soft, nondistended, nontender, negative hepatosplenomegaly, negative palpable masses. PELVIC: Normal female external genitalia. Bartholin, urethral, and Skene's glands are normal. Vaginal vault, normal-appearing discharge. There are no lesions. Cervix parous without cervical motion tenderness. Uterus 12-14 cm in maximal vertical dimension. Adnexa without masses or tenderness bilaterally. <PERTINENT RESULTS> pathology pending <MEDICATIONS ON ADMISSION> GABAPENTIN [NEURONTIN] - 300 mg Capsule - 1 Capsule(s) by mouth at hs increase progressively to tid HYDROCODONE-ACETAMINOPHEN [VICODIN ES] - 7.5 mg-750 mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for pain do not exceed 5 tablets in a 24 hour period IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth daily as needed for pain Don't take more than 4 per day PROPRANOLOL - 40 mg Tablet - 1 Tablet(s) by mouth twice daily SERTRALINE - 100 mg Tablet - 2 Tablet(s) by mouth daily SUMATRIPTAN SUCCINATE - 25 mg Tablet - 1 Tablet(s) by mouth at the start of a migraine <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *80 Tablet(s)* Refills: *0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* 3. propranolol 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. sumatriptan succinate 25 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 5. gabapentin 400 mg Capsule Sig: One (1) Capsule PO ONCE MR1 (Once and may repeat 1 time) as needed for pain for 1 doses. 6. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain for 2 weeks. Disp: *50 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> dysmenorrhea, pain, 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. * No strenuous activity, no heavy lifting of objects >10lbs for 6 weeks. * Nothing in the vagina (no tampons, no douching, no sex) until cleared by your physician. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, leave them on. They will be removed during your followup visit.
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Ms ___ underwent an uncomplicated TAH, right oophorectomy, and lysis of adhesions; please see operative report for full details. She had an uncomplicated postoperative course and was discharged home in good condition on postoperative day #2: ambulating, urinating, and tolerating a regular diet, and with pain adequately controlled with PO medications.
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10562137-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> wound infection <MAJOR SURGICAL OR INVASIVE PROCEDURE> wound debridement and wound vac placement <HISTORY OF PRESENT ILLNESS> ___ woman s/p total abdominal hysterectomy, lysis of adhesions and right salpingo-oophorectomy on ___ now presenting with wound infection. Pt has been noticing foul odor for ___ wks. She stood up from watching TV tonight and noticed a large amount of drainage from the incision site. +Pain, no fevers/chills. Feels well otherwise. Last seen for post-op care ___ - area of skin breakdown w/ minimal drainage noted. Pt was to return for follow up in one week. Pt initially evaluated in the ED tonight. Started on vancomycin. <PAST MEDICAL HISTORY> OB/GYN Hx: - cesarean section x 3 - first w/ wound infection - TAB x 1 - chronic pelvic pain - menorrhagia - fibroids - abnormal Pap in 1990s, negative colposcopy - no hx STIs PMH: -HTN -migraine headaches -back pain secondary to degenerative disc disease -sickle cell trait PSH: -cesarean section x3 -bilateral tubal ligation -D&C x1, ___ -diagnostic/operative hysteroscopy D&C, NovaSure endometrial ablation, diagnostic laparoscopy, aspiration of ovarian cyst and lysis of adhesions. In ___, she had a left L5-S1 microdiscectomy. <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On presentation: T 98.1 HR 92 BP 134/78 RR 14 NAD, obese RRR CTAB abd obese, fold beneath pannus moist w/ strong odor, area of skin breakdown, induration, erythema approx 6x5cm with opening draining yellow fluid, wound probed and found to track to right approx 18cm, fascia intact, wound approx 10cm deep, abdomen tender surrounding wound Labs: wound cx, WBC in ED 7.8 <PERTINENT RESULTS> ___ 02: 00AM WBC-7.8 RBC-4.29 HGB-11.8*# HCT-33.9* MCV-79* MCH-27.5 MCHC-34.8 RDW-14.1 ___ 02: 00AM UREA N-9 CREAT-0.6 SODIUM-137 POTASSIUM-5.9* CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 ___ 02: 08AM LACTATE-1.6 K+-3.6 <MEDICATIONS ON ADMISSION> Propanolol 40 twice daily, Imitrex prn, nicotine patch <DISCHARGE MEDICATIONS> 1. propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Disp: *12 Tablet(s)* Refills: *0* 4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> wound infection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were hospitalized for a wound infection and had a wound vacuum placed to assist wound healing. Please follow your visiting nurse's instruction on how to care for it. You were prescribed antibiotics. Please complete the full course. You were prescribed stool softeners. Please take as directed to have one normal bowel movement a day. You were prescribed Dilaudid for pain. Do not drive while taking narcotics. Call your doctor for: * fever > 100.4 * severe abdominal pain * redness or drainage from wound * pus or foul odor from wound * 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 General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks from your initial surgery on ___. * You may eat a regular diet. Wound care: * Please follow your visiting nurse's instruction for wound care. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ underwent an uncomplicated excisional debridement of necrotic and infected tissue and wound vac placement for wound dehiscence and infection; the procedure was a joint case with general surgery, see operative report for details. She received four days of broad-spectrum intravenous antibiotics and remained afebrile with a normal white count throughout her hospital course. . On postoperative day 2, the wound was again debrided and vac changed. She had O2 sats to the mid-80s in the recovery room, received nebulizers and a non-rebreather mask. EKG and CXR were unremarkable. On the floor she remained on a face mask for another day, and her O2 sats returned to her baseline mid-90s on room air with encouraged ambulation and deep breaths. . She went home on oral Bactrim for a seven-day course and with a visiting home nurse to change her wound vac three times weekly. She was discharged home on postoperative day #5 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication. Patient will follow-up with general surgery team for wound care.
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10566210-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> thimerosal / Percocet / Vicodin <ATTENDING> ___ <CHIEF COMPLAINT> vaginal prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> ROBOTIC ASSISTED LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY WITH BILATERAL SALPINGECTOMIES, SACROCERVICOPEXY WITH SYNTHETIC GRAFT, SUBURETHRAL SLING AND CYSTOSCOPY <PHYSICAL EXAM> Discharge: General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, nondistended, appropriately mildly tender to palpation without rebound or guarding, umbilical dressing saturated with serosang drainage, otherwise dressings clean/dry/intact, dressings removed and incisions without erythema or induration GU: pad with minimal spotting, foley draining clear urine Extremities: no edema, no calf tenderness/erythema/swelling, pneumoboots in place bilaterally Pre-admission: Neuro/Psych: Oriented x3, Affect Normal, NAD. Nodes: No inguinal adenopathy. Heart: No pedal edema Lungs: Normal respiratory effort. GI: Non tender lower abdomen, Non distended, No masses, guarding or rebound, No hepatosplenomegaly, No hernia. Ext: No clubbing, cyanosis, edema. Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. Cervix: no lesions, no discharge Uterus: non-tender Adnexa: no masses non tender. <PERTINENT RESULTS> N/A <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a ROBOTIC ASSISTED LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY WITH BILATERAL SALPINGECTOMIES, SACROCERVICOPEXY WITH SYNTHETIC GRAFT, SUBURETHRAL SLING AND CYSTOSCOPY. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV toradol. On post-operative day 1, her diet was advanced without difficulty, and she was transitioned to oral oxycodone, ibuprofen and acetaminophen. Her Foley catheter was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 200 mL with 54 mL residual. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever Do not take more than 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 dilaudid to prevent severe constipation. RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice per day as needed Disp #*28 Tablet Refills:*0 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Do not operate heavy machinery while using. RX *hydromorphone 2 mg ___ tablet(s) by mouth Every 6 hours as needed Disp #*10 Tablet Refills:*0 4. Ibuprofen 600 mg PO Q6H Please take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6hours as needed Disp #*40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: incomplete uterovaginal prolapse, stress incontinence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10571820-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> "I go to the bathroom more than 10 times". <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Vaginal Hysterectomy Monarc Sling Posterior Repair Perineorrhaphy Cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 6 Para ___ who presents today in the office for a consultation requested by Dr. ___ ___ urinary frequency. She is in fact complaining of urgency as well as frequency. Her symptoms have been present for approximately ___ years. She believes that they are now worse. She reports 0 incontinence events . She voids ___ times per day and ___ times per night. She uses 0 pads per day. She 0 admits to some urgency, she denies any dysuria and reports bladder emptying with normal flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ also denies any vaginal pressure or palpable prolapse. She also denies any constipation. She is not sexually active and does not experience dyspareunia. She denies any vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. DCIS 2. Latent TB 3. Osteoporosis/OA 4. HTN PAST SURGICAL HISTORY 1. Left carpal tunnel release 2. Left Breast surgery + Radiation PAST OB HISTORY G6P6004 Vaginal: 6 PAST GYN HISTORY She denies having Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Colon Cancer. <PHYSICAL EXAM> Physical Examination by Dr. ___ ___: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Normal sounds, no murmurs Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Ext: No edema or varicosities. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skin & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: no lesions, no discharge Uterus: small; non-tender Adnexa: no masses non tender. POP-Q Exam: Aa: +0.5 Ba: +0.5 TVL: 9 D: -5 C: -4 ___: 5 PB: 2.5 Ap: +1 Bp: +1 Stage ___ Exam: Cystocele: 3 Uterus/Cervix: 2 Vault: 2 Ant enterocele: Post enterocele: Rectocele: 3 Grade VAGINAL EXAM - There was severe vaginal atrophy: Ulcerations were absent Empty Supine Stress Test was: negative Her (PVR) post void residual was 120 ml assessed by [straight catheterization <PERTINENT RESULTS> urodynamics test showed that she has: 1) stress urinary incontinence with urethral hypermobility. Pre-procedure Diagnoses: Dysfunctional voiding Post-procedure Diagnoses: Occult Stress urinary incontinence Procedure: Patient was taken to the urodynamic suite. A consent form had been signed. Time-out was completed as per ___ policy. She underwent a sterile prep with betadine and catheterization. The procedure was performed in a sitting position. Air-charged catheters were placed in the urethra and vagina. Urodynamics were done utilizing routine techniques. The prolapse was reduced with the posterior blade of a speculum. There were no complications. She was given prophylactic antibiotics. Urodynamic Findings: 1. Complex Uroflow (performed using computerized uroflowmetry): a. Voided volume (ml): 135 b. Qmax (ml/sec): 18.3 c. Qave (ml/sec): 9.5 d. Flow time (sec): 14.2 e. Flow pattern: f. Comments: i. Bell-shaped curve iii. No straining 2. Post void residual volume (ml): 60 3. There was a negative urinalysis. 5. Complex Cystometrogram: Performed using a 7 ___ dual lumen urethral catheter with simultaneous vaginal catheter placement for abdominal pressure monitoring. Sterile water was instilled into the bladder at rate of 50 ml/min. a. First sensation: 72 (ml) b. First desire : 189 (ml) c. Normal desire : 215(ml) d. Strong desire : 276(ml) e. Urgency: 279(ml) f. Max Cystometric Capacity : 285 (ml) g. Comments: h. Sensation: iii. Increased i. Compliance: i. Normal j. Capacity: i. Normal k. Detrusor overactivity: i. not seen l. Leak Pressure Test: performed utilizing both urethral and vaginal balloon catheters for simultaneous vesical and abdominal pressure monitoring. Straining maneuvers consisting of coughing and graded valsalva efforts were performed in an effort to induce leakage. i. Leakage was seen woth cough at 235 ml and with Valsalva at 215ml. ii. Leakage was seen at 215 ml with a valsalva leak point pressure of 127 cmH2O 6. Urethral pressure profiles: Performed using 7 ___ urethral catheter with a slow constant pull using a mechanical arm at a rate of 1mm/sec. a. MUCP empty (cmH2O): 78 FUL empty (cm): 4.6 7. Pressure Flow Test: Performed using both bladder and vaginal catheters for detrusor, vesical, and abdominal pressure monitoring. a. Infused volume (ml): 285 ml b. Attempt to void: yes c. Detrusor contraction: present / voluntary d. Qmax (ml/sec): 24.5 e. Qave (ml/sec): 14.0 f. Pdet at Qmax (cm H2O): 23.9 g. Max Pdet (cm H2O): 34.7 h. Voided volume (ml): 338 ml i. Catheterized PVR (cc): j. Comments: no straining 8. EMG performed using perineal patch electrodes a. Recruitment: normal recruitment was seen corresponding with strain maneuvers. b. Activity during voiding: synergistic <MEDICATIONS ON ADMISSION> - Alendronate - chlortalidone 12.5mg daily - gabapentin 300mg TID - imipramine 25mg daily - letrozole 2.5mg daily - ca + vit D <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: please do not exceed 4g of acetaminophen in 24 hours. Disp: *20 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *20 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic Organ Prolapse Stress Urinary Incontinence Cystocele Rectocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * 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. * Please call if you're unable to void within ___.
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Ms. ___ was admitted into the gynecology service for routine post-operative care following her procedure. Her surgery was uncomplicated. Please see operative note for full details of the surgery. She had an episode of emesis on post-operative day 0. This resolved with zofran. Her pain was well controlled over the course of the night. On post-operative day 1, her vaginal packing was discontinued and found to be moderately saturated with serosanguinous drainage. Her foley was discontinued, her iv heplocked and her voiding trial performed. She did pass her voiding trial. The results are as follows; We instilled 240cc, she voided 150 with a PVR of 200. We reinstilled only 120cc due to intolerance, she voided 150cc with a PVR of 0. She was given strict instructions to call if any signs of urinary retention such as lack of void within ___ hours. She did void a second time while in house but missed the hat. Ms ___ was discharged on post-operative day 1 in good condition, adequate pain control, tolerating a regular diet, voiding and ambulating without difficulty.
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10572449-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ___ <ATTENDING> ___. <CHIEF COMPLAINT> left lower quadrant abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G3P1 at approximately 9wks EGA presents to ED with worsening LLQ abdominal pain which began earlier this evening. Patient reports that she has been suffering from hyperemesis and chronic constipation throughout the pregnancy. She did have a bowel movement after self rectal stimulation earlier today. She has been taking zofran from her nausea. Around 5pm this evening, patient reports that she suddenly developed severe left sided abdominal pain. She says that the pain comes in waves. She has had some nausea and emesis she feels is secondary to her pain. She denies any fevers, chills, chest pain, vaginal bleeding, loss of fluid, dysuria. she does note blood tinged urine today. <PAST MEDICAL HISTORY> OB Hx: - SVD x1 - Molar pregnancy ___, s/p D&C GYN Hx: lipoma in right breast resected in ___ PMH: - anxiety - depression - recent near-syncopal episode while pt was trying to have BM; w/u in ED was neg PSH: - lipoma resection - molar pregnancy termination <SOCIAL HISTORY> ___ <FAMILY HISTORY> none contributory <PHYSICAL EXAM> O: 98 108 136/80 18 100% Patient tearful in bed RRR CTAB ABD: soft, tender to deep palpation in left lower quadrant, no r/g Ext: NT BiManual Exam: Mobile, NT, uterus, no adnexal masses palpated <PERTINENT RESULTS> Bedside U/S: SIUP, +___ Labs: CBC: 7.1>13.1/37.3<231 chem7: 135/103/7 <113 Ca 9.0 Mg 2.2 Ph 2.9 3.6/___/0.5 ALT 9 AST 12 AlkP 48 Lipase 33 UA: few bacteria, mod leuks, neg blood, 15 ketones U/S ___ normal sized ovaries, small L CL cyst <MEDICATIONS ON ADMISSION> Zoloft 50mg once daily, Zofran 4mg PRN <DISCHARGE MEDICATIONS> 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp: *60 Tablet(s)* Refills: *2* 4. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for reflux. 5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for nausea. Disp: *30 Tablet(s)* Refills: *3* 6. Promethazine 12.5 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for nausea. Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 9 weeks pregnant Left lower quadrant pain, possible nephrolithiasis Hyperemesis <DISCHARGE CONDITION> Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You may eat a regular diet. Eat small meals with bland food. It is important to drink fluids while you are pregnant. Take Zofran and Phenergan for nausea. You may take Tylenol for pain.
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Ms. ___ was admitted to the Gyn Service for pain control of her left lower quadrant abdominal pain. Pt's UA was positive for blood and calcium oxalate. This finding indicated for possible nephrolithasis. However, pt's renal US showed: normal renal ultrasound; no stones, no hydronephrosis; normal left ureteral jet. Right ureteral jet not visualized, but no hydroureter; given left sided symptoms, further imaging for a right ureteral jet was not pursued. Her pelvic US showed: single live intrauterine pregnancy with size equaling dates; no evidence of ovarian torsion; appendix is not visualized. Pt received IV dilaudid for pain control, then decreased to PO Tylenol. Pt denied passing any stones during her hospitalization, however her left abdominal pain improved. She was also placed on Colace for constipation, Zofran for hyperemesis of pregnancy, and her home medication Zoloft 50mg once daily for hx of depression and anxiety. Ms. ___ was discharged on hospital day #2 in stable condition: afebrile, able to tolerate some PO intake, under adequate pain control with oral medications, and ambulating and urinating without difficulty.
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10573097-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Missed AB <MAJOR SURGICAL OR INVASIVE PROCEDURE> D&C ___ <HISTORY OF PRESENT ILLNESS> ___ was noted on routine US at ___ to have fetal demise measuring 14 weeks, and had a scheduled D&C on ___. She had laminaria placed the day before. She was without significant past medical history except for easy bruising/bleeding and although work up for ___ disease was negative. she was told her Factor levels were a little on the low side. The procedure itself was uncomplicated, although intra-operatively she developed transient hypotension to 75/40, tachycardia to 130s, and de-satted to 88. She subsequently experienced uterine and cervical oozing and bleeding from IV lines and her mouth and was given IVF, O2 and levophed. Given concern for DIC and to keep her comfortable she was intubated. Total crystalloid received 3200 cc. EBL 500, UOP 300cc. Intra-op, the patient received 16U ddAVP, 1 U FFP, 2U cryo for concern for DIC. Also received methergen, Pitocin, and cytotec, a foley was placed in the uterus and packing placed in the cervix and vagina. On arrival to MICU, patient was intubated and sedated, hemodynamically stable, with persistent oozing from oropharynx, peripheral IVs, and in uterine foley. Phenylephrine weaned within minutes of FICU transfer. <PAST MEDICAL HISTORY> Possible Bleeding disorder, prior hematology evaluation for VWF neg. Prior C-section and SVD without known bleeding complications Miscarriage without complications <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of clotting or bleeding disorders. <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM --=== VITALS: T 98.4 BP 129/77 HR 65 O2 sat 100% FiO2 100% GENERAL: Intubated, sedated, intermittently agitated HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact DISCHARGE PHYSICAL EXAM --=== Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> LABS -========= ___ 05: 44AM BLOOD WBC-10.8* RBC-3.22* Hgb-9.8* Hct-28.3* MCV-88 MCH-30.4 MCHC-34.6 RDW-14.4 RDWSD-46.5* Plt ___ ___ 11: 30AM BLOOD WBC-14.5*# RBC-3.05* Hgb-9.3* Hct-26.5* MCV-87 MCH-30.5 MCHC-35.1 RDW-14.6 RDWSD-46.1 Plt ___ ___ 05: 11AM BLOOD WBC-9.6 RBC-2.66* Hgb-8.0* Hct-23.7* MCV-89 MCH-30.1 MCHC-33.8 RDW-14.4 RDWSD-46.7* Plt Ct-58* ___ 01: 39AM BLOOD WBC-11.5* RBC-2.36* Hgb-7.3* Hct-20.7* MCV-88 MCH-30.9 MCHC-35.3 RDW-14.4 RDWSD-45.8 Plt Ct-60* ___ 09: 56PM BLOOD WBC-17.0* RBC-2.65* Hgb-8.2* Hct-23.7* MCV-89 MCH-30.9 MCHC-34.6 RDW-14.4 RDWSD-46.6* Plt Ct-63* ___ 06: 40PM BLOOD WBC-20.3* RBC-3.13* Hgb-9.7* Hct-27.1* MCV-87 MCH-31.0 MCHC-35.8 RDW-14.3 RDWSD-44.2 Plt Ct-81* ___ 05: 29PM BLOOD WBC-24.0* RBC-3.30* Hgb-10.2* Hct-28.7* MCV-87 MCH-30.9 MCHC-35.5 RDW-14.0 RDWSD-44.3 Plt Ct-96* ___ 06: 40PM BLOOD Neuts-87* Bands-3 Lymphs-4* Monos-4* Eos-0 Baso-1 ___ Metas-1* Myelos-0 AbsNeut-18.27* AbsLymp-0.81* AbsMono-0.81* AbsEos-0.00* AbsBaso-0.20* ___ 06: 40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-OCCASIONAL Schisto-1+ Burr-OCCASIONAL ___ 05: 44AM BLOOD ___ PTT-25.4 ___ ___ 11: 30AM BLOOD ___ PTT-25.1 ___ ___ 05: 11AM BLOOD ___ PTT-25.1 ___ ___ 01: 39AM BLOOD ___ PTT-26.1 ___ ___ 09: 56PM BLOOD ___ PTT-29.6 ___ ___ 06: 40PM BLOOD ___ PTT-42.9* ___ ___ 11: 30AM BLOOD ___ 05: 11AM BLOOD ___ 01: 39AM BLOOD ___ ___ 09: 56PM BLOOD ___ ___ 06: 40PM BLOOD Fibrino-78* ___ 05: 11AM BLOOD Ret Aut-2.6* Abs Ret-0.07 ___ 06: 40PM BLOOD Ret Aut-2.5* Abs Ret-0.08 ___ 11: 30AM BLOOD FacVIII-136 ___ 06: 40PM BLOOD FacVIII-44* ___ 11: 30AM BLOOD VWF AG-299* VWF Act-PND ___ 06: 40PM BLOOD VWF AG-250* VWF Act-PND ___ 05: 11AM BLOOD Glucose-83 UreaN-10 Creat-0.4 Na-131* K-3.3 Cl-105 HCO3-19* AnGap-10 ___ 06: 40PM BLOOD Glucose-93 UreaN-7 Creat-0.5 Na-134 K-3.0* Cl-103 HCO3-18* AnGap-16 ___ 06: 40PM BLOOD ALT-14 AST-34 LD(LDH)-490* AlkPhos-60 TotBili-1.3 ___ 05: 11AM BLOOD Calcium-7.1* Phos-3.7 Mg-2.3 ___ 06: 40PM BLOOD Calcium-8.5 Phos-3.7 Mg-1.5* ___ 06: 40PM BLOOD Hapto-22* ___ 05: 29PM BLOOD D-Dimer-7854* ___ 05: 48AM BLOOD Type-ART pO2-187* pCO2-35 pH-7.41 calTCO2-23 Base XS--1 ___ 01: 50AM BLOOD Type-ART pO2-187* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 ___ 06: 47PM BLOOD Type-ART pO2-527* pCO2-35 pH-7.39 calTCO2-22 Base XS--2 ___ 05: 54PM BLOOD Type-ART pO2-309* pCO2-42 pH-7.32* calTCO2-23 Base XS--4 Intubat-INTUBATED ___ 04: 21PM BLOOD Type-ART pO2-78* pCO2-35 pH-7.33* calTCO2-19* Base XS--6 ___ 01: 50AM BLOOD Lactate-0.7 ___ 06: 47PM BLOOD Lactate-1.8 ___ 05: 54PM BLOOD Glucose-85 Lactate-1.8 Na-135 K-3.3 Cl-104 ___ 04: 21PM BLOOD Lactate-1.5 ___ 05: 54PM BLOOD Hgb-10.5* calcHCT-32 ___ 04: 21PM BLOOD Hgb-12.6 calcHCT-38 ___ 01: 50AM BLOOD freeCa-1.05* ___ 05: 54PM BLOOD freeCa-0.92* ___ 09: 56PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09: 56PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 09: 56PM URINE Hours-RANDOM ___ 09: 56PM URINE Uhold-HOLD IMAGING -========= CTA ___ IMPRESSION: Suboptimal exam due to poor contrast bolus timing but no evidence of lobar or segmental pulmonary emboli. If there is persistent concern for pulmonary embolism, a repeat CT can be performed. MICROBIOLOGY -========= ___ 9: 56 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 9: 56 pm BLOOD CULTURE Source: Venipuncture 2 OF 2. Blood Culture, Routine (Pending): Time Taken Not Noted Log-In Date/Time: ___ 9: 10 pm BLOOD CULTURE 1 OF 2. Blood Culture, Routine (Pending): <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. This patient is not taking any preadmission medications <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 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Missed abortion, Disseminated Intravascular Coagulopathy <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 sex, no tampons) 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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___ year old female with history of easy bruising, transferred to FICU after D&C complicated by post-operative bleeding and hemodynamic instability with concern for either pulmonary embolis or amniotic fluid embolism followed by DIC. FICU COURSE =========== In the FICU she was noted to have low fibrinogen and elevated coags confirming the concern for DIC. Patient received intra-op ddAVP, 1U FFP, 2U cryo, with persistent oozing from peripheral IVs and orpharyngeal laceration. She underwent a CTA which was negative for pumonary embolis Heme-onc was consulted for her history of a possible bleeding disorder and management of DIC. She Remained hemodynamically stable and with good perfusion on exam. In FICU, received 2 U platelets and 1 additional 1 U cryo. DIC labs improved by post-op day 1. #Hypoxic respiratory failure: #Airway protection: Transient desatting in OR in the setting of hypotension that resolved. Intubated in setting of hemodynamic instability; CXR without evidence of acute pulmonary process and CTA without evidence of PE. Successful extubation on post-op day 1. Amniotic fluid embolism remains the most likely inciting event and she had a risk factor of a prolonged fetal demise and the D&C. #Leukocytosis: WBC elevated to 20.; likely stress response in the setting of surgery and DIC. No fevers concerning for underlying infection; CXR without infiltrate. Received doxy 100mg IV x 1 as per OBGYN. GYN: Patient had 2 vaginal packings in place along with intrauterine foley, which were removed on post-op day 1. Minimal vaginal bleeding was noted at the time. Rh+, RhoGAM was not indicated. #?History of VWD: Husband reports prior w/u was not definitive for VWD. Heme-onc was consulted, and ___ panel was sent. Results pending at time of discharge. FLOOR COURSE: ============ On POD#1, pt was called out of the FICU. She remained hemodynamically stable with minimally stained pad. She was advanced to a regular diet with no issues. On the morning of POD#2, her labs showed a stable HCT of 28.3 from 26.5 and platelets 119. Her coags were also stable. By post-operative day 2, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She had minimal vaginal bleeding. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10573256-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Avocado / cantalope / Banana / mango flavor <ATTENDING> ___ <CHIEF COMPLAINT> pelvic organ prolapse, urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> total vaginal hysterectomy, bilateral salpingo-oophorectomy, tension free vaginal tape, cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 4 Para 3013 who presented for a consultation regarding vaginal prolapse. She is complaining of vaginal bulging which is interfering with walking and bending. Her symptoms have been present for approximately 6 months. She believes that they are now worse. She reports rare stress incontinence events mostly with coughing and laughing. She voids ___ times per day and ___ times per night. She uses no pads per day. She denies any urgency, she denies any dysuria and reports bladder emptying with interrupted flow. She denies any hematuria, kidney stones or pyelonephritis. Last UTI was in ___ Mrs. ___ also admits to some vaginal pressure and palpable prolapse. She also admits to constipation and is not sexually active. She denies any vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. HTN 2. DM 3. Hypercholesterolemia 4. Hypothyroidism 5. GERD PAST SURGICAL HISTORY 1. Eyelid surgery 2. ? cataract FAMILY/Soc Hx: Her family history is unremarkable for Breast, Ovarian or Colon cancer. She is married. She denies any current tobacco/illicit drug use She denies any ETOH PAST OB HISTORY Gravida 4 Para 3013 Vaginal: 3 PAST GYN HISTORY She denies having an abnormal Pap test She is Postmenopausal and denies post-menopausal bleeding. <PHYSICAL EXAM> INITIAL PHYSICAL EXAMINATION Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: Supple, 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 clubbing, cyanosis, edema or varicosities. Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: no lesions, no discharge Uterus: non-tender Adnexa: no masses non tender. POP-Q Exam: Aa: +1 Ba: +1 TVL: 8 D: -4.5 C: +0.5 ___: 4 PB: 3 Ap: -1.5 Bp: -1.5 ___ Exam: Cystocele: 2 Uterus/Cervix: 2 Vault: 2 Ant enterocele: Post enterocele: Rectocele: VAGINAL EXAM - There was moderate vaginal atrophy: Empty Supine Stress Test was: Positive ESST UROFLOW: Maximum flow: 2 ml/s Average flow: 3 ml/s Voiding time: 17 sec Flow time : 9 sec Voided vol : 29 ml Comments: Intermittent low flow Point of Care Urine Dipstick sheet entries: ___: Color: Yellow. ___: Glucose (mg/dL): Negative. ___: Bilirubin: Small. ___: Ketone (mg/dL): 15. ___: Specific Gravity: 1.020. ___: Blood: Trace-intact. ___: pH: 5.5. ___: Protein (mg/dL): Trace. ___: Urobilinogen (mg/dL): 0.2. ___: Nitrite: Negative. ___: Leukocytes: Large. <PERTINENT RESULTS> ___ 08: 10AM BLOOD WBC-8.5 RBC-3.55* Hgb-10.2* Hct-31.2* MCV-88 MCH-28.8 MCHC-32.7 RDW-13.5 Plt ___ ___ 08: 10AM BLOOD Plt ___ ___ 08: 10AM BLOOD Glucose-204* UreaN-10 Creat-0.5 Na-130* K-4.1 Cl-96 HCO3-24 AnGap-14 ___ 08: 10AM BLOOD Calcium-8.7 Phos-4.4# Mg-1.3* <MEDICATIONS ON ADMISSION> 1. Atenolol 100 mg PO DAILY 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY 3. Ibuprofen 400 mg PO Q6H: PRN pain take with food RX *ibuprofen 400 mg 1 tablet(s) by mouth q6h: prn Disp #*60 Tablet Refills: *0 4. Januvia (sitaGLIPtin) 100 mg oral qAM 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. NIFEdipine CR 30 mg PO DAILY 9. OxycoDONE (Immediate Release) 5 mg PO Q6H: PRN pain DO NOT: drive, take with alcohol or sedatives RX *oxycodone 5 mg 1 tablet(s) by mouth q6h: prn Disp #*40 Tablet Refills: *0 10. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation BID 11. TraMADOL (Ultram) 50 mg PO Q6H: PRN pain DO NOT: drive, take with alcohol or sedatives RX *tramadol 50 mg 1 tablet(s) by mouth q6h: prn Disp #*40 Tablet Refills: *0 12. Glargine 54 Units Breakfast Insulin SC Sliding Scale using HUM <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain do not take over 4000mg in 24 hours RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth q6h: prn Disp #*60 Tablet Refills: *0 2. Albuterol Inhaler ___ PUFF IH Q4H: PRN wheeze 3. Atenolol 100 mg PO DAILY 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Ibuprofen 400 mg PO Q6H: PRN pain take with food RX *ibuprofen 400 mg 1 tablet(s) by mouth q6h: prn Disp #*60 Tablet Refills: *0 6. Januvia (sitaGLIPtin) 100 mg oral qAM 7. Levothyroxine Sodium 25 mcg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. NIFEdipine CR 30 mg PO DAILY 11. OxycoDONE (Immediate Release) 5 mg PO Q6H: PRN pain DO NOT: drive, take with alcohol or sedatives RX *oxycodone 5 mg 1 tablet(s) by mouth q6h: prn Disp #*40 Tablet Refills: *0 12. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation BID 13. TraMADOL (Ultram) 50 mg PO Q6H: PRN pain DO NOT: drive, take with alcohol or sedatives RX *tramadol 50 mg 1 tablet(s) by mouth q6h: prn Disp #*40 Tablet Refills: *0 14. Glargine 54 Units Breakfast Insulin SC Sliding Scale using HUM Insulin <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 bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___ Ms. ___ underwent an uncomplicated total vaginal hysterectomy, bilateral salpingo-oophorectomy, tension free vaginal tape placement, and cystoscopy for pelvic organ prolapse and 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 ketorolac and hydromorphone. On post-operative day 1, she passed a formal voiding trial and subsequently voided spontaneously. Her diet was advanced without difficulty and she was transitioned to acetaminophen, ibuprofen, tramadol and oxycodone. By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Elevated BPs at office visit <MAJOR SURGICAL OR INVASIVE PROCEDURE> -- <HISTORY OF PRESENT ILLNESS> ___ G2P1 at 36w4d sent from ___ during routine monitoring after BP 164/104 in office. Repeat 180/120. Today at ___ per verbal report from Dr. ___ was ___, post placenta, ___, AFI 19, reactive NST, u dip negative for protein. Last weight 2 weeks ago 2321g 32%. Normal dopplers. <PAST MEDICAL HISTORY> PNC: no access to prenatal records *) Dating: EDC: ___ by LMP *) Labs: B+ /Ab neg /RPRNR/RI/HbsAg neg/HIV neg/GBS - *) Routine: - GLT: 91 - U/S: nl full fetal survey per pt - Genetics LR ERA *) Issues - cHTN, has been on aldomet 500 TID and procardia XL 30mg daily, nifedipine caused severe HA and was changed to labetalol 200mg TID on ___. No record of baseline 24 hour urine - Fibroids: R fundal 5cm, right mid 9cm, left fundal 5cm - Pt HbS carrier, FOB HbC carrier, previous infant Hb SC dz. Both p and FOB also alpha thal carriers. Saw genetics during last pregnancy, declined this pregnancy. POBHx: SVD at 37wga of 6#7oz infant, PEC PGynHx: Denies STDs or abnl paps, fibroids PMH: HTN PSH: None <SOCIAL HISTORY> Denies EtOH/ Smoking/ Drugs <PHYSICAL EXAM> Exam on admission: T 98.5 HR 76 RR 18 BP 172/101->172/101->182/111 General: NAD Cardiac: RRR Abdomen: soft, NT, gravid Pulm: CTA FHT: 130/mod var TOCO: irregular SVE: deferred until IV BP meds given Neuro: patellar reflexes 1+ and symmetric B/L <PERTINENT RESULTS> ___ WBC-14.4* RBC-4.15* Hgb-11.1* Hct-32.9* MCV-79* MCH-26.7* MCHC-33.6 RDW-15.5 Plt ___ ___ WBC-23.1*# RBC-4.70 Hgb-12.8 Hct-37.7 MCV-80* MCH-27.2 MCHC-33.9 RDW-16.3* Plt ___ ___ WBC-10.4 RBC-4.76 Hgb-12.9 Hct-38.3 MCV-80* MCH-27.2 MCHC-33.8 RDW-16.1* Plt ___ ___ Creat-0.6 ___ Creat-0.7 ___ Creat-0.6 ___ ALT-19 ___ ALT-22 ___ ALT-19 ___ UricAcd-5.8* ___ UricAcd-5.5 ___ UricAcd-4.8 <MEDICATIONS ON ADMISSION> labetalol 200mg TID, aldomet 500mg TID <DISCHARGE MEDICATIONS> 1. labetalol 200 mg Tablet Sig: Four (4) Tablet PO three times a day. Disp: *360 Tablet(s)* Refills: *2* 2. methyldopa 500 mg Tablet Sig: One (1) Tablet PO three times a day. Disp: *90 Tablet(s)* Refills: *2* 3. methyldopa 250 mg Tablet Sig: One (1) Tablet PO three times a day. Disp: *90 Tablet(s)* Refills: *2* 4. nifedipine 10 mg Capsule Sig: One (1) Capsule PO three times a day. Disp: *90 Capsule(s)* Refills: *2* 5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 6. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> s/p vaginal delivery, CHTN <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> See discharge instructions. Call for increased headache, blurred vision, worsening blood pressure.
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Ms. ___ presented to OB triage for evaluation of elevated BPs in the setting of chronic hypertension. While in triage she had elevated BPs as high as 180s/110s and received a total of 30 mg IV labetalol . Given her acutely elevated BPs the decision was made to proceed with induction of labor. Her blood pressures were maintained on oral labetalol. Her preeclampsia labs on admission were within normal limits. . After routine induction of labor she had a spontaneous vaginal delivery. Please see delivery note for full details. While on labor and delivery, immediately postpartum, her blood pressures again increased to 170s/100s so she received IV hydralazine with good response. She then had aldomet added to her oral regimen. Given the severity of her BPs she was started on post-partum magnesium which she remained on for 12 hours. The patient declined a full 24 hours of postpartum magnesium sulfate. . On post-partum day 2 her blood pressures were again elevated to the 180s/100s despite the labetalol 600 mg TID and aldomet 500 mg TID. She was transferred up to L+D for further monitoring where she received 5 mg IV hydralazine with good response. Her methyldopa was also titrated to 750 mg TID. She then was transferred back to the post-partum floor. On postpartum day 3 here blood pressures again started to increase and she nifedipine 10 mg TID was added to her regimen. Her blood pressure continued to remain acceptable on nifedipine 10 mg TID, labetalol 600 mg TID and 750 methyldopa. She was discharged home in good condition on post-partum day 3 with follow-up.
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10575218-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> oxycodone <ATTENDING> ___. <CHIEF COMPLAINT> Bartholin's Abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> Marupializatino of left Bartholin's gland abscess <HISTORY OF PRESENT ILLNESS> ___ year-old female here presenting to the ED due to continued vulvar pain and swelling. She reports that ___ she noted left sided vulvar swelling. She called her PCP who ___ TID which she started ___. Throughout the day she noted increased pain and swelling, subjective fevers started ___ with Tmax at home of ___ F. PO. Took Tylenol this am around 0300. Last ate 10 pm. Reports this is the ___ occurrence of similar symptoms ___ years ago had Bartholins cyst, s/p I&D and Word cath ___ years ago had another I&D. Last in ___ treated conservatively with Abx. ROS: Constitutional: + subjective fever. No nausea, vomiting, overly fatigued Endocrine: No unexplained weight changes, hair loss or heat/cold intolerance Psych: No feelings of depression, anxiety or inability to focus or concentrate Pulm: No cough, sputum, night sweats, wheezing CV: No chest pain, palpitations, difficulty breathing while walking GI: No diarrhea, constipation, black stools, red blood per rectum, or dyspepsia GU: No dysuria, leaking, frequency, or bloody urine GYN: No discharge, excessive bleeding or abnormal bleeding <PAST MEDICAL HISTORY> PGYNHx: Recurrent Bartholin's cysts/abscesses. ___, current Menses: regular Fibroids/ STIs: denies Sexually active: yes, with one partner- husband. Contraception: Implant x ___ year ___ abnormal Paps: denies POBHx: SVD x 1, ___ years ago. denies complications PMH: denies PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> PHYSICAL EXAM on ADMISSION Pain ___ 99.1 98 134/80 18 100%ra 97.9 58 125/79 18 98%ra GEN: WN/WD, NAD HEENT: grossly normal LUNGS: Clear bilaterally CARDIAC: RRR. No murmurs ABD: Soft, NT, ND, No HSM, No masses EXT: No CT, No edema PHYSICAL EXAM on DISCHARGE Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, nt, nd Pelvic: Left sided vaginal incision c/d/I. Minimal spotting on pad. Mild erythema, improved since day prior. Ext: no TTP <PERTINENT RESULTS> ___ 05: 48AM BLOOD WBC-9.8 RBC-3.61* Hgb-10.9* Hct-33.6* MCV-93 MCH-30.2 MCHC-32.4 RDW-13.0 RDWSD-44.8 Plt ___ ___ 07: 00PM BLOOD WBC-12.0* RBC-3.64* Hgb-11.1* Hct-33.3* MCV-92 MCH-30.5 MCHC-33.3 RDW-13.2 RDWSD-45.1 Plt ___ ___ 05: 49AM BLOOD WBC-15.3* RBC-4.40 Hgb-13.4 Hct-40.6 MCV-92 MCH-30.5 MCHC-33.0 RDW-13.3 RDWSD-44.8 Plt ___ ___ 05: 48AM BLOOD Neuts-80.1* Lymphs-12.0* Monos-6.7 Eos-0.2* Baso-0.4 Im ___ AbsNeut-7.85* AbsLymp-1.18* AbsMono-0.66 AbsEos-0.02* AbsBaso-0.04 ___ 07: 00PM BLOOD Neuts-79.8* Lymphs-12.1* Monos-6.7 Eos-0.3* Baso-0.4 Im ___ AbsNeut-9.59* AbsLymp-1.45 AbsMono-0.81* AbsEos-0.04 AbsBaso-0.05 ___ 05: 49AM BLOOD Neuts-83.2* Lymphs-9.5* Monos-6.1 Eos-0.3* Baso-0.4 Im ___ AbsNeut-12.77* AbsLymp-1.45 AbsMono-0.94* AbsEos-0.04 AbsBaso-0.06 ___ 05: 48AM BLOOD ___ PTT-37.0* ___ ___ 07: 00PM BLOOD ___ PTT-36.9* ___ ___ 07: 00PM BLOOD ___ ___ 05: 48AM BLOOD Glucose-86 UreaN-7 Creat-0.5 Na-140 K-4.4 Cl-107 HCO3-24 AnGap-13 ___ 05: 49AM BLOOD Glucose-107* UreaN-10 Creat-0.8 Na-134 K-8.3* Cl-104 HCO3-21* AnGap-17 ___ 05: 48AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.2 ___ 06: 00AM BLOOD K-7.2* . ___ 05: 35AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05: 35AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM ___ 05: 35AM URINE RBC-4* WBC-3 Bacteri-FEW Yeast-NONE Epi-4 ___ 05: 35AM URINE Mucous-OCC ___ 05: 35AM URINE UCG-NEGATIVE . GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Pending): Blood Culture, Routine (Pending): x2 . Pathology Pending <MEDICATIONS ON ADMISSION> Bactrim Tylenol <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H Maximum 4000 mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain Do not drive while taking. RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *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 5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*28 Tablet Refills: *0 1. Acetaminophen ___ mg PO Q6H Maximum 4000 mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain Do not drive while taking. RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *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 5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*28 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> left Bartholin's gland abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service with a left Bartholin's gland abscess. You underwent surgical marsupialization. You have recovered well and the team believes you are ready to be discharged home on oral antibiotics. 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 for 4 weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower. * Please use ___ bath (or take a bath) three times daily for soaking. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. You are being discharged with antibiotics. Please take as prescribed.
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On ___, Ms. ___ was admitted to the gynecology service after being seen in the Emergency Department for a Bartholin's abscess. She was taken to the operating room on hospital day 1 for a Batholin's marsupialization and biopsy of cyst base for a recurrent Bartholin's abscess with overlying cellulitis and failed conservative management. . Initially on presenting to hospital, patient was febrile with a Tmax of 101.6. She was initiated on IV clindamycin and IV vancomycin for 24 hours afebrile. After, she was transitioned to a 14 day course of oral augmentin and remained afebrile during hospital stay. . Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with oral ibuprofen and acetaminophen around the clock with oral or IV dilaudid for breakthrough pain. Her vaginal packing and surgical were removed on post-operative day 1. Her diet was advanced without difficulty and she was able to tolerate a regular diet. She was able to void spontaneously the entire hospital stay. . 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 on oral antibiotics in stable condition with outpatient follow-up scheduled.
| 2,390
| 275
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10575317-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> nausea/vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Patient is a ___ year old G1P0 at approximately 15+2 weeks by unsure LMP of ___ presenting to the ED with nausea and vomiting unable to tolerate PO intake for 3 days. Patient reports a history of hyperemesis gravidarum since about 8 weeks gestation. She was seen for an initial prenatal visit by RN-Midwife at ___. She denies having had any ultrasounds yet. She has had her initial prenatal labs. She had a prescription for PO Zofran which she said was not helping. She was seen twice at the ___ urgent care unit for IVF and IV antiemetics. Symptoms persisted for 1 month before spontaneous resolving. Her symptoms recurred on ___ with severe nausea and vomiting. Last meal was chicken soup on that date which she could not keep down. She has tried water and ginger ale which also makes her nauseated. She is not currently taking any antiemetics. ROS: (+) Back/shoulder pain with emesis, (+) epigastric pain with emesis, (+) chills, (+) 8 lb weight loss. Denies fever, myalgias, diarrhea, SOB, dizziness, rhinorrhea, cough. No sick contacts. Seasonal flu shot 1 month ago. No H1N1. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ by 17wk U/S (changed from initial ___ ___ *)Labs: A+/Ab-,RI,HbsAg-,RPRnr,HIV-,GC/CT- *)CF negative, nl hgb electrophoresis *)No screening/ultrasound prior to this admission PAST OBSTETRIC HISTORY G1 PAST GYNECOLOGIC HISTORY - no paps yet - denies STDs - normal menses PAST MEDICAL HISTORY denies PAST SURGICAL HISTORY denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> (on admission) PE: T 97.8->98.4, BP 129/62->103/56, P ___, RR 20, O2 100% FHR: 156 bpm GENERAL: appears tired and weak, lying in stretcher. CV: RRR ABDOMEN: soft, gravid, tender to palpation in epigastrium, mildly tender RLQ EXTREMITIES: no edema (___) RUQ ULTRASOUND IMPRESSION: Normal-appearing gallbladder. No findings to suggest acute cholecystitis. ___ FETAL SURVEY There is a single live intrauterine pregnancy with fetus in cephalic position. The placenta is fundal. There is no evidence of previa. There is a normal amount of amniotic fluid. Views of the head, face, stomach, cord insertion site, bladder were normal. There is an echogenic focus in the left cardiac ventricle. There is polydactyly in the left hand and probably polydactyly in the left foot. Both kidneys show caliectasis measuring 3 mm. The following biometric data were obtained: BPD: 17 weeks 2 days HC: 16 weeks 6 days AC: 17 weeks 4 days FL: 17 weeks 5 days AGE BY ULTRASOUND: 17 weeks 2 days AGE BY LMP: 15 weeks 3 days EFW: 199g IMPRESSION: Single live intrauterine pregnancy at 17 weeks 2 days. There is an echogenic focus in the left ventricle. Bilateral caliectasis without hydronephrosis. Left hand polydactyly. <PERTINENT RESULTS> ___ WBC-12.7 RBC-3.63 Hgb-10.7 Hct-32.5 MCV-89 Plt-460 ___ Neuts-90.2 ___ Monos-2.1 Eos-0.2 Baso-0.1 ___ ___ PTT-30.7 ___ ___ Glu-97 BUN-4 Cre-0.5 Na-138 K-3.4 Cl-107 HCO3-14 ___ Glu-89 BUN-3 Creat-0.4 Na-139 K-3.1 Cl-111 HCO3-16 ___ Glu-86 BUN-2 Creat-0.3 Na-138 K-3.2 Cl-109 HCO3-18 ___ ALT-9 AST-13 AlkPhos-48 TotBili-0.5 Lipase-17 ___ Calcium-8.7 Phos-2.1 Mg-1.5 TSH-0.062 ___ Calcium-8.4 Phos-3.8 Mg-2.0 ___ Calcium-7.7 Phos-2.6 Mg-1.5 ___ BLOOD T4-11.0 T3-149 Lactate-0.9 ___ BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY EIA URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> Flintstones vitamins <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 17 weeks gestation hyperemesis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> try to stay hydrated. Use medication as needed for your nausea. call your doctor with any abdominal pain/cramping, leaking of fluid, vaginal bleeding, fevers > 100.4, persistent nausea/vomiting, unable to tolerate fluids, or with any questions or concerns you may have
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___ G1 admitted at 17+1 weeks gestation with hyperemesis. . Ms ___ was admitted for IV hydration, antiemetics, and electrolyte repletion. She complained of epigastric pain and she underwent a right upper quandrant ultrasound which was normal. Her ___ was recalculated based on her full fetal survey. An additional finding on her fetal survey included an echogenic focus in the left ventricle and bilateral caliectasis without hydronephrosis, and left hand polydactyly. Ms ___ was counseled regarding these findings and opted to have a Quad Screen and declined an amniocentesis. The Quad screen was sent during this admission. By hospital day #3, she was tolerating po's and was discharged home. She will have close outpatient followup.
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10575410-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> intrauterine fetal demise <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P1 at ___ who presents to L&D from ___ with confirmed IUFD. Patient was seen in clinic earlier today with report of DFM today. No FHR able to be appreciated in clinic and patient was sent to ___ for ultrasound. IUFD was confirmed in ___ and an amniocentesis was performed. Patient presents today with mother and father. She denies any abdominal pain, bleeding, or LOF. No contractions or abnormal discharge. She denies any fevers, chills, or recent sick contacts. No HA, CP, SOB. <PAST MEDICAL HISTORY> PNC: - Labs O+/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg - Screening: neg zika testing, ___ wnl. per pt genetic testingof donors all negative pt herself neg for CF , neg ___ panel, neg fragile x and neg SMA inpast - FFS: wnl - GLT: nl - U/S: (___) IUFD confirmed. FHR 0. EFW 2370g, 55%. AFI 19.6. Amniocentesis performed with collection sample of 30cc fluid. (___) EFW 1842g, 97%. AC >98%. No fetal morphologic abnormalities. AFI 23. OBHx: - G1: c/s for arrest of decent. 7lb 15oz. - G2: current. IVF pregnancy with donor egg (donor age ___ and donor sperm. GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - anxiety/depression: on celexa and followed by therapist - hx of back pain and degenerative disc disease PSH: - LTCS - knee surgery - foot surgery - finger surgery <SOCIAL HISTORY> SHx: denies T/E/D <PHYSICAL EXAM> VS: ___ 14: 08BP: 143/80 (92) ___ ___: 87 ___ 14: 08Temp.: 97.9°F ___ 14: 08Resp.: 20 / min Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness SVE: L/C/P @ 1325 per Dr ___: flat <PERTINENT RESULTS> ___ 01: 56PM BLOOD WBC-10.9* RBC-3.97 Hgb-10.5* Hct-32.3* MCV-81* MCH-26.4 MCHC-32.5 RDW-15.1 RDWSD-44.2 Plt ___ ___ 03: 25AM BLOOD WBC-14.6*# RBC-3.39* Hgb-8.7* Hct-28.0* MCV-83 MCH-25.7* MCHC-31.1* RDW-15.2 RDWSD-45.0 Plt ___ ___ 03: 55PM BLOOD WBC-18.6* RBC-2.50* Hgb-6.7* Hct-20.1* MCV-80* MCH-26.8 MCHC-33.3 RDW-15.1 RDWSD-43.8 Plt ___ ___ 09: 15AM BLOOD WBC-10.1* RBC-2.89* Hgb-8.0* Hct-24.7* MCV-86 MCH-27.7 MCHC-32.4 RDW-15.5 RDWSD-47.9* Plt ___ ___ 01: 56PM BLOOD ___ PTT-27.0 ___ ___ 01: 56PM BLOOD Plt ___ ___ 07: 24PM BLOOD ___ PTT-25.7 ___ ___ 05: 43PM BLOOD ___ ___ 01: 56PM BLOOD ALT-23 LD(___)-___* ___ 09: 57AM BLOOD ALT-14 AST-35 <DISCHARGE INSTRUCTIONS> Void every 2 to 3 hours. Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the ___ Clinic or Emergency Line if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting or any other concerns.
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Ms. ___ was admitted to labor and delivery on ___. She was seen by social work, chaplain services and maternal fetal medicine consult. She was started on Pitocin for induction of labor. A foley balloon was placed for cervical ripening. She received dilaudid and then an epidural for pain control. She progressed to fully dilated and began to push. She had a spontaneous vaginal delivery of a stillborn female infant on ___. There was some uterine atony and 1000mcg misoprostol were placed rectally. There was a second degree laceration that was repaired in the typical fashion. Initial EBL was 300mL. She intermittently had further bleeding constituting a post partum hemorrhage. She was taken to the operating room for an US guided D&C and Bakri balloon placement. She received 1 g Ancef, 1 unit pRBC, 3 units FFP, 1 unit of cryoprecipitate, total EBL 1500cc due to intermittent atony. She also received an additional 60 units of pitocin, and 2 doses of hemabate. Her post operative HCT was noted to be 20.1 and she was subsequently transfused an additional 2 units of packed RBCs, with a post transfusion HCT of 22.2. On PPD#1, her Bakri balloon and vaginal packing was removed. On PPD#1, Her foley catheter was removed but she was only able to void ___ after 8 hours. Foley was replaced for 620cc given urinary retention. It was kept in place for 18 hours and she was able to void spontaneously. On PPD#2, she was noted to have chest pressure. She had a stat EKG done which did not show any signs of ischemia. Troponin was negative. CBC showed improving HCT of 24.7. Her chest pressure resolved spontaneously. For her gestational hypertension, she had normal PIH labs and a negative P:C on admission. Her BPs remained in the normal to mild range and she did not have any pre-eclampsia symptoms. Given IUFD, she was followed by social work and chaplain services. By PPD#2, she was discharged home in stable condition with close follow up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 2. Dermoplast Spray 1 SPRY TP Q6H:PRN perineal pain 3. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 5. Citalopram 20 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: -vaginal delivery after history of C-section -IUFD at 33 weeks -gestational hypertension -postpartum hemorrhage s/p uterotonics, D&C, Bakri balloon, vagainal packing and blood products transfusion (3 units pRBC, 3 unit FFP, 1 unit cryo -urinary retention, s/p bladder rest with foley catheter, post void residual 92 cc. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10575410-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Transferred to NICU proximity <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ ___ (1 IUFD) s/p VBAC on ___ at 33 weeks transferred for NICU proximity. Patient was visiting family in ___ when she went into pretem labor and delivered at an OSH. Per patient and records, delivery was an uncomplicated VBAC with EBL ~ 300cc and a second degree perineal laceration. She has a history of Factor V Leiden (heterozygous per patient, homozygous per records) with a plan to contine ppx lovenox 40mg SC for 6 weeks postpartum. Baby is in NICU doing well, breathing on own. Ambulating and voiding without difficulty. Pain adequately controlled. Lochia moderate. <PAST MEDICAL HISTORY> PNC: - Labs O+/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg - Screening: neg zika testing, Harmony wnl. per pt genetic testingof donors all negative pt herself neg for CF , neg ___ panel, neg fragile x and neg SMA inpast - FFS: wnl - GLT: nl - U/S: (___) IUFD confirmed. FHR 0. EFW 2370g, 55%. AFI 19.6. Amniocentesis performed with collection sample of 30cc fluid. (___) EFW 1842g, 97%. AC >98%. No fetal morphologic abnormalities. AFI 23. OBHx: - G1: c/s for arrest of decent. 7lb 15oz. - G2: current. IVF pregnancy with donor egg (donor age ___ and donor sperm. GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - anxiety/depression: on celexa and followed by therapist - hx of back pain and degenerative disc disease PSH: - LTCS - knee surgery - foot surgery - finger surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> PHYSICAL EXAM - limited given that patient was seen and examined in the NICU ___ 2345 Temp: 97.8 PO BP: 116/75 R Sitting HR: 73 RR: 18 O2 sat: 96% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___ Gen: Well-appearing, sitting comfortably with baby CV: well-perfused Lungs: Normal work of breathing Abdomen: soft, appropriately tender without rebound Ext: WWP <DISCHARGE INSTRUCTIONS> nothing in the vagina for 6 weeks
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Patient is s/p VBAC and was hospitalized for 2 days for routine postpartum care. She was discharged home with Lovenox for FVL heterozygosity. Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 1 once a day Disp #*42 Syringe Refills:*1 3. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Vaginal birth Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10578209-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic bilateral salpingo-oopherectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ female with metastatic pancreatic cancer s/p C10 Pembrolizumab with ___ who has had anenlarging right ovarian cyst evaluated by Gyn/onc with plan for resection on ___, now presenting with acutely worsening RLQ pain and inability to eat. Patient found to have an enlarging multiloculated cystic adnexal structure measuring 13.___b/pelvis on ___ that had enlarged from 8 cm on previous imaging. Given concern for possible pancreatic metastasis vs primary ovarian cancer vs benign ovarian mass, she was evaluated by OB/GYN with plan for laproscopic resection on ___ ___. Planned for bilateral salpingoopherectomy. Patient presented to outpatient clinic with acute increase in right sided abdominal pain, fatigue and inability to eat given significant pain. She has been sleeping through most of the day. Noted pain radiating to the right upper quadrant as well. She had an episode of diarrhea after taking laxative to help with bowel movements. Otherwise review of system was negative per clinic note without fever/chills or night sweats. She was admitted from clinic for pain management, hydration and urgent evaluation by GYN/ONC given acute worsening of abdominal pain and symptoms. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Anal Fissure Neuropathy The patient denies any history of asthma, heart disease, diabetes, hypertension, thromboembolic disorder. She reports that she is up-to-date with mammograms and colonoscopies. PAST SURGICAL HISTORY: denies OB/GYN history: G0, ___ years postmenopausal. She denies any history of abnormal Pap smears. She denies any history of pelvic infections. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother died at age ___ of complications of ___ disease. Mother also had ___. Maternal aunt died of ovarian cancer in her ___. Maternal uncle died of diabetes. Father had a history of polyps. Brother, ___, alive and well. Paternal grandmother had colon cancer in her ___ or ___. <PHYSICAL EXAM> Discharge: Vitals: stable and within normal limits General: NAD, comfortable appearing. Neuro: AxO x 3, affect appropriate. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Cardiovascular: RRR, no rubs/murmurs/gallops. Pulmonary: normal rate and work of breathing, Lungs CTAB Abdomen: normoactive bowel sounds. Soft, minimally tender to palpation, nondistended. No rebound/guarding. Incisions c/d/I without surround erythema or induration GU: minimal blood on pad MSK: Lower extremities without edema, erythema, or TTP. Pneumoboots in place. <PERTINENT RESULTS> --======== LABS ON ADMISSION --======== ___ 09: 53AM BLOOD WBC-5.7 RBC-3.81* Hgb-11.7 Hct-33.7* MCV-89 MCH-30.7 MCHC-34.7 RDW-15.0 RDWSD-47.8* Plt ___ ___ 09: 20AM BLOOD ___ PTT-31.6 ___ ___ 09: 20AM BLOOD UreaN-16 Creat-0.4 Na-138 K-3.9 Cl-103 HCO3-20* AnGap-15 ___ 09: 20AM BLOOD ALT-16 AST-20 AlkPhos-204* TotBili-0.6 ___ 09: 20AM BLOOD Albumin-4.6 Calcium-8.7 Phos-2.5* Mg-2.4 ___ 06: 55PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06: 55PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD* ___ 06: 55PM URINE RBC-<1 WBC-5 Bacteri-FEW* Yeast-NONE Epi-1 ___ 06: 55PM URINE Mucous-RARE* URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL. LACTOBACILLUS SPECIES. 10,000-100,000 CFU/mL. --======== IMAGING ON ADMISSION --======== Pelvic ultrasound ___: 1. Limited assessment due to large pelvic cystic mass which was better visualized on prior CT performed ___. 2. The ovaries are not definitively visualized. Trace free fluid. 3. Tubular right adnexal structure may represent a hydrosalpinx. --======== Pathology: --======== Bilateral Tubes and Ovaries, and Pelvic Washings ___: Pending --======== RELEVANT IMAGING: --======== ___ 05: 01AM BLOOD WBC-4.0 RBC-3.13* Hgb-9.6* Hct-28.3* MCV-90 MCH-30.7 MCHC-33.9 RDW-15.0 RDWSD-48.8* Plt ___ ___ 05: 01AM BLOOD ___ PTT-30.0 ___ ___ 05: 01AM BLOOD Glucose-127* UreaN-9 Creat-0.4 Na-142 K-3.8 Cl-110* HCO3-21* AnGap-11 ___ 05: 01AM BLOOD ALT-12 AST-15 AlkPhos-167* TotBili-0.3 ___ 05: 01AM BLOOD Calcium-7.4* Phos-2.4* Mg-2.2 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. LORazepam 1 mg PO QHS: PRN insomnia 2. Ondansetron 8 mg PO Q8H: PRN nausea 3. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate 4. Omeprazole 20 mg PO DAILY 5. Prochlorperazine 10 mg PO Q6H: PRN nausea 6. Senna 17.2 mg PO BID 7. Docusate Sodium 200 mg PO BID 8. Creon 12 2 CAP PO TID W/MEALS 9. Montelukast 10 mg PO DAILY 10. Cetirizine 10 mg PO DAILY 11. Naproxen 500 mg PO BID <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q8H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 3. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills: *2 4. OxyCODONE (Immediate Release) 10 mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*60 Tablet Refills: *0 5. Cetirizine 10 mg PO DAILY 6. Creon 12 2 CAP PO TID W/MEALS 7. Docusate Sodium 200 mg PO BID 8. LORazepam 1 mg PO QHS: PRN insomnia 9. Montelukast 10 mg PO DAILY 10. Naproxen 500 mg PO BID 11. Omeprazole 20 mg PO DAILY 12. Ondansetron 8 mg PO Q8H: PRN nausea 13. Prochlorperazine 10 mg PO Q6H: PRN nausea 14. Senna 17.2 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pancreatic cancer, adnexal/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 hospital with worsening abdominal pain. The gynecologic oncology service evaluated you and determined that you needed surgery to remove the mass in your right pelvis. 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) until the post-op visit in about 6 weeks * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . 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 ___. Best wishes, Your ___ GYN Oncology Team
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Ms. ___ is a ___ year old woman with a history of metastatic pancreatic cancer and a known right pelvic cystic mass who presented with worsening right lower quadrant (RLQ) pain. Upon presentation, she was hemodynamically stable. Her exam was notable for a mobile right adnexal mass without nodules or tethering. GYN/Oncology was consulted, and she was initially admitted to the Medical Oncology service for observation. Labs showed anemia at baseline (___), normal white blood cell count and chemistries (except for elevated Alkaline phosphatase which was ___ elevated to 204). The pelvic ultrasound re-demonstrated the large pelvic, complex cystic mass. She was initially admitted to the Medical Oncology floor for observation. She continued to experience severe pain overnight from hospital day ___ requiring opiate analgesia. The decision was made to proceed with bilateral salpingo-oopherectomy, and the patient was transferred to the Gynecologic Oncology service. Intraoperatively, the large cystic mass appeared to replace the left ovary. There was also military studding on the pelvic peritoneum and mesentery. Estimated blood loss was 25 ml. Please see the operative report for further details. Post-operatively, she recovered well. Immediately postoperatively, her pain was controlled with IV morphine. Her diet was advanced without difficulty and she was transitioned to oral acetaminophen, ibuprofen, and oxycodone. On post-operative day #0, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Regarding her pancreatic cancer, she was in an ongoing clinical trial (#protocol ___ with ___ and Pembrolizumab. Overall, this issue was stable and there were no changes to the specific plan of care. By post-operative day #1 (hospital 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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10578317-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal/pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, ovarian cystectomy, endometrioma drained <HISTORY OF PRESENT ILLNESS> ___ yo G1P1 transferred from OSH with sudden onset pelvic pain. She was in her usual health until this morning at 10 am when she developed sudden onset midline pelvic pain. The pain is sharp and constant now but was originially cramping "like labor" and non radiating. She was standing up from sitting when the pain started. She has never had pain like this before. Movement makes the pain worse and IV morphine makes it better. She denies fevers or chills. She reports nausea associated with pain and emesis x 1 this morning when the pain started. She denies any abnormal vaginal discharge. She denies early satiety, change in abdominal girth, recent weight loss or gain. (She has lost #50 slowly over the last ___ years through diet and exercise). She denies urinary symptoms or diarrhea. LMP was ~ ___. regular menses. She was seen in an OSH ED where an abd CT showed, " 6.2 cm simple cyst in the right ovary and a 3.5 cm and 4.1 cm complex appearing cyst on the left ovary. diffuse mesenteric intestinal wall edema is noted " A pelvic ultrasound showed, "uterus measuring 8.5 x 3.8 x 4.6. 9 mm endometrium. Right ovary measuring 6.8 x 4.3 x 6.3 cm. Left ovary measures 6.5 x 3.7 x 4.5 cm with a 3.2 x 3.0 x 2.9 cm cyst with low level echos (? hemorrhagic cyst vs endometrioma). There is a 3.4 x 1.9 x 2.6 cm atypical cyst posterior to the uterus with a thin septation. small amount of free fluid." In the OSH ED her vital signs were: T 98, HR 88, RR 22, BP 100/50, 99% RA. A WBC was 16.2 and Lipase was 109. glucose was 150. She received 500 mg IV flagyl, 750 mg PO Levaquin, morphine, zofran and she was tranferred to ___ for further management. <PAST MEDICAL HISTORY> POBHx: SVD x 1 ___ years ago. During pregnancy a 9 cm dermoid cyst in the right ovary was present and was followed through the pregnancy which she was told resolved on 6 week postpartum follow up ultrasound. PGynHx: Denies STD's / no abnl paps / no fibroids. Sexually active with husband, believes monogamous. PMH: denies PSH: femoral hernia as a child <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VS: 99.1 86 113/71 16 98% RA 5"2, 170# NAD CTA RRR Abd: diffuse mild tenderness to palpation, no rebound or guarding. focal TTP in LLQ Bimanual: palpable firm mobile mass in LLQ which is exquisitely tender to palpation with voluntary guarding. on discharge: VSS, afebrile NAD, comfortable RRR, CTAB abd soft, NT, ND incision c/d/i no edema <PERTINENT RESULTS> ___ 06: 50AM BLOOD WBC-6.1# RBC-2.57* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.4 MCHC-33.1 RDW-14.2 Plt ___ ___ 09: 30AM BLOOD WBC-13.5* RBC-3.25* Hgb-10.0* Hct-29.7* MCV-91 MCH-30.7 MCHC-33.6 RDW-12.8 Plt ___ ___ 04: 05AM BLOOD WBC-25.9* RBC-3.80* Hgb-11.5* Hct-34.8* MCV-92 MCH-30.1 MCHC-32.9 RDW-13.2 Plt ___ ___ 06: 30PM BLOOD WBC-18.9* RBC-4.62 Hgb-13.7 Hct-42.2 MCV-91 MCH-29.7 MCHC-32.5 RDW-12.8 Plt ___ ___ 06: 30PM BLOOD Neuts-92.8* Lymphs-4.0* Monos-2.5 Eos-0.3 Baso-0.3 ___ 09: 30AM BLOOD ___ PTT-27.3 ___ ___ 04: 05AM BLOOD Plt ___ ___ 04: 05AM BLOOD ___ PTT-28.1 ___ ___ 06: 30PM BLOOD ___ PTT-28.2 ___ ___ 09: 30AM BLOOD ___ 04: 05AM BLOOD ___ 06: 30PM BLOOD ESR-9 ___ 06: 50AM BLOOD Glucose-109* UreaN-7 Creat-0.5 Na-139 K-3.5 Cl-106 HCO3-30 AnGap-7* ___ 09: 30AM BLOOD Glucose-136* UreaN-8 Creat-0.5 Na-138 K-4.1 Cl-105 HCO3-27 AnGap-10 ___ 04: 05AM BLOOD Glucose-184* UreaN-9 Creat-0.6 Na-138 K-3.9 Cl-106 HCO3-23 AnGap-13 ___ 06: 30PM BLOOD Glucose-160* UreaN-12 Creat-0.5 Na-137 K-4.0 Cl-103 HCO3-24 AnGap-14 ___ 06: 30PM BLOOD ALT-14 AST-20 LD(LDH)-184 AlkPhos-80 TotBili-0.5 ___ 06: 30PM BLOOD CRP-11.7* CEA-<1.0 CA125-68* ___ 06: 46PM BLOOD Lactate-1.4 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *2* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* 4. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day: take with colace to avoid constipation. Disp: *60 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrioma and ovarian cysts <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. 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 ___ with acute onset abdominal pain and imaging findings notable for complex cystic structures on the bilateral ovaries with irregular walls and homogeneous internal echos, + flow, + free fluid, concerning for endometriomas. She underwent diagnostic LSC, ex-lap, right ovarian cystectomy, extenstive LOA, left ovarian cyst drainage for ruptured endometrioma. Intraoperative findings were notable for severe and extensive endometriosis with evidence of left ovarian endometrioma cyst rupture, diffuse cyst material coating abd. Intraoperative surgical consult was called to assist in visualization and repairing retroperitoneal bleeding branch adjacent to IP; total EBL was 1000cc. Post-operatively, she did well. Her post-operative course was routine and her pain greatly improved. She was discharged to home on POD 1/ HD 2 in good condition with ob/gyn follow-up.
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10580442-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Metastatic gallbladder cancer and a right ovarian mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic omental biopsy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old female with known metastatic gallbladder cancer who is undergoing chemotherapy. She initially was noted to have asymptomatic jaundice after presenting with a rash that was diagnosed as Lyme disease. She underwent ERCP in ___ and was found to have gallbladder cancer with metastases to the liver and lung, as well as a pulmonary embolism. An 8cm adnexal mass was also noted on her CT. Gyn Onc was consulted in ___ for postmenopausal bleeding and evaluation of the adnexal mass. She underwent an endometrial biopsy that was benign. Her pelvic ultrasound showed a 8 cm large mass in the right adnexa with solid and cystic components that was concerning for an ovarian mass, as well as a 2cm endometrial lesion and a 2 cm structure on the left side consistent with an enlarged lymph node. Since then, she has undergone three cycles of gemcitabine/cisplatin between ___ and ___. Her CA ___ initially declined with treatment. She underwent surveillance CT on ___ that showed relatively stable disease in the lungs and liver, however there was noted to be interval progression of metastatic disease with persistent omental studding, a new soft tissue mass adjacent to the cecum, and interval increase in the size of the right ovarian mass to 12.5cm, which was slightly compressing the bladder and sigmoid colon. These new findings were felt to represent either metastatic gallladder cancer versus a second ovarian primary cancer. A CA-125 was checked and was 158 on ___. Her CA ___ also slightly increased when most recently checked and was ___ on ___, up from ___. Per Dr. ___ recent clinic note, her recommendations for chemotherapy would varify depending on the type of malignancy suspected. Specifically, if the pelvic findings were consistent with a metastatic gallbladder cancer, she would recommend treatment with FOLFOX. If the pelvic disease was primary ovarian cancer, however, she would recommend carboplatin/paclitaxel. Dr. ___ ___, who indicated the omental nodules were not amenable to biopsy. Therefore, the patient was referred to Gyn Oncology for consideration of diagnostic laparoscopy and omental biopsy for tissue diagnosis of omental disease. Today in clinic, patient reports doing well with no complaints. Previously had anorexia with chemotherapy, but reports improved appetite now on Zyprexa with weight gain of two pounds recently. Endorses having persistent mild, intermittent vaginal spotting, which she notices sporadically on her underwear. No bleeding on toilet paper with wiping. Denies abdominal or pelvic pain, nausea, vomiting, abnormal vaginal discharge. <PAST MEDICAL HISTORY> PAST ONCOLOGIC HISTORY: - ___ when she was diagnosed with Lyme disease. During that visit she was found to have jaundice - ___ CT identified a gallbladder mass. - ___ ERCP on identified a gallbladder stricture, and brushings were positive for adenocarcinoma. - ___ CT torso showed a liver mass centered at the gallbladder measuring 7.8 x 6 0 x 6.6 cm occupying segment V of the liver with associated periportal and mediastinal lymphadenopathy, also with bilateral lung nodules. Her ___ ___ U/ml. - ___: combination chemotherapy with gemcitabine/cisplatin x 3 cycles - ___: relatively stable disease in the lungs and liver, interval progression of metastatic disease with persistent omental studding, a new soft tissue mass adjacent to the cecum, and interval increase in the size of the right ovarian mass to 12.5cm, which was slightly compressing the bladder and sigmoid colon - ___: CA-125 158, CA ___ ___ GynHx: no h/o abnormal Pap, menopausal age ___ without postmenopausal bleeding prior to this setting under anticoagulation. last Pap at time of ED presentation ___ normal. OBHx: G3P3 with SVD x3, no pregnancy complications, children all living PMHx: Cholangiocarcinoma, obstructive jaundice, pulmonary embolism on anticoagulation and IVC filter in place, h/o lyme Health maintenance: has not had ___, colonoscopy or DEXA Surg Hx: - ERCP x2, permanent biliary stent in place. - IVF filter placed ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> No hx of gynecologic cancers in her family. Specifically, no history of ovarian, endometrial, cervical, breast, or colon cancer. <PHYSICAL EXAM> At the time of discharge: Afebrile, vital signs stable Gen: no acute distress, comfortable, thin, elderly CV: Regular rate and rhythm, ___ systolic murmur Pulm: clear to auscultation bilaterally Abd: soft, non-tender, no rebound/guarding, non-distended, incisions with overlying dressings appear clean/dry/intact Ext: non-tender, no edema <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> 1. DEXAMETHASONE - dexamethasone 4 mg tablet. 1 tablet(s) by mouth daily for three additional days following chemotherapy 2. ENOXAPARIN - enoxaparin 60 mg/0.6 mL subcutaneous syringe. 55 mg subcutaneous Q12hour for cancer associated pulmonary embolism; ICD-9 156.9 - (Dose adjustment - no new Rx) 3. OLANZAPINE [ZYPREXA] - Zyprexa 5 mg tablet. 1 tablet(s) by mouth at bedtime as needed for nausea and loss of appetite increase to BID as tolerated 4. ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth q8hour as needed for nausea/vomiting 5. PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet. 1 tablet(s) by mouth q6hour as needed for nausea/vomiting <DISCHARGE MEDICATIONS> 1. Enoxaparin Sodium 55 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 2. OLANZapine 5 mg PO DAILY PRN anxiety 3. OxycoDONE (Immediate Release) 5 mg PO Q6H: PRN pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cholangiocarcinoma, adnexal mass, urinary retention <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. * No heavy lifting of objects >10lbs for ___ weeks. * You may eat a regular diet. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. There are white steri-strips underneath, 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 a laparoscopic omental biopsy. Please see the operative report for full details. Her post-operative course is detailed as follows. Her post-operative course was complicated by possible urinary retention. In the OR, she produced 250cc of urine and her foley catheter was removed at the end of the case. In the PACU, she voided 75cc, however, there was concern that she was retaining urine so a foley catheter was reinserted for 175cc. On post-operative day #1, her urine output was adequate so her foley catheter was removed and she passed a voiding trial ___ instilled, 200cc voided within 20 minutes). She continued to void spontaneously without difficulty. Postoperatively, she did not require any pain medications. Her diet was advanced without difficulty and she was eating a regular diet on post-operative day #1. Early in the morning on post-operative day #1, she spiked a temperature to 100.5 degrees fahrenheit. She was asymptomatic at the time with a heart rate in the low 100s, which was her baseline. Her exam was non-focal. She spontaneously defervesced within one hour and remained afebrile through the course of the day. By the afternoon of 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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10584073-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal Bleeding, fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> D+C <HISTORY OF PRESENT ILLNESS> ___ s/p medical abortion ___ at 7w1d, at Planned Parenthood, presents with fever x 24h (Tmax 103.0 ___ ___ and vaginal bleeding x 5d. She has f/u U/S at PP on ___ revealing "lots of blood clots in my uterus" per pt. She had minimal bleeding and no fever at that time. She had minimal abdominal cramping since the med AB. She began passing clots 5 days ago, changing her pad up to every 2hours; today she has only changed her pad 3 times b/c she has been lying down/not feeling well. Denies dizziness, SOB, CP, abdominal cramping, cough, sick contacts, myalgias, changes in bowel or bladder habits. Last ate at 9pm. in ED: given Unasyn, 1L LR. Pelvic U/S (prelim) revealed vascular echogenic material in endometrial cavity concerning for retained products of conception. EMS 1.62cm. <PAST MEDICAL HISTORY> POBHX: G1P0010 - med AB as above PGYNHX: - LMP: early ___ - menstrual triad: ___, regular flow - Paps: hx abnl ___ (had warts, s/p cryotherapy), nl f/u last ___ wnl - STIs: denies - contraceptive hx: OCP, none at time of conception PMH: depression/anxiety PSH: wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VS: 99.5 78 92/53 20 97RA (Tm in ED 100.7) GENERAL: NAD CARDIO: RRR PULM: CTAB ABDOMEN: soft, NTND EXTREMITIES: NT b/l SSE: minimal blood in vault, cleared w 2 scopettes, os closed, no lesions SVE/BME: AV uterus ~7cm, nontender throughout, no palpable adnexa <PERTINENT RESULTS> ___ 11: 20PM WBC-10.4# RBC-3.42* HGB-10.4* HCT-30.1* MCV-88 MCH-30.3 MCHC-34.4 RDW-13.4 ___ 11: 20PM NEUTS-92.5* LYMPHS-3.8* MONOS-3.3 EOS-0.1 BASOS-0.3 ___ 11: 20PM PLT COUNT-193 ___ 11: 20PM HCG-397 ___ 11: 20PM GLUCOSE-127* UREA N-7 CREAT-0.7 SODIUM-136 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 ___ 03: 45AM WBC-7.4 RBC-2.98* HGB-9.0* HCT-26.5* MCV-89 MCH-30.3 MCHC-34.0 RDW-13.5 ___ 03: 45AM NEUTS-88.3* LYMPHS-7.9* MONOS-3.4 EOS-0.1 BASOS-0.2 ___ 03: 45AM PLT COUNT-175 <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: *60 Tablet(s)* Refills: *0* 2. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp: *28 Tablet(s)* Refills: *0* 4. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp: *28 Tablet(s)* Refills: *0* 5. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Retained POCs <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You had retained products of conception after a termination of pregnancy and were admitted for surgical dilatation and curettage as well as IV antibiotics. You have done well postoperatively and are ready to be discharged home. It is important that you continue to take oral antibiotics for two weeks and follow up with your OB/GYN at the end of that time period. If you have pain that is not relieved by oral ibuprofen or tylenol, please call your doctor.
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Ms. ___ was evaluated by the GYN team in the ED and was found to have ultrasound and exam findings concerning for retained products of conception. Informed consent was obtained, and she was taken to the OR for a D+C. This was performed without complications; please see dictated op note. Notably, she was given a dose of methergine for slightly more than expected bleeding. She was then admitted to the GYN floor and started on IV antibiotics. She received IV ceftriaxone, IV doxy, and oral Flagyl. By the end of the day, she was feeling very well, without fevers, pain, and her bleeding was light. She was felt ready for discharge and sent home with oral antibiotics.
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10586112-DS-25
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p recent ED visit for R>L pelvic/back pain (___) re-presents with worsening symptoms. Approx 10 days ago when she initially presented, her evaluation revealed the following: - CT A/P: Mesenteric fat stranding about the distal left gonadal vein with a normal sized left ovary (on the concomitantly acquired pelvic ultrasound) favors omental infarction with reactive thickening of the left gonadal vein; gonadal vein thrombosis or early pelvic inflammatory disease are less likely. - Pelvic US: 1. Although no vascular flow could be obtained within the left ovary, its normal size and appearance make ovarian torsion very unlikely. 2. No right ovarian torsion She was afebrile, with no leukocytosis, and her exam was not c/f ovarian torsion or PID. She was discharged home with outpatinet gyn follow-up. Today, pt re-presented to the ED endorsing worsening R sided pain. The pain is constant, sharp, and severe. The pain is present regardless of position, and is minimally improved with oxycodone. She endorses nausea. Denies emesis. No CP, SOB, dizziness. No dysuria or hematuria. <PAST MEDICAL HISTORY> OBHx: G5P5 GynHx: LMP ___. sexually active with ___ male partner. denies hx of fibroids, STIs, or abnl pap. PMH: GERD, constipation PSH: BTL, lsc CCY, left knee surgery, breast reduction All: bactrim <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family history of HTN and DM2. No other known family history. <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, minimal tender, no rebound/guarding; Ext: no tenderness to palpation <PERTINENT RESULTS> ___ 11: 11AM GLUCOSE-106* UREA N-8 CREAT-0.6 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-11 ___ 11: 11AM estGFR-Using this ___ 11: 11AM ALT(SGPT)-13 AST(SGOT)-16 ALK PHOS-114* TOT BILI-0.5 ___ 11: 11AM LIPASE-32 ___ 11: 11AM ALBUMIN-4.0 ___ 11: 11AM WBC-10.3* RBC-4.37 HGB-11.6 HCT-37.3 MCV-85 MCH-26.5 MCHC-31.1* RDW-13.2 RDWSD-41.3 ___ 11: 11AM NEUTS-66.8 ___ MONOS-7.5 EOS-0.5* BASOS-0.3 IM ___ AbsNeut-6.87* AbsLymp-2.52 AbsMono-0.77 AbsEos-0.05 AbsBaso-0.03 ___ 11: 11AM NEUTS-66.8 ___ MONOS-7.5 EOS-0.5* BASOS-0.3 IM ___ AbsNeut-6.87* AbsLymp-2.52 AbsMono-0.77 AbsEos-0.05 AbsBaso-0.03 ___ 11: 11AM PLT COUNT-308 ___ 10: 52AM OTHER BODY FLUID CT-NEG NG-NEG ___ 10: 23AM URINE HOURS-RANDOM ___ 10: 23AM URINE HOURS-RANDOM ___ 10: 23AM URINE UCG-NEGATIVE ___ 10: 23AM URINE CT-NEG NG-NEG ___ 10: 23AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10: 23AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 10: 23AM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE EPI-2 ___ 10: 23AM URINE MUCOUS-OCC* <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 follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking opioids (e.g. oxycodone, hydromorphone) * Take a stool softener such as colace while taking opioids to prevent constipation. * Do not combine opioid and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * 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 * abnormal vaginal discharge 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.
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On ___, Ms ___ was admitted to they gynecological service for inpatient management of pelvic pain concerning for pelvic inflammatory disease v. nephrolithiasis. Please see H&P for full details. At time of admission, she was afebrile with WBC within normal limit. Gonorrhea/chlamydia testing negative. CT abdomen/pelvis from prior visit on ___ demonstrated fat stranding at distal left gonadal vein possible omental infarction with reactive thickening of left gonadal vein. CT abdomen/pelvis on ___ with no findings to account for pelvic pain, however demonstrated punctate nonobstructing stone within the upper pole of the left kidney measuring approximately 3 mm. Pelvic ultrasound on ___ demonstrated 2cm right hemorrhagic corpus luteal cyst and normal left ovary but no flow could be obtained with pelvic ultrasound on with no evidence of torsion, normal appearance of ovaries, and 5mm endometrial polyp. She received one dose of IM ceftriaxone 250mg and was transitioned to PO azithromycin 1g every week for two weeks starting on ___. On hospital day 1, her hospital course was complicated by urinary retention possibly related to opioid use versus nephrolithiais (with +blood on urinalysis). At this time, patient endorse using oxycodone daily following orthopedic surgery, with approximately 80 tablets already scripts filled and remaining scripts at home. Had in-depth conversation on cessation of narcotics that had been taken since an orthopedic surgery ___. On hospital day 2, patient failed formal trial of void. Patient's pain was well controlled, ambulating voiding. Patient was deemed stable and discharged home with close follow-up for repeat voiding trial. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H Do not exceed 4000 mg per day. RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 2. Azithromycin 1000 mg PO ONCE Duration: 1 Dose RX *azithromycin 500 mg 2 (Two) tablet(s) by mouth once Disp #*1 Tablet Refills:*0 3. Ibuprofen 800 mg PO Q8H Do not exceed 2400 mg per day. Take with food. RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: abdominal pain pelvic inflammatory disease urinary retentions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10586949-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Dilaudid / Pollen/Hayfever <ATTENDING> ___. <CHIEF COMPLAINT> endometrial cancer (high grade) <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissections <HISTORY OF PRESENT ILLNESS> ___ with a history of anal carcinoma, s/p radiation therapy and resection of liver lesions, in remission since ___, who presented with episodes of postmenopausal bleeding in ___ and ___. She underwent an endometrial biopsy which was insufficient. Pelvic ultrasound at the time was notable for a 13 mm endometrial stripe with possible echogenic foci. On ___, she underwent hysteroscopy and D&C, with no tissue retrieved from the procedure. Repeat pelvic ultrasound on ___ again showed an abnormally thickened, however, homogeneous endometrium measuring 11 mm. The ovaries could not be seen, and there was no free fluid. She then went to the operating room on ___ for D&C with, again, no tissue obtained, and decision was made for close follow up. Pelvic ultrasound on ___ showed a hypervascular thickened endometrium measuring 17 mm. She continued to have light bleeding, so was counseled regarding a second attempt at D&C. Patient underwent ultrasound guided D&C on ___. Intraoperative findings showed an endometrium tha was atrophic. There was a large, hemorrhagic mass filling most of the uterine cavity which appeared to be originating from the fundus. Final pathology was notable for a high grade serous carcinoma. Stain for p53 was positive. Surgical management was recommended. <PAST MEDICAL HISTORY> PMH: anal cancer as above migraines borderline HTN hypothyroidism PSH: hepatic resections, ___ hip surgery following fracture, ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> - maternal GM with breast cancer - prostate ca in father and uncle - ___ a known family history of ovarian, uterine, cervical, or colon malignancy - Denies family history of bleeding or clot disorders <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 (staples in place), no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 05: 31AM BLOOD WBC-4.7 RBC-2.87* Hgb-9.0* Hct-28.0* MCV-98 MCH-31.4 MCHC-32.1 RDW-13.5 RDWSD-48.5* Plt ___ ___ 07: 15AM BLOOD WBC-5.5 RBC-2.70* Hgb-8.5* Hct-26.7* MCV-99* MCH-31.5 MCHC-31.8* RDW-14.0 RDWSD-50.7* Plt ___ ___ 05: 59AM BLOOD WBC-7.3 RBC-2.92* Hgb-9.2* Hct-28.9* MCV-99* MCH-31.5 MCHC-31.8* RDW-14.1 RDWSD-52.0* Plt ___ ___ 07: 00AM BLOOD WBC-9.2 RBC-3.15* Hgb-10.0* Hct-30.9* MCV-98 MCH-31.7 MCHC-32.4 RDW-13.7 RDWSD-49.3* Plt ___ ___ 01: 36PM BLOOD WBC-8.6# RBC-3.46* Hgb-11.0* Hct-33.5* MCV-97 MCH-31.8 MCHC-32.8 RDW-13.2 RDWSD-47.3* Plt ___ ___ 07: 15AM BLOOD Neuts-65.4 ___ Monos-10.5 Eos-1.8 Baso-0.5 Im ___ AbsNeut-3.62 AbsLymp-1.18* AbsMono-0.58 AbsEos-0.10 AbsBaso-0.03 ___ 05: 59AM BLOOD Neuts-72.2* Lymphs-17.1* Monos-9.1 Eos-0.7* Baso-0.3 Im ___ AbsNeut-5.24 AbsLymp-1.24 AbsMono-0.66 AbsEos-0.05 AbsBaso-0.02 ___ 05: 31AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-143 K-4.2 Cl-105 HCO3-29 AnGap-13 ___ 07: 15AM BLOOD Glucose-80 UreaN-6 Creat-0.6 Na-138 K-4.2 Cl-102 HCO3-27 AnGap-13 ___ 05: 59AM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 ___ 07: 00AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-139 K-5.5* Cl-104 HCO3-25 AnGap-16 ___ 01: 36PM BLOOD Glucose-165* UreaN-13 Creat-0.7 Na-138 K-3.5 Cl-104 HCO3-23 AnGap-15 ___ 05: 31AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.8 ___ 07: 15AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.8 ___ 05: 59AM BLOOD Calcium-7.8* Phos-2.2* Mg-1.8 ___ 07: 00AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.7* ___ 01: 36PM BLOOD Calcium-7.9* Phos-4.3 Mg-1.4* <MEDICATIONS ON ADMISSION> albuterol, fiorecet, fluticasone, levothyroxine 50 mcg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *1 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate do not drive or drink alcohol while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 6. Levothyroxine Sodium 50 mcg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <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: . Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. * If you have staples, they will be removed at your follow-up visit. . 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 abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymph node dissections for high grade serous 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 an epidural. She had 2 episodes of emesis on post operative day #1, which resolved with pepcid and Zofran. She was kept NPO but advanced to clears later in the day, as she was symptomatically improved with a stable abdominal exam and low suspicion for ileus. However, after a third episode of emesis, her diet was backed down again to NPO. Her diet was advanced without difficulty, and she was tolerating a regular diet by post operative day 2. Her epidural was capped on post operative day 3, and she was transitioned to PO oxycodone, Tylenol, and acetaminophen. On post-operative day #3, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. 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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10589186-DS-9
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<SEX> M <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Morphine / Codeine / Penicillins / Amoxicillin / Strawberry <ATTENDING> ___ <CHIEF COMPLAINT> abnormal uterine bleeding and dysmenorrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ is a ___, gravida zero, female to male transgender patient with a history of irregular vaginal bleeding and worsening dysmenorrhea. He has been using testosterone for greater than one year and has irregular bleeding and dysmenorrhea. Ultrasound on ___ showed a uterus, which measured 8.6 x 3.5 x 4.2 cm. The endometrium appeared unremarkable and measured 4 mm. Bilateral ovaries were within normal limits. There was no evidence of free fluid. These results were reviewed with the patient. The patient has failed medical therapy for the uterine pain and bleeding, and therefore, he is exploring other options for treatment. Because the patient is a transgendered man, a total hysterectomy with removal of ovaries is the requested procedure. Because the quality of his life has been compromised by irregular bleeding and uterine pain, he desires the aforementioned procedures. After all treatment options were reviewed, the patient elected for a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Benefits and risks of the procedure were discussed with the patient in full and informed consent was obtained prior to proceeding to the operating room. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at age ___, cycles every 20 to 32 days, bleeds typically for five to seven days. He, at times, passes softball-sized clots at the heaviest bleeding. He will change a tampon or pad every three hours. His last Pap smear was ___. He has never had an abnormal Pap smear, never had a mammogram, colonoscopy, or a bone density. Denies any sexually transmitted infections. He has never had a pregnancy. PAST MEDICAL HISTORY: Hypothyroidism, chronic sinusitis, dislocated knee. OPERATIVE HISTORY: In ___, sinus surgery, tonsillectomy, adenoidectomy. In ___, cholecystectomy. Bad reaction to anesthesia, yes he states that he is very aggressive and agitated on waking up. He will check to see if he has any anesthetic records that he can share with my anesthesia colleagues. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: Mother with diabetes, hypertension. Maternal grandmother, heart disease, died of stomach aneurysm. Father with hypertension. Paternal grandmother with bone, breast, and liver cancer, Bell's palsy. Paternal grandfather, heart disease and colon cancer. <PHYSICAL EXAM> Pre-operative physical examination: GENERAL: This is a well-developed, obese, male-appearing individual. VITAL SIGNS: Blood pressure 120/80, weight 300. ABDOMEN: Obese, soft, nondistended, and nontender. There was no hepatosplenomegaly. No palpable masses. PELVIC: Normal female external genitalia with clitoromegaly. There were two lesions on the upper vulva bilaterally that appeared consistent with ring worm. Vaginal vault, there was a normal-appearing discharge, no lesions. Cervix was nulliparous, without cervical motion tenderness. Uterus normal size, mobile, nontender. Adnexa was without masses or tenderness bilaterally. <PERTINENT RESULTS> No laboratory studies were required during this admission <MEDICATIONS ON ADMISSION> DICLOFENAC SODIUM - (Prescribed by Other Provider) - 100 mg Tablet Extended Release 24 hr - one Tablet(s) by mouth as needed LEVOTHYROXINE - (Prescribed by Other Provider) - 125 mcg Tablet - one Tablet(s) by mouth daily MISOPROSTOL - 200 mcg Tablet - one tablet(s) intravaginal x 1, place the night prior to procedure TESTOSTERONE CYPIONATE - (Prescribed by Other Provider) - 100 mg/mL Oil - 0.8 administered weekly <DISCHARGE MEDICATIONS> demerol for pain control <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abnormal uterine bleeding dysmenorrhea <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 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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Mr. ___ was admitted after undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy for abnormal uterine bleeding and dysmenorrhea. Please see ___ ___ note for complete details. His post-operative course was uncomplicated. . Mr. ___ was discharged on post-operative day 0 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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10591828-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fibroid uterus, urinary retention <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy <HISTORY OF PRESENT ILLNESS> ___ yo G0 presents to clinic after an ED visit for urinary retention. Patient was last seen in clinic in ___, at which time she was aware of fibroids, which had been diagnosed at age ___. The fibroids were larger in ___ than prior exam, but asymptomatic. Patient then not seen for care, and per her report asymptomatic until last weekend, when she developed urinary retention. She was found to have several large fibroids including a LUS fibroid thought to be blocking the urethra. Additionally, renal ultrasound showed bilateral hydronephrosis. Patient had foley inserted and presents to office to discuss treatment options. Denies other bowel or bladder symptoms, not sexually active. <PAST MEDICAL HISTORY> iron-deficiency anemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Initial <PHYSICAL EXAM> WT: 211.9 BMI: 38.1 BP: 122/90 Last years WT: 216.9 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm, No edema or varicosities. Lungs: Clear, Normal respiratory effort. Abdomen: Non tender, Non distended, No guarding or rebound, No hepatosplenomegally, No hernia, *Findings: Mass exteneds above umbilicus x 4 cm, NT, relatively non-mobile. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skein & bartholin glands normal, Urethra meatus central, no prolapse. <PERTINENT RESULTS> ___ 04: 30PM WBC-4.9 RBC-2.75* HGB-8.4* HCT-24.2* MCV-88 MCH-30.6 MCHC-34.8 RDW-12.8 ___ 04: 30PM PLT COUNT-346 ___ 04: 30PM ___ PTT-29.8 ___ ___ 01: 09PM WBC-5.4 RBC-3.40* HGB-10.4* HCT-30.5* MCV-90 MCH-30.5 MCHC-33.9 RDW-12.2 ___ 01: 09PM PLT COUNT-391 <MEDICATIONS ON ADMISSION> albuterol prn, vit D, omeprazole 20', percocet prn, acetaminophen prn, Ca, Fe, loratadine <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h: prn Disp #*50 Tablet Refills: *0 2. Omeprazole 20 mg PO DAILY 3. Acetaminophen ___ mg PO Q6H: PRN pain/fever Do not exceed 4000 mg of acetaminophen in 24 hours. 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive. 5. Docusate Sodium 100 mg PO BID Take to prevent constipation while taking narcotics. 6. Albuterol Inhaler ___ PUFF IH Q4H: PRN SOB <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> Dear Ms. ___, You were admitted to the gynecology service after undergoing the procedures listed below. You have recovered well and are ready for discharge home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing an abdominal myomectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with a TAP block, IV dilaudid PCA, and tylenol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to percocet and motrin. 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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10591889-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> VAGINAL CUFF BLEEDING <MAJOR SURGICAL OR INVASIVE PROCEDURE> exam under anesthesia, closure of partial vaginal cuff dehiscence <PHYSICAL EXAM> Physical exam at discharge -========= Vital signs: ___ 0345 Temp: 98 PO BP: 139/91 HR: 61 RR: 18 O2 sat: 100% O2 delivery: ra Pain Score: ___ Ins: > Since MN: 30 PO, 600 ml IV intra-op Outs: > Since MN: EBL 600 prior to Or and 10 ml inra-op, 250 ml urine General: NAD, comfortable CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding GU: pad with minimal red spotting Extremities: no edema, no TTP <PERTINENT RESULTS> ___ 06: 00PM URINE HOURS-RANDOM ___ 06: 00PM URINE UCG-NEGATIVE ___ 06: 00PM URINE COLOR-RED* APPEAR-Hazy* SP ___ ___ 06: 00PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-SM* ___ 06: 00PM URINE RBC->182* WBC->182* BACTERIA-FEW* YEAST-NONE EPI-3 ___ 06: 00PM URINE HYALINE-24* ___ 06: 00PM URINE MUCOUS-OCC* ___ 05: 40PM GLUCOSE-116* UREA N-9 CREAT-1.0 SODIUM-139 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13 ___ 05: 40PM WBC-5.1 RBC-2.08* HGB-6.9* HCT-20.4* MCV-98 MCH-33.2* MCHC-33.8 RDW-14.2 RDWSD-49.9* ___ 05: 40PM NEUTS-38.8 ___ MONOS-10.8 EOS-0.6* BASOS-0.4 IM ___ AbsNeut-1.98 AbsLymp-2.51 AbsMono-0.55 AbsEos-0.03* AbsBaso-0.02 ___ 05: 40PM PLT COUNT-187 ___ 05: 40PM ___ PTT-36.5 ___ ___ 02: 20PM WBC-6.1 RBC-2.23* HGB-7.3* HCT-21.4* MCV-96 MCH-32.7* MCHC-34.1 RDW-13.8 RDWSD-48.5* ___ 02: 20PM PLT COUNT-216 <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the Gynecology service with vaginal bleeding from an opening at vaginal cuff (top of the vagina that was closed after hysterectomy). You had a procedure to examine the vagina and close the opening to stop the bleeding. You have recovered well and the team now feels that you are ready to go home. Please follow the instructions below: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * 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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Ms. ___ was admitted to the GYN service on ___, after undergoing a partial closure of the vaginal cuff. She originally had a total laparoscopic hysterectomy, bilateral salpingectomies, and cystoscopy on ___. On ___ she subsequently presented to the emergency room with heavy vaginal bleeding and acute blood loss anemia. She was taken to the operating room where there was found to be a right posterior lateral vaginal cuff with active oozing vessel, which was made hemostatic. Please see operative report in OMR for complete details. Immediately postoperatively her pain was controlled with oral Tylenol and oxycodone. She was continued on Biktarvy (bictegrav-emtricit-tenofov ala) for HIV, amlodipine for hypertension, Celexa and Depakote for PTSD. On POD1, she was noted to have minimal vaginal bleeding. She was tolerating a regular diet, pain was controlled on oral medication, she is voiding urine without difficulty, and ambulating independently without dizziness. Her hematocrit was trended and found to rise appropriately to 26.5 after 1 unit of packed red blood cells, and was stable at discharge at 25.6. She was discharged home with close outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. amLODIPine 5 mg PO DAILY 3. Biktarvy (bictegrav-emtricit-tenofov ala) 50-200-25 mg oral DAILY 4. Citalopram 40 mg PO DAILY 5. Divalproex (DELayed Release) 500 mg PO DAILY 6. TraZODone 100 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Partial vaginal cuff dehiscence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10592521-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ? SROM <MAJOR SURGICAL OR INVASIVE PROCEDURE> NSVD PPTL <HISTORY OF PRESENT ILLNESS> ___ G3P2 at 35w4d with ? SROM with clear fluids. She denies any vaginal bleeding, contractions or decreased fetal movement. The patient was previously hospitalized on the antepartum unit for her work-up of gestational hypertension, and is currently on nifedipine 30mg QD and labetalol 300mg TID. Denies headache, visual changes, SOB/CP and RUQ pain <PAST MEDICAL HISTORY> PNC: -___: ___ by LMP -Labs: B+/Ab-/HBsAg-/TPAbNR/RI/HIV unk/GBS- -Screening: CF neg, declined ERA, abnormal AFP, increased risk for spinal cord defect and DS, declined amnio -FFS: WNL, GIRL! -GTT: 129, passed -EFW: ___, BPP ___ -Issues: AMA, obesity, abnormal AFP, +PPD, CXR neg ___ OBHx: -___ 3175g 40+0 SVD male in ___ -___ 3629g 40+0 SVD female in ___ GynHx: neg for high risk HPV ___ PMH: GERD PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) <PHYSICAL EXAM> -VS: 98.0 19 133/84 82 -Gen: NAD -Abd: obese, gravid, soft, NT -NST: baseline 135, mod var, +accels, no decels, reactive -Toco: flat -TAUS: VTX, anhydramnios - negative nitrazine, negative ferning, negative pooling SVE: 2/L/P <PERTINENT RESULTS> ___ 09: 50PM CREAT-0.8 ___ 09: 50PM ALT(SGPT)-32 AST(SGOT)-35 ___ 09: 50PM URIC ACID-4.6 ___ 09: 50PM URINE HOURS-RANDOM CREAT-199 TOT PROT-42 PROT/CREA-0.2 ___ 09: 50PM WBC-6.1 RBC-4.52 HGB-12.0 HCT-36.2 MCV-80* MCH-26.5 MCHC-33.1 RDW-14.5 RDWSD-41.9 ___ 09: 50PM PLT COUNT-155 ___ 09: 50PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 09: 50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 09: 50PM URINE RBC-10* WBC-5 BACTERIA-FEW YEAST-NONE EPI-7 TRANS EPI-<1 ___ 09: 50PM URINE MUCOUS-RARE <MEDICATIONS ON ADMISSION> PNV Randitidine <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 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: *1 3. NIFEdipine CR 30 mg PO DAILY RX *nifedipine 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *0 4. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Gestational HTN PPROM NSVD <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> SVD: Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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Ms. ___ is a ___ who was transferred from ___ ___ with severe-range gestational hypertension and rule out preeclampsia evaluation. Her labs were all wnl and her 24hr urine collection was <6. She received magneiusm up on L*D for neuroprotection and her antihypertensives were titrated to 300mg TID of labetalol and 30mg CR nifedipine. Once her blood pressures were well controlled, she was ready to go home.
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10595343-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Wellbutrin / Okra <ATTENDING> ___ <CHIEF COMPLAINT> here for induction of labor for postdates <MAJOR SURGICAL OR INVASIVE PROCEDURE> spontaneous vaginal delivery Dilation and curettage Blood transfusion <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old G2P0 at 41 weeks 2 days gestational age who presents for induction of labor for post dates. She is comfortable. Feels occasional contractions. Denies VB, SROM and DFM. <PAST MEDICAL HISTORY> PNL: B+, ab screen NEG Rubella +, Varicella immune; NEG for HepBsAg/HIV/RPR/GC/Chlamydia, CF screen , Hgb electrophoresis: Hemoglobic SC disease, early 1h GCT ___, 2h GTT wnl; GBS negative Aneuploidy screen: ERA low risk Fetal survey: wnl ___ EFW 4047gms, (87%) Gestational thrombocytopenia (plts at IOB 165k) [x] ___ at 30wks plts 133k [x] ___ at 33wks plts 140k [x] ___ at 38wks plts 142k (baseline PIH labs wnl) OBHx: G2P0, SAB x1 PAST MEDICAL HISTORY: Hemoglobin SC disease (abnormal Hb electrophoresis ___ - history of pain syndrome as a child, none since ___ - FOB testing - possible alpha thal carrier - Hematology consult ___: no need for iron transfusion, rec'd iron QD or QOD LLE compartment syndrome chronic ___ edema anemia h/o depression PAST SURGICAL HISTORY: left leg fasciotomy right knee biopsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On Admission: O: ___ 08: 48 BP: 119/46 (63) ___ ___ MHR: 100 T 97.4 Abd: obese, gravid unable to do Leopolds FHT: 140/mod/+accels/ no decels/ reactive Toco: q ___ min TAUS: vtx On Discharge: Vitals: 24 HR Data (last updated ___ @ 352) Temp: 98.2 (Tm 98.2), BP: 100/64 (99-107/55-74), HR: 63 (63-85), RR: 18, O2 sat: 98% (98-100), O2 delivery: RA Fluid Balance (last updated ___ @ 354) Last 8 hours Total cumulative -300ml IN: Total 1700ml, PO Amt 1700ml OUT: Total 2000ml, Urine Amt 2000ml Last 24 hours Total cumulative 500ml IN: Total 4500ml, PO Amt 4500ml OUT: Total 4000ml, Urine Amt 4000ml ___ Total Output: 4200ml Urine Amt: 4200ml General: NAD, A&Ox3 CV: RRR Lungs: No respiratory distress, LCTAB Abd: soft, nontender, fundus firm below umbilicus Lochia: minimal Extremities: no calf tenderness, +2 edema bilataerally of lower extremiteis <PERTINENT RESULTS> ___ 09: 01AM BLOOD WBC-6.8 RBC-2.93* Hgb-8.4* Hct-24.5* MCV-84 MCH-28.7 MCHC-34.3 RDW-15.7* RDWSD-47.8* Plt ___ ___ 06: 52AM BLOOD WBC-6.6 RBC-2.80* Hgb-8.0* Hct-23.5* MCV-84 MCH-28.6 MCHC-34.0 RDW-15.8* RDWSD-49.1* Plt Ct-96* ___ 06: 38AM BLOOD WBC-8.2 RBC-2.84* Hgb-8.2* Hct-23.6* MCV-83 MCH-28.9 MCHC-34.7 RDW-15.9* RDWSD-48.7* Plt Ct-92* ___ 08: 10PM BLOOD WBC-9.2 RBC-2.59* Hgb-7.5* Hct-21.2* MCV-82 MCH-29.0 MCHC-35.4 RDW-16.1* RDWSD-48.4* Plt ___ ___ 01: 30PM BLOOD WBC-10.8* RBC-2.64* Hgb-7.6* Hct-21.8* MCV-83 MCH-28.8 MCHC-34.9 RDW-16.1* RDWSD-48.6* Plt ___ ___ 06: 30AM BLOOD WBC-10.7* RBC-2.69* Hgb-7.8* Hct-22.4* MCV-83 MCH-29.0 MCHC-34.8 RDW-16.1* RDWSD-48.7* Plt ___ ___ 07: 00PM BLOOD WBC-16.5* RBC-3.03* Hgb-8.7* Hct-25.1* MCV-83 MCH-28.7 MCHC-34.7 RDW-16.0* RDWSD-48.0* Plt Ct-86* ___ 02: 00PM BLOOD WBC-17.7* RBC-2.88* Hgb-8.4* Hct-23.3* MCV-81* MCH-29.2 MCHC-36.1 RDW-15.9* RDWSD-45.9 Plt ___ ___ 09: 50AM BLOOD WBC-23.1* RBC-3.01* Hgb-8.9* Hct-24.5* MCV-81* MCH-29.6 MCHC-36.3 RDW-15.7* RDWSD-46.2 Plt ___ ___ 05: 52AM BLOOD WBC-27.2* RBC-3.05* Hgb-9.0* Hct-25.0* MCV-82 MCH-29.5 MCHC-36.0 RDW-15.5 RDWSD-45.8 Plt ___ ___ 09: 00PM BLOOD WBC-42.2* RBC-2.71* Hgb-8.2* Hct-23.1* MCV-85 MCH-30.3 MCHC-35.5 RDW-15.8* RDWSD-47.8* Plt ___ ___ 03: 20PM BLOOD WBC-41.9* RBC-3.21* Hgb-9.6* Hct-28.4* MCV-89 MCH-29.9 MCHC-33.8 RDW-15.5 RDWSD-49.7* Plt ___ ___ 09: 20AM BLOOD WBC-14.3* RBC-3.22* Hgb-9.7* Hct-27.5* MCV-85 MCH-30.1 MCHC-35.3 RDW-17.3* RDWSD-53.8* Plt ___ ___ 12: 06AM BLOOD WBC-12.4* RBC-3.61* Hgb-10.7* Hct-31.0* MCV-86 MCH-29.6 MCHC-34.5 RDW-17.5* RDWSD-54.6* Plt ___ ___ 02: 59AM BLOOD WBC-10.4* RBC-3.41* Hgb-10.1* Hct-29.6* MCV-87 MCH-29.6 MCHC-34.1 RDW-17.6* RDWSD-55.1* Plt ___ ___ 11: 29PM BLOOD WBC-9.8 RBC-3.29* Hgb-9.8* Hct-28.3* MCV-86 MCH-29.8 MCHC-34.6 RDW-17.6* RDWSD-54.7* Plt ___ ___ 11: 56AM BLOOD WBC-9.0 RBC-3.17* Hgb-9.6* Hct-27.0* MCV-85 MCH-30.3 MCHC-35.6 RDW-17.7* RDWSD-54.7* Plt ___ ___ 08: 10PM BLOOD Neuts-73.4* Lymphs-17.5* Monos-5.8 Eos-2.1 Baso-0.8 Im ___ AbsNeut-6.78* AbsLymp-1.62 AbsMono-0.54 AbsEos-0.19 AbsBaso-0.07 ___ 09: 50AM BLOOD ___ PTT-29.2 ___ ___ 05: 52AM BLOOD ___ PTT-30.1 ___ ___ 03: 20PM BLOOD ___ PTT-29.0 ___ ___ 02: 20PM BLOOD ___ PTT-25.8 ___ ___ 11: 56AM BLOOD ___ PTT-27.4 ___ ___ 09: 50AM BLOOD ___ ___ 05: 52AM BLOOD ___ 03: 20PM BLOOD ___ 02: 20PM BLOOD ___ 11: 56AM BLOOD ___ 08: 10PM BLOOD Ret Aut-5.5* Abs Ret-0.14* ___ 09: 01AM BLOOD Creat-1.5* ___ 06: 52AM BLOOD Glucose-89 UreaN-21* Creat-1.7* Na-143 K-4.5 Cl-109* HCO3-21* AnGap-13 ___ 06: 38AM BLOOD Creat-2.2* ___ 08: 10PM BLOOD Creat-2.3* ___ 01: 30PM BLOOD Glucose-75 UreaN-26* Creat-2.3* Na-140 K-4.7 Cl-106 HCO3-21* AnGap-13 ___: 30AM BLOOD Creat-2.4* ___ 07: 00PM BLOOD Creat-2.4* ___ 02: 00PM BLOOD Creat-2.5* ___ 09: 50AM BLOOD Creat-2.5* ___ 05: 52AM BLOOD Glucose-85 UreaN-18 Creat-2.5* Na-136 K-4.5 Cl-104 HCO3-17* AnGap-15 ___ 09: 00PM BLOOD Glucose-76 UreaN-16 Creat-2.4* Na-135 K-4.5 Cl-101 HCO3-17* AnGap-17 ___ 03: 28PM BLOOD Glucose-87 UreaN-13 Creat-2.0* Na-135 K-4.3 Cl-104 HCO3-18* AnGap-13 ___ 09: 20AM BLOOD Creat-1.6* ___ 12: 06AM BLOOD Creat-1.1 ___ 06: 52AM BLOOD LD(LDH)-324* ___ 06: 38AM BLOOD ALT-16 AST-36 LD(LDH)-411* ___ 08: 10PM BLOOD LD(LDH)-416* TotBili-0.7 DirBili-0.3 IndBili-0.4 ___ 08: 10PM BLOOD ALT-14 AST-32 ___ 06: 30AM BLOOD ALT-13 AST-33 ___ 02: 00PM BLOOD ALT-11 AST-38 ___ 09: 50AM BLOOD ALT-11 AST-42* ___ 09: 20AM BLOOD ALT-8 AST-23 ___ 12: 06AM BLOOD ALT-7 AST-20 ___ 08: 10PM BLOOD cTropnT-<0.01 ___ 01: 30PM BLOOD cTropnT-<0.01 ___ 06: 52AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.9 ___ 01: 30PM BLOOD Calcium-8.5 Phos-4.7* Mg-2.3 ___ 05: 52AM BLOOD Albumin-2.4* Calcium-7.9* Phos-4.8* Mg-2.0 ___ 09: 00PM BLOOD Calcium-7.9* Phos-4.2 Mg-1.4* ___ 03: 28PM BLOOD Calcium-7.4* Mg-1.4* ___ 12: 06AM BLOOD UricAcd-7.9* ___ 05: 52AM BLOOD Hapto-<10* ___ 02: 00PM BLOOD Vanco-14.2 ___ 06: 43AM BLOOD Lactate-1.2 ___ 04: 51PM BLOOD Lactate-1.9 ___ 01: 45PM URINE Color-Straw Appear-Clear Sp ___ ___ 09: 20AM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 01: 45PM URINE Blood-MOD* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM* ___ 09: 20AM URINE Blood-LG* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG* ___ 01: 45PM URINE RBC-7* WBC-4 Bacteri-FEW* Yeast-NONE Epi-1 ___ 09: 20AM URINE RBC-37* WBC-13* Bacteri-FEW* Yeast-NONE Epi-1 TransE-<1 ___ 01: 45PM URINE Hours-RANDOM Creat-41 Na-48 TotProt-9 Prot/Cr-0.2 ___ 09: 20AM URINE Hours-RANDOM Creat-121 TotProt-33 Prot/Cr-0.3* ___ 5: 11 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. CXR ___: There is a parenchymal opacity in the left lower lobe which could represent subsegmental atelectasis however could also represent acute chest given history of a hemoglobin SC disease. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. VQ Scan ___: Normal lung scan. Renal Scan ___: No hydronephrosis. TTE ___: Adequate image quality. Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. EF 50-55% <DISCHARGE INSTRUCTIONS> Dear ___, ___ on the birth of your baby girl! Your delivery was complicated by a postpartum hemorrhage, acute kidney injury, chorioamninitis, and severe preeclampsia. You have recovered well and the team now feels that you are ready to go home. Please follow these instructions below. Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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Ms. ___ is a ___ G2P1 with Hgb SC disease, history of compartment syndrome, gestational thrombocytopenia, who underwent an induction of labor for postdates and subsequently a spontaneous vaginal delivery. Pleas see the delivery note. *)Postpartum hemorrhage She was noted to have postpartum hemorrhage due to atony and retained products of conception with an EBL of 1500cc. She received Pitocin, cytotec, hemabate, tranexamic acid. She also had a bakri balloon placed alng with vaginal packing. She required 5 units of packed red blood cells and 1 unit of fresh frozen plasma. Her hemoglobin was noted to be 7.6 so she received an additional 1 unit of packed red blood cells. Heme onc was consulted given her hemoglobin SC disease. They recommened obtaining hemolysis labs which were indicative of hemolysis with an elevated reticulocyte count and LDH. Her hemoglobin/hematocrit were checked daily and remained stable subsequently and the hemolysis labs also normalized. *) Preeclampsia, severe by ___ Patient had mild range blood pressures along with a P:C 0.3. The remainder of her labs were normal. She developed ___ due to preeclampsia and ischemic ATN secondary to large volume blood loss from the postpartum hemorrhage. Her baseline creatinine was 0.8 and peaked to 2.5 on ___ and ___. It then started to downtrend as her creatinine levels were checked daily and came down to 1.5 on day of discharge. She continued to have adequate UOP. Nephrology was consulted who suggested a renal ultrasound which was without evidence of hydronephrosis. Patients blood pressure continued to remain normal to mild range and did not require antihypertensives. Given that patient had pulmonary edema on chest x ray as described below, the decision to give magnesium for seizure prophylasis was deferred. *) Chest tightness Patient developed chest tightness on ___. Her EKG was normal sinus rhythm. Chest x ray showed atelectasis versus acute chest syndrome in the setting of Hg SC disease. She had repeat chest x ray later that day which was unchanged. She also had negative troponins x 2. Given the concerning finding on chest x ray, patient underwent a V/Q scan on ___ AM to rule out pulmonary embolism, which was normal. She also underwent a transthoracic echocardiogram which was normal with a LVEF 50-55%. Patient chest tightness was intermitted and spontaneously resolved. *) Chorioamnionitis Patient developed chorioamnionitis during labor. She initially received ampicillin, gentamicin, and clindamycin on ___. Given her fevers and unstable clinical picture, she was switched to zosyn which she received from ___ to ___. By postpartum day 5, her blood pressures were well controlled off of medications, ___ was resolving, chest tightness resolved, and she was meeting all postpartum milestones. She was thus deemed stable for discharge with plan for close follow up. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: spontaneous vaginal delivery Hemoglobin SC disease Acute kidney injury Severe preeclampsia Chorioamnionitis Gestational thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10595724-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa(Sulfonamide Antibiotics) <ATTENDING> ___ <CHIEF COMPLAINT> pain with lying flat <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ s/p oocyte retrieval on ___ with hCG trigger 10K Novarel on ___ presents with pain lying flat. She had her egg retrieval in the morning, where 10 oocytes were retrieved. When she got home, she was walking up stairs, was dizzy and had LOC. Husband caught her on way down so she did not sustain any trauma, she woke up very shortly after LOC and over the course of the day was able to eat bfast and lunch and felt better. However she has developed chest discomfort radiating up to shoulders, more in front in the epigastric area and RUQ. The chest discomfort does move all over, not cardiac in description. She says that it feels like it is hard to catch breath as expanding lungs hurts. Slight heartburn this time but less than last time. Slight increase in abdominal girth this time but nothing compared to last time where she actually did develop mild OHSS. Received Lupron/Gonal F for stimulation protocol. No vaginal bleeding or vaginal discharge. Last cycle had more vag bleeding. <PAST MEDICAL HISTORY> GYN Hx: PCOS, no abnl paps. S/p Clomid x 2 cycles, then IUI converted to IVF cycle ~1 month ago due to large number of developing follicles. She had a premature P4 rise prior to hCG trigger, and her E2 peaked at 3710. She developed mild OHSS with this cycle. None of the embryos developed enough for transfer. OB Hx: G0 PMHx: None PSHx: Hip arthroscopy for labrum tear in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> T 98.9 HR 86 BP 133/92 RR 14 O2 100% RA NAD appears well. Uncomfortable lying flat but able to breathe normally on RA RRR, no m/r/g CTAB Abd soft, mildly tender to palpation throughout without rebound. + BS. ___ Pelvic: done by ED staff, reportedly normal with minimal bleeding. <PERTINENT RESULTS> ___ 09: 40AM BLOOD WBC-9.0 RBC-2.82* Hgb-8.6* Hct-25.4* MCV-90 MCH-30.5 MCHC-33.8 RDW-13.1 Plt ___ ___ 05: 30AM BLOOD Hct-26.7* ___ 12: 25AM BLOOD WBC-15.1* RBC-3.59* Hgb-11.1* Hct-32.5* MCV-91 MCH-30.8 MCHC-34.0 RDW-12.2 Plt ___ ___ 12: 25AM BLOOD Neuts-81.9* Lymphs-14.8* Monos-2.4 Eos-0.3 Baso-0.5 ___ 12: 25AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-138 K-4.8 Cl-102 HCO3-26 AnGap-15 ___ 12: 25AM BLOOD ALT-11 AST-18 AlkPhos-32* TotBili-0.4 ___ 12: 25AM BLOOD Lipase-18 ___ 12: 25AM BLOOD Albumin-4.3 ___ 12: 25AM BLOOD D-Dimer-859* ___ 12: 25AM BLOOD HCG-207 ___ 02: 58AM URINE Color-Straw Appear-Clear Sp ___ ___ 02: 58AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 02: 58AM URINE UCG-POSITIVE CTA ___: IMPRESSION: 1. No PE detected to the subsegmental levels. No dissection. 2. Moderate amount of complex, possibly hemorrhagic, intra-abdominal ascites. CXR ___: IMPRESSION: No acute intrathoracic process. Pelvic US ___: IMPRESSION: 1. Moderate free fluid within the pelvis. 2. Left ovary measuring up to 8 cm, which could represent changes related to hyperstimulation. Lack of follicles may be due to recent harvesting. Correlate with any recent outside US examinations or reports for stability. <MEDICATIONS ON ADMISSION> MVI, Ca <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg tablet Sig: One (1) tablet PO every ___ hours as needed for pain: Do not take more than 4000mg acetaminophen in 24 hours. Disp: *5 tablet(s)* Refills: *0* 2. Colace 100 mg capsule Sig: One (1) capsule PO twice a day. Disp: *60 capsule(s)* Refills: *2* 3. Iron (ferrous sulfate) 325 mg (65 mg iron) tablet Sig: One (1) tablet PO twice a day. Disp: *60 tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Acute bleed following oocyte retrieval <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 * Bedrest until follow up appointment tomorrow
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Ms. ___ presented to the emergency department with pain, dizziness, and loss of consciousness one day s/p oocyte retrieval. She was found to have post-procedure intrapelvic bleeding and anemia with a hematocrit drop from 39 to 26.7. Patient was clinically stable with no further evidence of bleeding and repeat hematocrit was stable. She was discharged on hospital day 0 in good condition with pain well-controlled, ambulatory, tolerating a regular diet, and voiding on her own. She was instructed to follow up with her doctor the following day for repeat hematocrit.
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10596508-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> intracavitary brachytherapy for stage IIa cervical adenocarcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Tandem and ovoid placement Removal of implants <HISTORY OF PRESENT ILLNESS> Patient ___ woman with adenocarcinoma of the cervix, diagnosed in ___. She has stage IIA disease with evidence of a 1 cm of disease extending on the vaginal apex side wall. The tumor itself is not small and it extends into the uterine fundus. A PET scan was performed which reveals disease extending to the left adnexa. There is desmoplastic reaction to the parametria. She began radiation treatment with Dr. ___ in ___, and presented to hospital on ___ to undergo tandem and ovoid radiation. Detailed questioning reveals no symptoms of vaginal bleeding or discharge, pain, urinary symptoms and changes in bowel habits. <PAST MEDICAL HISTORY> PSH: Inguinal hernia repairs in ___ and ___, concussions as a child. PMH: Idiopathic upper extremity blood clots ___ years ago treated with Coumadin without recurrence. Seizure disorder characterized by occasional loss of motor control and consciousness without medication or symptoms within the recent past. Hyperlipidemia. Wisdom teeth surgery. GYNECOLOGIC HISTORY: Menarche age ___, menopause age ___. G1P0, not aware of abnormal Papanicolaou smears. Abdominal myomectomy in ___ in ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> A paternal aunt had breast cancer. <PHYSICAL EXAM> On discharge Well appearing, No acute distress RRR, NL S1 S2, no murmurs/rubs/gallops CTAB, no rales or ronchi, no use of accessory muscles S/NT/ND, normal positive bowel sounds NT/NE vaginal pad, slight blood <PERTINENT RESULTS> ___ 07: 15AM BLOOD WBC-4.3 RBC-2.87* Hgb-8.8* Hct-26.3* MCV-92 MCH-30.8 MCHC-33.6 RDW-14.9 Plt ___ ___ 07: 15AM BLOOD Neuts-87.1* Lymphs-6.3* Monos-5.1 Eos-1.4 Baso-0 ___ 07: 15AM BLOOD Plt ___ ___ 07: 15AM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-138 K-3.9 Cl-104 HCO3-29 AnGap-9 ___ 07: 15AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.7 <MEDICATIONS ON ADMISSION> MEDICATIONS: ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - ___ Tablet(s) by mouth every ___ hours as needed for pain FLUCONAZOLE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth three times per ay as needed for as needed for nausea, anxiety or insomnia ONDANSETRON - (Prescribed by Other Provider) - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth every 6 hours as needed for as needed for nausea OXYCODONE - (Prescribed by Other Provider) - 5 mg Tablet - ___ Tablet(s) by mouth every 4 hours as needed for as needed for pain PROCHLORPERAZINE MALEATE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for as needed for nausea LOPERAMIDE <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: *2* 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 3. loperamide 2 mg Capsule Sig: One (1) Capsule PO q 6 hours (). 4. acetaminophen-codeine 300-30 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 5. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp: *20 Patch 24 hr(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> stage IIA adenocarcinoma of the 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 to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * Nothing in the vagina (no tampons, no douching, no sex) until otherwise instructed by your gynecologist, no heavy lifting of objects >10lbs for 3 weeks. * You may eat a regular diet To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Patient was referred to the gynecological oncology service after her procedure POD0 Radioactive materials were placed POD1 Nausea, relieved by ondansetron WBC 5.5 RBC 2.87 Hgb 8.7 Hct 26.6 Neuts 88.8 Lymphs 6.4 Mg 1.5, given IV Magnesium. Radioactive implants removed at 21:55 Foley discontinued at 22:00 and she subsequently voided POD2 Slight Hematuria (pinkish), likely due to removal of tandem and ovoids WBC 4.3 RBC 2.87 Hgb 8.8 Hct 26.3 (stable from previous value) Neuts 87.1 Lymphs 6.3 Ambulating, Tolerating PO solids diet Patient was discharged on post-procedure day 2 in good condition and with follow up in place.
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10596508-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> Left lower abdominal/flank pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ postmenopausal woman with stage IIA cervical adenocarcinoma s/p chemo/radiation completed in ___, presented with L flank and LLQ pain. Pain started ___ felt like she had "hip soreness" which turned into more focal L flank pain. She laid in bed for most of day, had significant pain throughout day with episodes of nausea related to pain. Had shaking chills, took temp and was 99.9 max. No changes in BM - last was the other day, normal. Denied pain with urination or increased frequency of urination. Has noted a slight amount of vaginal bleeding but no change in vaginal d/c. <PAST MEDICAL HISTORY> PSH: Hyperlipidemia, upper extremity blood clots at age ___ treated with Coumadin without recurrence, concussions as a child. Seizure disorder characterized by occasional loss of motor control and consciousness without medication or symptoms within the recent past. PMH: Wisdom teeth surgery, inguinal hernia repairs in ___ and ___, myomectomy OBSTETRIC/GYNECOLOGIC HISTORY: Menarche age ___, menopause age ___. G1P0, SAB x1. Abdominal myomectomy in ___ in ___ ___. EBRT/vaginal brachytherapy with concomittant cisplatin completed ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> A paternal aunt had breast cancer. <PHYSICAL EXAM> On day of discharge: VS - 99.3 70 103/66 99%RA, UOP >100cc per hour voiding NAD, comfortable RRR, CTAB Abd softly and mildly distended, tympanitic, minimal discomfort, no rebound/guarding No CVA tenderness Extremeties NT NE, soft <PERTINENT RESULTS> Hospital Day 1: ___: - 10: 40AM BLOOD Glucose-114* UreaN-14 Creat-0.9 Na-141 K-4.0 Cl-101 HCO3-29 AnGap-15 - 10: 40AM BLOOD WBC-10.0# RBC-3.85*# Hgb-11.9*# Hct-35.7*# MCV-93 MCH-30.9 MCHC-33.2 RDW-11.8 Plt ___ - 10: 40AM BLOOD Neuts-90.7* Lymphs-4.3* Monos-4.8 Eos-0.1 Baso-0.1 ___ Urine culture - contaminated ___ Blood culture x 2 - PENDING ___ Urine Cytology - PENDING Hospital Day 4 ___: - 07: 34AM BLOOD WBC-5.8 RBC-3.48* Hgb-11.2* Hct-32.7* MCV-94 MCH-32.1* MCHC-34.2 RDW-11.9 Plt ___ - 07: 34AM BLOOD Glucose-147* UreaN-8 Creat-1.3* Na-140 K-4.2 Cl-106 HCO3-24 AnGap-14 - 07: 34AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.8 ---- ___ CT Abd/pelvis: 1. Enhancing urothelium with dilated left ureter is likely related to neoplastic involvement from a previously FDG-avid left adnexal mass which is adjacent to the left ureter. No renal stones identified. 2. Bilateral pars defect. ___ KUB: Nonspecific abdominal bowel gas pattern without obstruction or intraperitoneal free air. A slightly abnormal loop in the left upper quadrant might reflect an infectious or inflammatory process in the left upper quadrant such as pyelonephritis. ___ MRI Urogram: 1. Stable mild left hydronephrosis with moderate left hydroureter extending to the level of the brachytherapy artifact in the pelvis. Mild degree of hydronephrosis and slightly delayed, rather than absent, contrast excretion indicates partial obstruction as opposed to complete obstruction, though given artifact, MRI cannot differentiate between obstruction point due to radiation stricture vs. tumor involvement. Given the significant artifact from MRI, ureteral morphology on retrograde urogram might better demonstrate morphology (eccentricity, length) of the presumed stricture which might provide a better sense of the nature of this partial obstruction. 2. Trace bilateral pleural effusions, new since ___. <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *2 2. Bisacodyl ___AILY: PRN constipation RX *bisacodyl 10 mg 1 Suppository(s) rectally daily PRN Disp #*7 Suppository Refills: *0 3. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 5. Ibuprofen 600 mg PO Q6H RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *2 6. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4h PRN Disp #*30 Tablet Refills: *0 7. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8 hours Disp #*24 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Left hydroureteronephrosis <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 evaluation for your lower abdominal and lower back pain. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * You may eat a regular diet
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Ms. ___ was admitted to ___ on ___ for evaluation and management of left lower quadrant and flank pain. Her issues during admission are addressed below by relevant systems: 1. GU: Please refer to the CT and MR ___ results. The decision was made to defer her scheduled surgery on ___ due to the possibility of infection and local tumor extension. Urology was formally consulted and deferred stenting; they recommended pain control with scheduled Toradol, Tylenol and narcotics, empiric antibiotics, and urine cytology. Her creatinine was monitored daily and rose from 0.9 (baseline 0.9-1.1) to 1.3, which was within acceptable limits to the Urology consult, who advised further evaluation if creatinine reached 1.5-1.8. She received IV ciprofloxacin (due to penicillin allergy) and remained without fever or leukocytosis. Urine culture contained mixed flora, blood cultures had no growth to date. Urine output was closely watched and remained appropriate throughout. 2. Neuro: Her pain was controlled with the recommended regimen above, and she was discharged on scheduled oral Ibuprofen, Tylenol, and as-needed Oxycodone. 3. GI: On admission she was constipated and experienced nausea and abdominal distension. On Hospital Day 2 she was made NPO and received maintenance fluids and a bowel regimen. Please refer to abdominal xray results. Her symptoms improved, bowel movements returned, and her diet was advanced on Hospital Day 4. Her electrolytes were repleted daily as needed. She remained on prophylactic subcutaneous heparin and pneumatic compression boots. She was discharged on Hospital Day #4 in stable condition, tolerating a regular diet, with normal bowel and bladder function, ambulatory, and with adequate pain control on oral medication. She is to complete a total 10 day course of Ciprofloxacin and will follow-up with Dr. ___.
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10596508-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> abdominal distention <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo postmenopausal woman with stage IIA cervical adenocarcinoma s/p chemo/radiation completed in ___ who presents with abdominal pain, distension, and N/V. Pt reports onset of distention and nausea ___ followed by increasing abdominal discomfort and vomiting on ___. Sxs have been worsening. Pt reports daily small, hard bowel movements. Denies fevers/chills. Reports pinkish vaginal discharge. Reports taking meds to ___ for constipation, but is unsure what she has been taking. Patient also has noted leakage of urine at night. Urine is blood tinged. She denies dysuria. Regarding her recent disease course, she was initially scheduled for surgery on ___, but prior to that was admitted on ___ for L flank and LLQ pain. At that time she was found to have L hydroureter and hydronephrosis concerning for tumor extension vs. radiation scarring. She had a stent placed. She recovered well. Given that her findings were of unclear etiology and not necessarily tumor extension, plan was then for surgery on ___, which was cancelled due to Hurricane ___. She was rescheduled for surgery on ___. Plan was for laparoscopy, removal of the left tube and ovary, obtaining biopsies of the cervix to further understand the nature of her disease and the retroperitoneal disease, with possible laparotomy. <PAST MEDICAL HISTORY> PMH: Hyperlipidemia, upper extremity blood clots at age ___ treated with Coumadin without recurrence, concussions as a child. Seizure disorder characterized by occasional loss of motor control and consciousness without medication or symptoms within the recent past. PSH: Wisdom teeth surgery, inguinal hernia repairs in ___ and ___, myomectomy OBSTETRIC/GYNECOLOGIC HISTORY: Menarche age ___, menopause age ___. G1P0, SAB x1. Abdominal myomectomy in ___ in ___ ___. EBRT/vaginal brachytherapy with concomittant cisplatin completed ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> A paternal aunt had breast cancer. <PHYSICAL EXAM> Physical exam upon discharge: Afebrile, vital signs stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, mildly distended, mildly tender to palpation throughout, no rebound or guarding Ext: nontender to palpation, no edema <PERTINENT RESULTS> ___ 05: 00PM BLOOD WBC-7.6 RBC-3.95* Hgb-11.2* Hct-34.0* MCV-86# MCH-28.4# MCHC-33.0 RDW-14.1 Plt ___ ___ 05: 00PM BLOOD Neuts-86.8* Lymphs-6.1* Monos-6.2 Eos-0.8 Baso-0.2 ___ 06: 25AM BLOOD WBC-2.7* RBC-3.43* Hgb-9.8* Hct-29.8* MCV-87 MCH-28.5 MCHC-32.7 RDW-15.2 Plt ___ ___ 05: 15PM BLOOD WBC-2.6* RBC-3.30* Hgb-9.6* Hct-28.4* MCV-86 MCH-29.0 MCHC-33.8 RDW-14.3 Plt ___ ___ 05: 15PM BLOOD Neuts-73.0* Lymphs-10.9* Monos-10.4 Eos-5.6* Baso-0.1 ___ 06: 20AM BLOOD WBC-5.6# RBC-3.64* Hgb-10.2* Hct-30.9* MCV-85 MCH-28.0 MCHC-32.9 RDW-14.7 Plt ___ ___ 06: 20AM BLOOD Neuts-79.5* Lymphs-7.7* Monos-9.1 Eos-3.4 Baso-0.4 ___ 06: 15AM BLOOD WBC-6.6 RBC-3.33* Hgb-9.4* Hct-28.6* MCV-86 MCH-28.2 MCHC-32.8 RDW-15.0 Plt ___ ___ 06: 15AM BLOOD Neuts-82.6* Lymphs-7.4* Monos-7.7 Eos-2.2 Baso-0.2 ___ 06: 10AM BLOOD WBC-5.8 RBC-3.18* Hgb-8.9* Hct-27.6* MCV-87 MCH-28.0 MCHC-32.3 RDW-14.5 Plt ___ ___ 06: 10AM BLOOD Neuts-81.8* Lymphs-8.3* Monos-6.5 Eos-3.3 Baso-0.1 ___ 06: 10AM BLOOD WBC-6.1 RBC-3.13* Hgb-8.9* Hct-26.7* MCV-86 MCH-28.5 MCHC-33.3 RDW-15.4 Plt ___ ___ 06: 10AM BLOOD Neuts-82.7* Lymphs-6.9* Monos-8.0 Eos-2.1 Baso-0.2 ___ 07: 05AM BLOOD WBC-7.5 RBC-3.57* Hgb-9.9* Hct-30.5* MCV-85 MCH-27.6 MCHC-32.3 RDW-15.5 Plt ___ ___ 07: 05AM BLOOD Neuts-84.5* Lymphs-7.4* Monos-6.2 Eos-1.7 Baso-0.3 ___ 05: 23PM BLOOD Lactate-1.4 ___ 05: 00PM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-137 K-4.4 Cl-96 HCO3-27 AnGap-18 ___ 07: 05AM BLOOD Glucose-125* UreaN-3* Creat-0.9 Na-138 K-3.5 Cl-104 HCO3-23 AnGap-15 COAGULATION PROFILE: ___ 05: 47PM BLOOD ___ PTT-35.3 ___ ___ 12: 30AM BLOOD ___ PTT-77.0* ___ ___ 06: 20AM BLOOD ___ PTT-61.0* ___ ___ 06: 15AM BLOOD ___ PTT-66.5* ___ ___ 06: 10AM BLOOD ___ PTT-66.3* ___ ___ 06: 10AM BLOOD ___ PTT-36.3 ___ ___ 07: 05AM BLOOD ___ PTT-37.7* ___ URINE: ___ 01: 57AM URINE Color-Yellow Appear-Clear Sp ___ ___ 01: 57AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 01: 57AM URINE RBC-14* WBC-19* Bacteri-FEW Yeast-NONE Epi-1 PERITONEAL FLUID: ___ 03: 45PM ASCITES WBC-595* RBC-345* Polys-46* Lymphs-5* Monos-0 Eos-2* Mesothe-2* Macroph-45* ___ 03: 45PM ASCITES TotPro-4.1 MICROBIOLOGY: URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). PERITONEAL FLUID: GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. PATHOLOGY: SPECIMEN SUBMITTED: CELL BLOCK OF PERITONEAL FLUID Procedure date Tissue received Report Date Diagnosed by ___ ___. ___ Previous biopsies: ___ Slides referred for consultation. DIAGNOSIS: Peritoneal fluid, cell block: Groups of atypical epithelial cells with vacuolated cytoplasm consistent with metastatic adenocarcinoma; see note. IMAGING: 1) KUB, ___: IMPRESSION: Findings concerning for small bowel obstruction. 2) CT ABD/PEL, ___: IMPRESSION: 1. Bilateral adnexal enhancing soft tissue masses with peritoneal nodularity/enhancement and new ascites is suggestive of local extension of malignancy with possible carcinomatosis. There is also associated small bowel obstruction with a transition point within the distal ileum. 2. Severe left and mild right-sided hydroureter. 3) CXR, ___: IMPRESSION: 1. Small left pleural effusion and possibly a tiny right pleural effusion. 2. NG tube terminates in the expected location of the stomach. 3. Moderate distention of small and large bowel. 4) CT ABD/PEL, ___: IMPRESSION: 1. In this patient with history of advanced cervical cancer with uterine invasion, nodularity and peritoneal thickening more pronounced in the lower abdomen/pelvis is worrisome for peritoneal carcinomatosis. 2. Stable partial small-bowel obstruction with transition point in the right lower quadrant of the abdomen where small bowel loops are tethered. 3. Interval improvement of the left hydroureteronephrosis, status post placement of a new stent in appropriate position. 4. Multiple enlarged retroperitoneal lymph nodes, similar to the recent prior study. Deep venous thrombosis involving the right common iliac vein. <MEDICATIONS ON ADMISSION> lorazepam, oxybutynin, percocet <DISCHARGE MEDICATIONS> 1. Enoxaparin Sodium 50 mg SC Q12H RX *enoxaparin 60 mg/0.6 mL inject 50 mg twice a day Disp #*60 Syringe Refills: *1 2. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *2 3. Lorazepam 0.5 mg PO Q4H: PRN anxiety, pain RX *lorazepam 0.5 mg 1 tablet by mouth every four (4) hours Disp #*20 Tablet Refills: *0 4. Ondansetron ___ mg PO Q8H: PRN nausea RX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills: *1 5. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 6. Promethazine 25 mg PO Q6H: PRN nausea RX *promethazine 25 mg 1 tablet by mouth every six (6) hours Disp #*60 Tablet Refills: *1 7. Acetaminophen 1000 mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> small bowel obstruction right iliac deep vein thrombosis advanced cervical cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service for treatment of a small bowel obstruction. Your obstruction was managed with a nasogastric tube and medications to manage your nausea and pain. You also developed a fever while you were admitted and received antibiotics. In addition, you were found to have a blood clot for which you received anticoagulation. You have made excellent progress and the team feels you are now ready for discharge. Please follow the below instructions. * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * You may eat a regular diet To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecologic oncology service from the ED for conservative management of a partial small bowel obstruction; at time of presentation, it was unclear whether the obstruction had evolved from progressive disease or as a sequelae of her radiation therapy. She was initially made NPO and managed with nasogastric tube, IV pain medications and anti-emetics. CT abd/pelvis obtained on ___ demonstrated likely partial small bowel obstruction with a transition point at the distal ileum, an enhancing mass at the uterine fundus and new onset ascites. A diagnostic paracentesis was performed on ___. On ___, the patient developed fever to 102.9. Her WBC was noted to trend down from 7.6 on admission to a nadir of 2.6; her ANC was 3000. Chest x-ray was obatined and was significant for a new small left pleural effusion that could represent a parapneumonia, but no focal consolidation was noted, and lung fields were otherwise clear. UA did not demonstrate signs of infection, and urine culture showed no growth. Blood cultures were also obtained, but these also demonstrated no growth. A C. difficile assay returned negative. KUB was obtained which showed worsening SBO with a diameter up to 6.7 cm, but without free air or pneumatosis. The patient was started on broad spectrum antibiotics with ciprofloxacin and flagyl. Due to worsening abdominal distention in the setting of her febrile illness without a clear source for infection, CT abd/pelvis was obtained on ___ to evaluate for bowel perforation, worsening obstruction and/or worsening disease. CT abd/pelvis demonstrated stable partial SBO, mildly improved left hydroureter and new right common iliac DVT. A heparin drip was initiated. It was felt that her DVT was the most probable source of her fever; she was continued on IV flagyl and ciprofloxacin and did not have any additional fever for the remainder of her hospitalization. On ___, ___ medical oncology, colorectal surgery and nutrition consults were also placed. Medical oncology recommended no role for chemotherapy at present given the presence of infection compounded by her SBO. Colorectal surgery advised no role for surgical intervention for her SBO; conservative management was recommended. Nutrition consult advised that if patient was unable to tolerate po, given that she had been without adequate nutrition for 5 days, enteral or parenteral feeds should be initiated. The patient was continued on a heparin drip until final paracentesis cytology returned positive for adenocarcinoma on ___. On ___, the nasogastic tube fell out, but was not replaced given that the patient had no nausea or emesis. Nasogastric output prior to falling out had been ~250cc over a 12 hour period. On ___, she was transitioned from her heparin drip to lovenox. On ___, her diet was advanced successfully and she was transitioned from her dilaudid PCA to IV toradol and morphine to po tylenol and oxycodone. Throughout her hospitalization, she continued to pass flatus and have loose bowel movements. On ___, the patient was tolerating a regular diet and po anti-emetics, her pain was well controlled on po pain medication, and she was receiving lovenox injections. She completed a seven day course of IV antibiotics; at time of discharge, her leukocyte count had normalized, and all cultures remained without growth. Although her primary medical oncologist, Dr. ___, had requested a port-a-cath be placed if possible prior to discharge, this in fact was not possible at time of discharge. On ___, the patient was discharged home with outpatient follow-up scheduled.
| 3,034
| 787
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10596626-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> ruptured ovarian cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion <HISTORY OF PRESENT ILLNESS> CC: hemoperitoneum HPI: Ms. ___ is a ___ G0 who presents to the ED with diffuse abdominal pain, pressure and rectal pressure that started on ___. She reports that she has felt weak, has some shortness of breath on exertion. ROS: She denies chest pain, nausea, lightheadedness, dizziness. All other areas negative except for pertinent positives/negatives mentioned above. OBHx: G0 GYNHx: - Menarche 11 - Now amenorrheic s/p endometrial abalation - Last Pap ___ - Hx of STIs - No hx of fibroids, endometriosis - Hx of ruptured hemorrhagic cyst s/p hemoperitoneum - s/p course of Lupron and norethindrone (not taking <PAST MEDICAL HISTORY> PMH: CONGENITAL HEART DISEASE HEART ATTACK COAGULATION DISORDER HISTORY OF BLOOD TRANSFUSSIONS ANEMIA PSORIASIS HYPTONIC BLADDER PELVIC CYST ARTIFICIAL HEART VALVE SEASONAL ALLERGIES HYPOTHYROIDISM NEUPATHIC BLADDER LIPOPROTEIN DISORDERS IRON DEFICIENCY ANEMIA HEMORRHOIDS ALLERGIC RHINITIS CARDIAC VALVE REPLACEMENT (MECHANICAL) AVR PSH: ENDOMETRIAL ABLATION ___ CARDIAC VALVE REPLACEMENT (MECHANICAL) ___ ANKLE REPAIR, left <SOCIAL HISTORY> Presents with boyfriend, not sexually active. Denies T/D. Reports ___ drink per week <PHYSICAL EXAM> Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, mild tenderness diffusely, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> --===== Labs --===== ___ 05: 10PM BLOOD WBC-6.5 RBC-3.59*# Hgb-10.5*# Hct-32.7*# MCV-91 MCH-29.2 MCHC-32.1 RDW-13.5 RDWSD-45.0 Plt ___ ___ 11: 45AM BLOOD WBC-6.1 RBC-2.60* Hgb-7.7* Hct-23.9* MCV-92 MCH-29.6 MCHC-32.2 RDW-13.4 RDWSD-44.2 Plt ___ ___ 04: 10PM BLOOD WBC-6.6 RBC-2.75*# Hgb-8.2*# Hct-25.5*# MCV-93 MCH-29.8 MCHC-32.2 RDW-13.2 RDWSD-44.8 Plt ___ ___ 05: 10PM BLOOD Neuts-64.0 ___ Monos-12.4 Eos-2.2 Baso-0.3 Im ___ AbsNeut-4.15 AbsLymp-1.33 AbsMono-0.80 AbsEos-0.14 AbsBaso-0.02 ___ 11: 45AM BLOOD Neuts-70.5 Lymphs-16.7* Monos-10.3 Eos-1.5 Baso-0.3 Im ___ AbsNeut-4.30 AbsLymp-1.02* AbsMono-0.63 AbsEos-0.09 AbsBaso-0.02 ___ 05: 10PM BLOOD ___ PTT-35.0 ___ ___ 11: 45AM BLOOD ___ PTT-37.2* ___ ___ 11: 45AM BLOOD Glucose-87 UreaN-9 Creat-0.6 Na-139 K-3.6 Cl-105 HCO3-24 AnGap-14 ___ 04: 10PM BLOOD UreaN-12 Creat-0.6 Na-134 K-3.7 Cl-100 HCO3-26 AnGap-12 ___ 11: 45AM BLOOD ALT-26 AlkPhos-59 TotBili-0.6 ___ 04: 10PM BLOOD ALT-27 AST-25 AlkPhos-60 TotBili-0.3 ___ 11: 45AM BLOOD Lipase-45 ___ 11: 45AM BLOOD Albumin-4.2 ___ 11: 45AM BLOOD HCG-<5 ___ 11: 55AM BLOOD Lactate-1.7 ___ 11: 45AM URINE Color-Straw Appear-Clear Sp ___ ___ 11: 45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 11: 45AM URINE UCG-NEGATIVE URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. --===== Imaging --===== Pelvic ultrasound ___ FINDINGS: The uterus measures 7.8 x 3.4 x 5.6 cm. The endometrium is homogenous and measures 6 mm. New from the prior pelvic ultrasound, there is a heterogeneous left-sided large lesion in the region of the left adnexa with cystic components, including some fluid-fluid levels. There is internal vascularity with arterial and venous waveforms within this lesion, suggestive of ovarian tissue. The lesion measures 8.18 x 9.13 x 7.6 cm. There is associated moderate amount of complex fluid in the pelvis compatible with hemo peritoneum. A normal left ovary is not visualized. The right ovary measures 2.5 x 3.8 x 2.2 cm and is unremarkable. IMPRESSION: Interval development of a large heterogeneous left adnexal lesion measuring up to 9.1 cm containing cystic components, including some fluid-fluid levels. Some internal vascularity is noted within this lesion with waveforms suggestive of ovarian tissue. There is associated moderate hemoperitoneum. Constellation of findings suggests a ruptured hemorrhagic left ovarian cyst with hemoperitoneum or a left adnexal hematoma that involves the left ovary. <MEDICATIONS ON ADMISSION> Active Medication list as of ___: Medications - Prescription AMOXICILLIN - amoxicillin 500 mg tablet. 4 tablet(s) by mouth once as needed for 1 hour prior to dental work - (Prescribed by Other Provider) AZELASTINE - azelastine 0.15 % (205.5 mcg) nasal spray. 2 puffs each nostril twice a day CLOBETASOL - clobetasol 0.05 % topical ointment. - (Prescribed by Other Provider) ENOXAPARIN - enoxaparin 60 mg/0.6 mL subcutaneous syringe. 1 sz sc twice a day LEVOTHYROXINE - levothyroxine 75 mcg tablet. 1 tablet(s) by mouth daily PAROXETINE HCL - paroxetine 10 mg tablet. 1 tablet(s) by mouth daily POLYETHYLENE GLYCOL 3350 - polyethylene glycol 3350 17 gram/dose oral powder. 1 powder(s) by mouth daily - (Prescribed by Other Provider) (Not Taking as Prescribed)Entered by MA/Other Staff TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 capsule(s) by mouth once daily TRETINOIN [RETIN-A] - Retin-A 0.1 % topical cream. - (Prescribed by Other Provider) WARFARIN - warfarin 10 mg tablet. 1 tablet(s) by mouth once a day 12.5 mg daily WARFARIN - warfarin 7.5 mg tablet. Take one tablet(s) by mouth daily or as directed by the ___ clinic WARFARIN [COUMADIN] - Coumadin 2.5 mg tablet. 1 tablet(s) by mouth once a day 12.5 mg daily Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) CALCIUM CITRATE - Dosage uncertain - (Prescribed by Other Provider) CETIRIZINE [ZYRTEC] - Dosage uncertain - (Prescribed by Other Provider) CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain - (Prescribed by Other Provider) FERROUS SULFATE [SLOW RELEASE IRON] - Slow Release Iron 142 mg (45 mg iron) tablet,extended release. tablet(s) by mouth - (Prescribed by Other Provider) FLUTICASONE [FLONASE ALLERGY RELIEF] - Flonase Allergy Relief 50 mcg/actuation nasal spray,suspension. 2 spray intranasally twice a day MULTIVITAMIN - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed)Entered by MA/Other Staff <DISCHARGE MEDICATIONS> 1. Enoxaparin Sodium 60 mg SC BID Start: ___, First Dose: STAT 2. norethindrone (contraceptive) 5.0 mg oral DAILY 3. norethindrone acetate 5 mg oral DAILY RX *norethindrone acetate 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *6 4. Aspirin 81 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Levothyroxine Sodium 75 mcg PO DAILY 7. PARoxetine 10 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Warfarin 12.5 mg PO ONCE Duration: 1 Dose <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ruptured ovarian cyst anemia, s/p blood transfusion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital for observation of a ruptured ovarian cyst in the setting of receiving anticoagulation for a heart valve. The team feels you are stable for discharge home. After consulting with heme/onc and cardiology, we developed the plan below: - Prior to discharge tonight, you have received lovenox 60 units and Coumadin 12.5mg - Continue taking lovenox 60 units twice daily until your INR is 2.5 - Take Coumadin 15mg tomorrow and resume alternating between 12.5mg and 15mg daily - Check your INR on a daily basis - Follow up with the ___ clinic - Please begin taking the new norethindrone dose 5mg daily starting tomorrow morning
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On ___, Ms. ___ was admitted for observation given concern for ruptured ovarian cyst and anemia. Prior to admission, her hematocrit was noted to be 25.5 (___) from a baseline of 38 (___). While in the emergency department, her hematocrit was repeated and found to be 23.9. Pelvic ultrasound showed heterogenous left adnexal mass with solid and cystic components, vascularity with arterial and venous waveforms along with associated complex fluid in the pelvis consistent with a ruptured hemorrhagic ovarian cyst. She received 2 units packed red blood cells and was admitted for further observation. On arrival, patient noted improved abdominal pain. A post-transfusion hematocrit was 32.7. Given her stable hematocrit from ___ to ___, her appropriate increase in hematocrit with transfusion, and her improved symptoms after transfusion, it was felt that there was low risk of continued bleeding. Given her history of ruptured hemorrhagic cyst, risks and benefits of restarting norethindrone was discussed and pt agreed with restarting norethindrone 5mg daily to suppress ovulation. For her history of prosthetic heart valve, hematology-oncology and cardiology were consulted. Patient was supratherapeutic on arrival with last INR noted to be 7 in the outpatient setting on ___. In the ED, her INR was noted to be 2.6 and 1.9. Per hematology oncology, goal INR should be ___. Given low concern for continued bleeding from the ruptured cyst, cardiology recommended bridging with lovenox 60mg and coumadin 12.5 mg prior to discharge. Patient was instructed to continue lovenox 60 units BID until INR is 2.5; coumadin 15mg ___ and alternating 12.5 mg and 15mg daily. Her INR should be checked on a daily basis and patient will follow-up with the ___ clinic. She was discharged home in stable condition with outpatient follow-up scheduled.
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10597253-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> loss of fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p postpartum hysterectomy, s/p massive blood transfusion <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 @ 41w3d with prior LTCS presents after clear LOF at 0200. She denies VB. She has irregular contractions. +FM. Desires trial of labor. <PAST MEDICAL HISTORY> POBHx: G2P1 - G1 LTCS ___ at 36w4d 5#3oz for breech, oligo, IUGR c/b intra-op hemorrhage from uterine atony requiring B-Lynch stitch. pod#2 hct 34, no transfusions. Possible arcuate uterus per operative note. - G2 current PGynHx: Denies STDs or abnl paps PMH: none PSH: LTCS <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> PE: 97.7 105/68 87 18 Gen: NAD Abd: soft, gravid, NT, 7.5# EFW by ___ SVE: 1-2/80/-2 ___ at 11: 20 am FHT: 140, mod var, +accels, no decels Toco: q8 min <PERTINENT RESULTS> ___ 08: 50AM WBC-9.5 RBC-4.63 HGB-13.3 HCT-40.1 MCV-87# MCH-28.7 MCHC-33.2 RDW-13.1 RDWSD-40.8 ___ 08: 50AM PLT COUNT-117* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN fever 2. Prenatal Vitamins 1 TAB PO DAILY 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 4. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *2 5. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p vaginal birth after cesarean ___ liveborn baby boy ___ s/p postpartum hemorrhage/DIC/hemorrhagic shock, s/p hysterectomy, s/p massive blood transfusion blood loss anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see nursing sheet no heavy lifting for 6 weeks
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Ms. ___ is a ___ G2P2 who presented with clear SROM, early labor, GBS positive, and desire for trial of labor. She underwent pitocin and had successful VBAC that was complicated by postpartum hemorrhage and DIC requiring hysterectomy. A hysterectomy was required due to persistent hemorrhage despite uterotonics, D&C, bakri balloon, B-lynch, and box stitch. Massive transfusion protocol was required. She had also developed hives intraoperatively, which was thought to either be due to a reaction to products received or possible AFE. EBL was 4000mL. Intraoperatively, total products received were 8 units pRBCs (of which 1 unit was interrupted due to possible transfusion reaction), ___ FFP, 3 platelets and 2 cryoprecipitate. Please see operative note for full details. She was admitted to the FICU postoperatively where she continued to be monitored: - For the postpartum hemorrhage/DIC/hemorrhagic shock/blood loss anemia, she received short course of pressors and additional 2 units of pRBCs. Fibrinogen nadired to 82 and normalized later pod#0. After transfusion, hct remained stable at ___ without any evidence of ongoing bleeding. In total over hospitalization, pt received 9 to 10 units of PRBCs, 3 Platelets, 2 Cryoprecipitate, ___ FFP. - Presumed sepsis was managed with IV vancomycin and zosyn until over 24hours afebrile. No source was identified while in the hospital. Urine and blood cultures were all negative and WBC normalized. Patient was extubated on pod#1 and transferred to the normal postpartum floor on pod#2. By pod#2 patient was ambulating, voiding spontaneously and had bowel movement. She tolerated POs, was encouraged to breastfeed and breastpump, and had satisfactory pain control. She was discharged on pod#6 in stable condition.
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| 436
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10598437-DS-17
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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> Amniocentesis <HISTORY OF PRESENT ILLNESS> Pt is ___ yo G8P2 at ___ ___ GA who was sent over from ___ because the radiologists noted the cervix was open on routine fetal survey. Pt reports no recent bleeding, LOF or cramping. <PAST MEDICAL HISTORY> Gyn Hx: LEEP, denies hx sexually transmitted infections. OBHx: ___ 4 TABs; first trimester without complications 1 LTCS for arrest dilation 9# 15 oz 1 VBAC 8#12 oz, no complications at term 1 SAB PMHx: Depression PSHx: Cesarean delivery <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> BP: 105/76 HR: 64 T: 98.7 RR: 20 Abd: soft, NT/ND, uterus non-tender SSE: Cervix 3cm dilated with membranes visible <PERTINENT RESULTS> ___ WBC-17.0 RBC-3.96 Hgb-11.3 Hct-33.7 MCV-85 Plt-272 ___ Neut-75.1 ___ Mono-4.4 Eos-1.0 Baso-0.4 ___ WBC-11.1 RBC-3.71 Hgb-11.0 Hct-30.8 MCV-83 Plt-265 ___ WBC-14.5 RBC-3.89 Hgb-10.9 Hct-32.5 MCV-84 Plt-261 ___ Neuts-76.1 ___ Monos-7.7 Eos-1.0 Baso-0.2 ___ Hct-25.8 ___ Glu-90 ___ URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 01: 25PM URINE RBC-2 WBC-226* Bacteri-FEW Yeast-NONE Epi-1 ___ AMNIOTIC FLUID - GRAM STAIN neg - CULTURE neg - ANAEROBIC CX (prelim) NEG ___ GC/CT neg ___ VAGINAL SWAB neg yeast, neg BV ___ URINE CULTURE +E.COLI <MEDICATIONS ON ADMISSION> Macrobid <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> stable s/p preterm vaginal delivery w/ manual removal of placenta <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine postpartum instructions
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The patient was admitted to Labor and Delivery following an incidental finding of a dilated cervix upon abdominal ultrasound for her full fetal survey. . The patient had no clear etiology for the incompetence cervix. A physical exam revealed a dilated cervix 3cm with bulging of membranes into the vagina. The patient underwent extensive testing with gonorrhea, chlamydia, yeast and bacterial vaginosis swabs obtained. Urinalysis was suspicious for a UTI and she was treated with a dose of Ceftriaxone. An ___ consult was obtained and recommended an amniocentesis. The gram stain was negative and the culture returned without growth. Glucose was 39. The patient was not found to be a candidate for a rescue cerclage given the advanced cervical dilation of 4 centimeters on repeat vaginal exam. The patient was observed on Labor and Delivery; she declined induction of labor. She received a social work consult given the poor prognosis of the pregnancy. After transfer to the antepartum floor, the patient had cramping and vaginal bleeding. She was found to be fully dilated on exam and delivered a previable fetus at 18 weeks 5 days gestation on Labor and Delivery. She had a retained placenta and cord avulsion, therefore, required a manual extraction of placenta which was in the vagina and intact. Please see operative note in OMR for details. She was treated with triple antibiotics for 24 hours Postpartum. Her urine culture revealed an E.Coli UTI and she was switched to po Macrobid upon discharge.
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10602608-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> RLQ pain and pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ year old G1 at 5w3d by LMP with positive home pregnancy who presented with one day of RLQ/flank and bilateral low back pain. Has worsened throughout the day and sometimes worse with movement. Not associated with eating, no other exacerbating or relieving factors. No n/v/fevers. Has also has ___ days of brown vaginal spotting. This pregnancy is highly desired. She was just starting an infertility evaluation at ___ after ___ years of trying to become pregnant with her husband of ___ years with regular intercourse. She denies history of pelvic infections or STI. Does have a history of extremely painful periods when she was young. Often causing her to miss school or even pass out from the pain. ROS otherwise negative. <PAST MEDICAL HISTORY> PMH: -chronic constipation -chronic low back pain since falling down stairs a few years ago -hyperlipidemia -insomnia -vitamin D deficiency Denies history of heart disease, HTN, VTE. PSH: -breast fibroadenoma excision x6 -foot surgery Denies anesthesia or post-operative complications. Obhx: G1 Gyn hx: q28-31 day periods. reports history of menorrhagia as teenager severe enough to cause her to miss school and sometimes pass out from pain. Started on OCPs with marked improvement in menorrhagia. Denies history of STI, cysts, fibroids, PID. Mutually monogamous relationship with her husband of ___ years. <SOCIAL HISTORY> works as a ___ grade ___. Married ___ years. Husband is a ___ at a local ___. denies tob/etoh/drugs. <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> ___ 07: 40PM ALT(SGPT)-28 AST(SGOT)-29 ___ 07: 40PM WBC-5.1 RBC-4.56 HGB-12.4 HCT-38.1 MCV-84 MCH-27.2 MCHC-32.5 RDW-14.0 RDWSD-42.8 ___ 07: 40PM PLT COUNT-252 ___ 07: 40PM ___ PTT-29.8 ___ ___ 10: 56PM GLUCOSE-92 UREA N-15 CREAT-0.9 SODIUM-136 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17 ___ 10: 56PM estGFR-Using this ___ 10: 56PM HCG-1338 ___ 10: 56PM WBC-4.2 RBC-4.47 HGB-11.9 HCT-38.0 MCV-85 MCH-26.6 MCHC-31.3* RDW-13.8 RDWSD-43.0 ___ 10: 56PM NEUTS-53 BANDS-0 ___ MONOS-8 EOS-3 BASOS-1 ATYPS-1* ___ MYELOS-0 AbsNeut-2.23 AbsLymp-1.47 AbsMono-0.34 AbsEos-0.13 AbsBaso-0.04 ___ 10: 56PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 10: 56PM PLT SMR-NORMAL PLT COUNT-262 ___ 08: 20PM URINE HOURS-RANDOM ___ 08: 20PM URINE UCG-POSITIVE ___ 08: 20PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08: 20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG IMAGING ___ PUS IMPRESSION: 1. Edematous right ovary measuring up to 7.1 cm with preserved vascular flow, unchanged compared to prior, which remains concerning for intermittent torsion. Unchanged appearance of the simple and complex cysts within the right ovary. 2. Small amount of fluid within the endometrial canal. No definite gestational sac visualized. 3. Small amount of simple free fluid. ___ MRI A/P IMPRESSION: 1. Nonvisualization of the appendix in the right lower quadrant, with no secondary signs of acute appendicitis. 2. Markedly enlarged right ovary measuring 6.5 x 5.8 cm containing a 3.4 cm simple cyst and a 2.3 cm complex cyst. The asymmetrically enlarged right ovary raises suspicious for ovarian torsion. There is diffusely thickened endometrium without identification of a discrete gestational sac. This could be related to very early gestation. Normal appearance of the left ovary. 3. Small amount of simple free fluid in the pelvis. ___ US Appendix IMPRESSION: Appendix not visualized. If there is a high clinical concern for appendicitis, MRI is recommended. ___ PUS IMPRESSION: 1. The right ovary is markedly enlarged compare the left ovary raising the suspicion of ovarian torsion, despite the presence of flow surrounding the complex cyst within the right ovary. The right ovary also demonstrates presence of an anechoic simple cyst measuring 3.0 cm. 2. A complex cystic lesion in the ovary without internal vascularity measuring up to 2.2 cm. There is also complex free fluid in the right adnexa. These findings are most compatible with a ruptured hemorrhagic cyst. Ectopic pregnancy is less likely. 3. Diffusely thickened and heterogeneous endometrium measuring up to 3 cm without visualization of intrauterine gestational sac. The thickened endometrium is likely secondary to an early intrauterine pregnancy. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy of unknown location <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call the office with any questions or concerns ___. Please follow the instructions below. General instructions: * Take a stool softener such as colace while taking narcotics to prevent constipation. * 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 gynecology service for observation of RLQ/flank/back pain in the context of pregnancy of unknown location (5+ weeks by LMP). She underwent an pelvic US in the ED which revealed an R ovary markedly enlarged compared to L ovary concerning for ovarian torsion though there was presence of flow around a complex cyst w/o internal vascularity within R ovary measuring 2.2cm. These findings were more compatible with a ruptured hemorrhagic cyst, less likely ectopic. There was also an additional anechoic simple cyst on the R ovary. There was a diffusely thickened and heterogeneous endometrium without visualization of an intrauterine gestational sac, likely early intrauterine pregnancy. Appendix was not visualized on US and MRI was recommended. MRI again did not visualize the appendix, there were also no signs of acute appendicitis. It also confirmed findings on US and there was a small amt of simple free fluid. A repeat US showed an edematous R ovary up to 7.1cm w/ preserved flow, unchanged from prior, as were the presence of simple and complex cysts in the R ovary. Again, there was a small amt of fluid within endometrial canal w/o visualized gestational sac. Her beta-hCG was found to be 1338 (at 22:56 on ___ at the time of admission which increased to 1859, 36 hours later (at 05:40 on ___. Her hct was 38 at the time of admission which dropped to 35.3 on HD2. She was hemodynamically stable. She was kept NPO overnight with serial abdominal exams and her pain improved with Tylenol. On HD2, she was advanced to a regular diet without issues. Given her clinical improvement, she was discharged to follow up in clinic for a repeat beta-hCG the following day (___).
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10603088-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Toradol / Reglan <ATTENDING> ___. <CHIEF COMPLAINT> N/V, epigastric pain, inability to void <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G3P0 @ ___ with multiple presentations and admissions for for nausea/vomiting/epigastric pain (last discharged ___ and dehydrations who presents with persistent nausea/vomiting for the past 2 days. She reports inability to tolerate PO and vomiting for the past two days, taking in minimal po and reports no voids since last evening. She reports similar epigastric pain as has had prior with associated lightheadedness and chills. Denies fevers, diarrhea, dysuria, VB. She has tried zofran, unisom, B6, pantoprazole, sucralfate, prochlorperazine with no sustained relief and recurrent symptoms. Her prenatal care has otherwise been uncomplicated, with low risk ERA and physical exam noting appropriate fundal growth. She has minimal gain, but no significant weight loss. <PAST MEDICAL HISTORY> PNC: -___: ___ by ___ -Labs: A pos/Ab neg/RI/RPR NR/HBsAg neg/HIV neg OB Hx: G3P0 - SAB x1 - TAB x1 with D&C - current GYN Hx: Denies h/o abnl Paps or STIs PMH: GERD, cyclic vomiting syndrome, followed by GI service at ___. No etiology has been identified for her symptoms. PSH: tonsillectomy, D&C, ganglion cyst excision <SOCIAL HISTORY> ___ <FAMILY HISTORY> Grandmother died of pancreatic cancer. Brother with peptic ulcer disease. <PHYSICAL EXAM> (on admission) VS: T 97.8 HR 90 BP 102/55 RR 18 O2Sat 100%/RA Gen: NAD, AxO Abd: Soft, NT, ND, no Rebound, guarding, no masses or hepatospenomegaly. Uterus approximately 1 cm from umbilicus Ext: no edema <PERTINENT RESULTS> ___ WBC-10.0 RBC-3.85 Hgb-11.6 Hct-34.9 MCV-91 Plt-161 ___ Glu-65 BUN-13 Creat-0.6 Na-134 K-3.8 Cl-100 HCO3-21 ___ Glu-76 BUN-3 Cre-0.5 Na-138 K-3.3 Cl-108 HCO3-25 AnGap-8 ___ Albumin-2.8 Calcium-8.6 Phos-3.4 Mg-1.4 ___ URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-4 pH-6.5 Leuks-LG ___ URINE RBC-9 WBC-32* Bacteri-FEW Yeast-NONE Epi-21 TransE-<1 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG <MEDICATIONS ON ADMISSION> Protonix 40 bid Sucralfate 1gm quid Zofran 4mg q6prn nausea Compazine 10 q6 prn nausea PNV daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain 2. Docusate Sodium 100 mg PO BID: PRN Constipation 3. Pantoprazole 40 mg PO Q12H 4. Ondansetron 4 mg PO Q8H: PRN nausea 5. Prochlorperazine 10 mg PO Q6H: PRN nausea 6. Sucralfate 1 gm PO QID 7. DiphenhydrAMINE 25 mg PO QHS: PRN insomnia 8. Pyridoxine 50 mg PO TID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Nausea, vomiting 19 weeks pregnant <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call for fever, vaginal bleeding, inability to eat of drink.
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___ y/o G3P0 admitted at 19w1d with recurrence of nausea, vomiting, and epigastric pain and resultant dehydration as she has had frequently during the pregnancy. She was admitted for IV hydration, protonix, and antiemetics. Her predominant symptoms was epigastric pain and this was managed with acetaminophen. She requested pain relief with narcotics, and morphine but this not deemed necessary given her exam, the unclear etiology for her pain and the intermittent nature of the symptoms. She did receive IV Ativan on occasion for her nausea and pain, which provided some relief. The GI service was re-consulted, with recommendations that included sym0ptoms relief as doing with current medications, avoidance of narcotics and no additional imaging or procedures. They felt it was unusual for her symptoms to not improve when NPO and agreed with recommendation for Psychiatric followup and discussion via family meeting. During her admission, the patient was also re-offered the services of the Pain Service and treatment with accupuncture and other non medication related supports. she declined this. A concern for anxiety and the potential contribution of this to her symptoms was explained. She declined psychiatric input. For a period of time she tolerated Ensure supplements in small amounts, but continued to attempt po with food brought form home or ordered. She often did not tolerate these foods with vomiting shortly after or several hours after eating them. She continued to have complaints of epigastric pain - often after eating, without associated emesis with blood or persistent pain. The family members to ___ in a meeting, her mother and brother were unable to come to the hospital and thus a phone converstion was had between her brother ___ and Dr ___. This occurred on ___. I summary Dr ___ her treatment thus far and prolonged nature of her symptoms, declining nutritional status and the lack of improvement despite usually very effective medications. Dr ___ the potential contribution to anxiety depression and need to consider other modalities to assist with her pain symptoms and improve her well being. Mr ___ agreed to review with his sister To date her weight has been stable, and fetal status is normal, with appropriate growth thus far. On the evening of ___, Ms ___ requested to be discharged home and will follow up at next scheduled visit.
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10614092-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Ibuprofen / morphine / Oxycodone / Tylenol / adhesive <ATTENDING> ___ <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal excision of mesh Cystoscopy <HISTORY OF PRESENT ILLNESS> ___ woman who had excision of an eroded Mersilene mesh from prior surgery at ___ several years ago. The mesh erosion recurred and last ___ I did a total hysterectomy and sacral colpopexy, removing the Mersilene mesh at that time and using a polypropylene mesh for the suspension. Unfortunately, she has granulation tissue at the vaginal vault and although I cannot see mesh behind it, I can palpate a little bit. We are planning on an excision a few months ago, but she had foot surgery and wanted to recover from that before undergoing her pelvic surgery. She comes in today having healed from her foot surgery and wishing to schedule the excision of the vaginal mesh. She has had more bleeding and pinkish spotting since I last saw her a few months ago. She has not been sexually active since her last surgery. She continues to use the estrogen vaginally on a regular basis. She thinks she might be having some urinary incontinence and interestingly feels that she is more either incontinence or discharges at night. Although her foot has healed, they are planning to remove the screw from the heel at the end of ___. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Positive for arthritis, hypertension and low back pain. Past Surgical History: 1. Laparoscopic sacral cervical colpopexy and paravaginal repair and TVT sling in ___, Dr. ___ at ___. 2. Foot surgery. 3. Excision of the posterior vaginal mesh erosion and anterior repair in ___, Dr. ___. 4. Robot-assisted total hysterectomy and colpopexy, ___. OB/Gyn Hx: G2P2, SVD x 2, h/o endometriosis and fibroids <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother had lung and esophageal cancer. Maternal grandmother, colon cancer. Sister, hypothyroidism. Father, lung cancer. Paternal grandfather, lung cancer. Brother, heart condition. <PHYSICAL EXAM> On day of discharge: afebrile, vital signs stable Gen: NAD CV: RRR Pulm: CTAB, normal work of breathing Abd: soft, nondistended, appropriate tenderness to palpation Pelvic: vaginal packing removed with light pink staining <PERTINENT RESULTS> none <MEDICATIONS ON ADMISSION> clobetasol, vagifem, irbesartan 150mg daily, ASA 81 <DISCHARGE MEDICATIONS> 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 3. HYDROmorphone (Dilaudid) ___ mg PO Q3H: PRN pain DO NOT: drive, or take with alcohol RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four hours Disp #*20 Tablet Refills: *0 4. irbesartan 150 mg oral qd <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal mesh erosion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing vaginal excision of mesh and cystoscopy for anterior vaginal mesh erosion. 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 urine output was adequate so her foley was removed and she voided spontaneously. On postoperative day 1 her diet was advanced without difficulty and she was transitioned to oral dilaudid. 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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10614092-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / morphine / Oxycodone / adhesive / strawberry / kiwi / Hibiclens / garlic / ibuprofen <ATTENDING> ___ <CHIEF COMPLAINT> vaginal separation, rectocele <MAJOR SURGICAL OR INVASIVE PROCEDURE> Excision vaginal mesh, wound debridement, posterior colporrhaphy, 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 Ext: no TTP <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. irbesartan 150 mg oral DAILY 2. clotrimazole-betamethasone ___ % topical BID: PRN 3. Aspirin 81 mg PO DAILY 4. Cetirizine 10 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*45 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 3. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID corneal abrasion RX *erythromycin 5 mg/gram (0.5 %) 1 cm eye four times per day Refills: *0 4. Gentamicin 0.3% Ophth. Soln 1 DROP LEFT EYE Q4H corneal abrasion RX *gentamicin 0.3 % 1 drop L eye every 4 hours Refills: *1 5. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Severe ___ cause sedation. Do not take with alcohol or while driving RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 6. Aspirin 81 mg PO DAILY 7. Cetirizine 10 mg PO DAILY 8. clotrimazole-betamethasone ___ % topical BID: PRN 9. irbesartan 150 mg oral DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal mesh erosion, vaginal separation and rectocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the gynecology service after your procedure. The anesthesia team noted that you had a left corneal abrasion after your procedure. You received eye drops and ointments for treatment. If you continue to have symptoms after ___, please follow-up with your ophthalmologist for care. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing excision vaginal mesh, wound debridement, posterior colporrhaphy, 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. In PACU, she was noted to have some left eye pain and was evaluated by anesthesia who was concerned for corneal abrasion. She was started on erythromycin and gentamicin ointments and instructed to follow-up with ophthalmology if symptoms did not improve by POD#2. Overnight she received Benadryl and sarna lotion for mild pruritus and erythema on her abdomen. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: instilled 300 mL, voided 475 mL with 0 mL residual. Her vaginal packing was removed without complications. Her diet was advanced without difficulty and she was transitioned to oral Tylenol and dilaudid. She was instructed to continue taking her home dose of irbesartan upon discharge. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10614092-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / morphine / Oxycodone / adhesive / strawberry / kiwi / garlic / ibuprofen <ATTENDING> ___ <CHIEF COMPLAINT> Vaginal mesh erosion <MAJOR SURGICAL OR INVASIVE PROCEDURE> Attempted RA lsc vaginectomy converted to laparotomy, vaginectomy, excision of pelvic mesh, adhesiolysis, cystorrhaphy, cystoscopy Blood transfusion (2 units packed red blood cells) <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> LABS -============ ___ 07: 17AM BLOOD WBC-7.8 RBC-2.74* Hgb-8.5* Hct-25.7* MCV-94 MCH-31.0 MCHC-33.1 RDW-13.1 RDWSD-44.3 Plt ___ ___ 06: 35AM BLOOD WBC-7.9 RBC-2.98* Hgb-9.4* Hct-28.3* MCV-95 MCH-31.5 MCHC-33.2 RDW-13.2 RDWSD-45.5 Plt ___ ___ 12: 52AM BLOOD WBC-13.0* RBC-3.06* Hgb-9.5* Hct-28.3* MCV-93 MCH-31.0 MCHC-33.6 RDW-13.2 RDWSD-45.2 Plt ___ ___ 12: 50PM BLOOD WBC-10.6* RBC-2.94* Hgb-9.0* Hct-27.3* MCV-93 MCH-30.6 MCHC-33.0 RDW-14.4 RDWSD-48.7* Plt ___ ___ 05: 10AM BLOOD WBC-11.5* RBC-3.27* Hgb-10.2* Hct-29.7* MCV-91# MCH-31.2 MCHC-34.3 RDW-14.2 RDWSD-47.8* Plt ___ ___ 06: 12PM BLOOD WBC-14.9*# RBC-3.78* Hgb-11.8 Hct-36.9 MCV-98 MCH-31.2 MCHC-32.0 RDW-14.0 RDWSD-49.9* Plt ___ ___ 06: 35AM BLOOD Neuts-74.2* Lymphs-13.0* Monos-8.1 Eos-3.8 Baso-0.5 Im ___ AbsNeut-5.88 AbsLymp-1.03* AbsMono-0.64 AbsEos-0.30 AbsBaso-0.04 ___ 12: 50PM BLOOD Neuts-79.9* Lymphs-12.2* Monos-7.0 Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.48* AbsLymp-1.29 AbsMono-0.74 AbsEos-0.02* AbsBaso-0.02 ___ 05: 10AM BLOOD Neuts-83.9* Lymphs-8.1* Monos-7.1 Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.65* AbsLymp-0.93* AbsMono-0.82* AbsEos-0.00* AbsBaso-0.02 ___ 06: 12PM BLOOD Neuts-92* Bands-7* ___ Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-14.75* AbsLymp-0.00* AbsMono-0.15* AbsEos-0.00* AbsBaso-0.00* ___ 07: 17AM BLOOD Plt ___ ___ 06: 35AM BLOOD Plt ___ ___ 12: 52AM BLOOD Plt ___ ___ 12: 50PM BLOOD Plt ___ ___ 05: 10AM BLOOD Plt ___ ___ 06: 12PM BLOOD Plt Smr-NORMAL Plt ___ ___ 06: 12PM BLOOD ___ PTT-26.0 ___ ___ 07: 17AM BLOOD Glucose-92 UreaN-6 Creat-0.4 Na-137 K-4.0 Cl-103 HCO3-20* AnGap-18 ___ 06: 35AM BLOOD Glucose-67* UreaN-8 Creat-0.4 Na-141 K-3.6 Cl-105 HCO3-21* AnGap-19 ___ 06: 23AM BLOOD Glucose-75 UreaN-12 Creat-0.9 Na-139 K-3.6 Cl-105 HCO3-20* AnGap-18 ___ 12: 52AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-134 K-4.0 Cl-101 HCO3-21* AnGap-16 ___ 12: 50PM BLOOD Glucose-95 UreaN-10 Creat-0.5 Na-138 K-3.5 Cl-104 HCO3-24 AnGap-14 ___ 06: 12PM BLOOD Glucose-130* UreaN-10 Creat-0.6 Na-140 K-4.4 Cl-106 HCO3-22 AnGap-16 ___ 12: 50PM BLOOD CK-MB-26* cTropnT-<0.01 ___ 05: 10AM BLOOD CK-MB-44* cTropnT-<0.01 ___ 07: 17AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.7 ___ 06: 35AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.7 ___ 06: 23AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.9 ___ 12: 52AM BLOOD Calcium-7.5* Phos-3.4 Mg-1.8 ___ 06: 12PM BLOOD Calcium-8.2* Phos-4.3 Mg-2.0 IMAGING -============ ___ CXR INDICATION: ___ year old woman with fluid overload s/p hemorrhage during OR procedure// r/o pulmonary edema IMPRESSION: No previous images. There is a large amount of free intraperitoneal gas, consistent with the recent abdominal operative procedure. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. ___ KUB INDICATION: ___ h/o TLH s/p attempted RA lsc vaginectomy converted to laparotomy, vaginectomy, excision of pelvic mesh, adhesiolysis, cystorrhaphy, cystoscopy for chronic vagino-pelvic sinus tract ___ pelvic mesh erosion with post-op nausea// ?ileus vs obstruction TECHNIQUE: Abdomen two views COMPARISON: Chest radiograph ___, CT ___, CT pelvis ___. FINDINGS: Mild volume free peritoneal air, it has decreased since ___, consistent with resolving postoperative status. Subcutaneous air right lateral abdominal wall. There multiple dilated small bowel loops, air-fluid levels, may represent partial small bowel obstruction or adynamic ileus. There is air within nondilated colon. Small pleural effusions. Left basilar opacity, likely atelectasis. Degenerative changes lower lumbar spine. Stomach is not dilated. IMPRESSION: Decreasing free peritoneal air, in keeping with recent postoperative status. Dilated small bowel loops, may represent partial small bowel obstruction or adynamic ileus, recommend follow-up radiograph.. Normal caliber colon. <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. *) 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 at ___ on ___ for a voiding cystogram (imaging study). Your foley catheter will be removed at that time.
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On ___ Ms. ___ was admitted to the gynecology service after undergoing a cystoscopy and placement of ureteral catheters bilaterally, robotic adhesiolysis, converted to laparotomy, upper vaginectomy and repair, extensive adhesiolysis, excision of sacral mesh, cystorrhaphy for a persistent non-healing vaginal vault thought to be secondary to vaginal mesh erosion. Please see the operative report for full details. *) Post-operative care: She had an estimated blood loss of 1800 mL, requiring intraoperative transfusion of 2 units packed red blood cells. She also received 3500 mL IVF intraoperatively. Due to concern for pulmonary edema, she underwent a post-operative CXR in the PACU which was reassuring. Immediately post-op, her pain was controlled with IV acetaminophen, IV torodol, and IV Dilaudid. When her diet was advanced she received PO acetaminophen and ibuprofen prn. Of note, pt received empiric post-operative antibiotics given her chronically eroded mesh. She was on IV vancomycin/cefepime/flagyl (___). She was started on PO macrobid (___-) for UTI prophylaxis for the foley catheter. She also received oxybutynin for bladder pain/spasms. She remained afebrile throughout her admission without evidence of infection. *) Chest pain: On post-operative day #1, pt developed chest and shoulder pain associated with abdominal gas pain. Her vital signs were within normal limits and her abdominal/cardiopulmonary exam were benign. An EKG was performed, which demonstrated normal sinus rhythm and no evidence of ischemia. Her troponins were negative x2 and there was low concern for acute coronary syndrome. *) Ileus: On post-operative day #3 she developed persistent nausea, abdominal distention. She was made NPO, and on post-operative day #4 she had a KUB which demonstrated an ileus vs. partial bowel obstruction. Her diet was slowly advanced between post-operative day #4 to #6 as she demonstrated slow return of bowel function. By post-operative day #6, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen 650 mg PO TID do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*1 3. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe may cause sedation. do not drink alcohol or drive while taking dilaudid RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills:*0 5. Ibuprofen 600 mg PO Q6H take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth daily Disp #*8 Capsule Refills:*0 7. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp #*12 Tablet Refills:*0 8. Phenazopyridine 100 mg PO Q8H:PRN pain at foley catheter insertion site Duration: 3 Days RX *phenazopyridine [Pyridium] 100 mg 1 tablet(s) by mouth every 8 hours Disp #*9 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: pelvic mesh erosion, chronic vagino-pelvic sinus tract Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10614092-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Ibuprofen <ATTENDING> ___ <CHIEF COMPLAINT> upper posterior mesh erosion and dyspareunia <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic-assisted total laparoscopic hysterectomy, mesh excision, sacrocolpopexy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ woman who had a laparoscopic sacrocervicopexy, laparoscopic specific cystocele repair (paravaginal repair), TVT suburethral sling, cystoscopy, perineorrhaphy at ___ ___. She did well initially. However, in ___, she was diagnosed with a mesh exposure in the upper posterior vagina from the Mersilene mesh of the sacrocolpopexy and was brought back to the OR again at ___ ___ by Dr. ___ on ___, where an excision of the posterior apical vaginal mesh exposure was performed vaginally and anterior colporrhaphy was performed for cystocele. She had increased bleeding since ___ ___s painful intercourse. She had spotting after intercourse. She was prescribed pelvic floor ___. She also did a workup for hematuria. She had CT scan from ___, which was negative. The patient denied significant stress incontinence. She went to bathroom every two and a half hours in the daytime. She reported getting up ___ times at night to urinate. She occasionally had urgency. She reported wear a mini pad because at the end of the day she had some small discharge in the underwear. She denied recurrent bladder infections, hematuria, or dysuria. She did not strain to urinate. Her bowel movements wernormal. She had no fecal incontinence. On exam, she had upper posterior Mersilene mesh erosion from sacrocervicopexy. Surgical management was planned. <PAST MEDICAL HISTORY> OB/Gyn Hx: G2P2, SVD x 2, h/o endometriosis and fibroids PMH: arthritis, HTN, tear in posterior tibial tending PSH: laparoscopic sacrocervicopexy, laparoscopic specific cystocele repair (paravaginal repair), TVT suburethral sling, cystoscopy, perineorrhaphy ___, ; excision of posterior vaginal mesh erosion and anterior repair in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother had lung and esophageal cancer. Maternal grandmother, colon cancer. Sister, hypothyroidism. Father, lung cancer. Paternal grandfather, lung cancer. Brother, heart condition. <PHYSICAL EXAM> On discharge: Gen: NAD, comfortable CV: RRR Lungs: CTAB Abd: soft, non-distended, port site incisions clean and intact with steri-strips in place GU: clear urine in foley, minimal spotting on pad Ext: non-tender <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. irbesartan 150 mg oral daily <DISCHARGE MEDICATIONS> 1. irbesartan 150 mg oral daily 2. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4000 mg acetaminophen in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID Take with narcotics to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *3 5. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q2H RX *dextran 70-hypromellose [Artificial Tears] 0.1 %-0.3 % ___ drops in right eye Q2h: prn Disp #*1 Tube Refills: *0 6. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID corneal abrasion Duration: 3 Days RX *erythromycin 5 mg/gram (0.5 %) 1 appl four times a day Disp #*1 Tube Refills: *0 7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY while foley catheter in place RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth daily Disp #*7 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> mesh erosion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet ** Apply the erythromycin ointment to your eye as prescribed. If irritation persists then you can apply the ointment and place a folded gauze taped over your eye. Once the eye irration is gone you can discontinue use of the gauze. Schedule a follow up appointment with your opthomologist in ___ weeks. Use the artificial tears as needed for eye irritation Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing robotic assisted total hysterectomy, meshexcision, adhesiolysis, sacral colpopexy, cystoscopy. Please see the operative report for full details. Her post-operative course was complicated by a corneal abrasion likely related to exposure keratopathy during general anesthesia. Ophthalmology was consulted. Per the recommendations, her eye was patched for 24 hours and she was started on topical erythromycin ointment. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 200 mL with 300 mL residual (bladder scan). 2. Instilled 300 mL, voided 200 mL with 347 mL residual. Her Foley catheter was replaced and she was instructed in its care. Her diet was advanced without difficulty and she was transitioned to oral. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10615503-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> robot-assisted sacrohysteropexy, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is an ___ woman who presents with bulge pressure symptoms for several months. She is very uncomfortable and she also has been having trouble initiating her urine flow. She does have urinary frequency of increasing frequency about every hour. She denies significant urinary incontinence. She denies constipation or fecal incontinence. She is not currently sexually active. She has no history of kidney stones or hematuria. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Hypercholesterolemia, hypertension, ex-smoker, asthma, hypothyroidism, renal insufficiency. Last creatinine 1.5 and BUN 41. Past Surgical History: Breast biopsy. Past OB History: Gravida 2, para 2, two prior vaginal deliveries. Birth weight of largest baby delivered vaginally 7 pounds 4 ounces. No forceps or vacuum-assisted vaginal delivery. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast, ovarian, colon cancer. Sister has heart disease. Brother, prostate cancer. <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM (PRE-OP VISIT) Weight 148, height 58-3/4, blood pressure was 172/67, pulse is 90. General: Well developed, well groomed, normal body habitus. Psych: Oriented x3, affect is normal. Skin: Warm and dry. Pulmonary: Normal respiratory effort. Abdomen: Soft, nontender. No masses, guarding, or rebound. No hepatosplenomegaly noted. Cardiovascular: Pulse normal rate and rhythm. No pedal edema or varicosities. Genitourinary: External Genitalia is . No lesions or discharge. Urethral Meatus: No caruncle, no prolapse. Urethra: Nontender, no masses or exudate. Bladder: Nonpalpable, nontender. Vagina is significant for prolapse, see POP-Q below, no abnormal discharge, atrophic. Cervix was grossly normal. Bimanual: No masses or tenderness, although exam is somewhat limited due to patient discomfort. Anus and Perineum: No masses or tenderness. POP-Q: Aa 0, Ba +1.5, C -1. ___ 3, PB 2.5, TVL 7. Ap -2, Bp -2, D -4. Supine empty stress test was negative. Post-void residual volume obtained via catheterization was good with post-void residual volume of 200 mL. The urinalysis was positive for small amount of small, trace protein, small leukocytes on the voided specimen. Uroflowmetry, patient voided 135 mL. The flow was uneven, the max flow rate was 23 mL/sec, average flow 7 mL/sec, voiding time 24 seconds, flow time 19 seconds, time to max flow 15 seconds. DISCHARGE PHYSICAL EXAM VSS and wnl NAD, comfortable RRR CTAB Abdomen soft, non-tender, non-distended Incisions: c/d/i with dermabond Ext: no edema, no tenderness, no erythema <PERTINENT RESULTS> ___ 06: 25AM BLOOD WBC-7.9 RBC-3.31* Hgb-10.5* Hct-30.5* MCV-92 MCH-31.7 MCHC-34.4 RDW-13.6 Plt ___ ___ 06: 25AM BLOOD Glucose-143* UreaN-29* Creat-1.6* Na-141 K-4.2 Cl-102 HCO3-28 AnGap-15 ___ 06: 25AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.9 <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Simvastatin 20 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Lisinopril 40 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID do not exceed more than 4000 mg in 24 hours RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 2. Hydrochlorothiazide 25 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*45 Tablet Refills: *0 6. Simvastatin 20 mg PO DAILY 7. Docusate Sodium 100 mg PO BID Take while taking narcotics to prevent constipation. Hold for loose stools. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> stage III uterovaginal prolapse, urinary retention <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after undergoing the procedures listed below. You have recovered well and the team feels that you are safe for discharge to home. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing robot-assisted sacrohysteropexy and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV acetaminophen and dilaudid. On post-operative day 1, she underwent a formal voiding trial with the following results: Instillation 300 cc, void ___, straight cath 400 Instillation 300 cc, void ___, pvr 0 She thus passed her voiding trial and foley was not replaced. Her diet was advanced without difficulty and she was transitioned to PO acetaminophen and oxycodone. Her home medications were restarted. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10615503-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> nausea, vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> open ventral hernia repair and reduction of incarcerated bowel <HISTORY OF PRESENT ILLNESS> ___ G2P2 ___ s/p robotic assisted hysteropexy and cystoscopy on ___ presents for nausea/vomiting and general malaise for 3 days. Reports that 2 days ago, she felt "lousy" with some nonbloody and nonbilious emesis. Felt slightly better yesterday without emesis and had a normal bowel movement for her last night. This morning woke up early with nausea and emesis again. Has not had much appetite and hasn't kept anything down. Was not able to take her home blood pressure medications. Had only been taking tylenol and colace up to today in addition to her pre-operative medications. Denies any fever/chills, dizziness, SOB/CP, palpitations, abdominal pain, difficulty voiding or dysuria. <PAST MEDICAL HISTORY> OB Hx: G2P2, SVD x 2 (largest 7#4) GYN Hx: pelvic organ prolapse PMH: hypercholesterolemia, hypertension, asthma, hypothyroidism, renal insufficiency, former smoker PSH: breast biopsy, RA-hysteropexy and cystoscopy <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast, ovarian, colon cancer. Sister has heart disease. Brother, prostate cancer. <PHYSICAL EXAM> ADMISSION EXAM: VS: 97.3, 189/74 -> 180/74, 82, 18, 100%RA Gen: NAD Abd: normoactive BS, soft, nondistended, nontender to palpation throughout and no rebound or guarding, robotic incisions c/d/i with slight bruising around the incisions but no induration DISCHARGE EXAM: VSS and wnl CV: RRR Lungs: CTAB Abdomen: soft, non-tender, non-distended Incision: c/d/i Ext: no edema, no tenderness <PERTINENT RESULTS> LABORATORY: ___ 11: 53AM BLOOD WBC-6.5 RBC-4.02* Hgb-12.5 Hct-36.8 MCV-92 MCH-31.1 MCHC-34.0 RDW-13.5 Plt ___ ___ 05: 45AM BLOOD WBC-10.2# RBC-4.26 Hgb-13.5 Hct-39.7 MCV-93 MCH-31.6 MCHC-34.0 RDW-13.1 Plt ___ ___ 04: 27AM BLOOD WBC-8.9 RBC-3.60* Hgb-11.3* Hct-34.0* MCV-95 MCH-31.5 MCHC-33.3 RDW-12.5 Plt ___ ___ 12: 40PM BLOOD WBC-6.5 RBC-3.59* Hgb-11.4* Hct-33.7* MCV-94 MCH-31.7 MCHC-33.9 RDW-13.7 Plt Ct-96* ___ 06: 30AM BLOOD WBC-9.6 RBC-3.06* Hgb-9.8* Hct-28.8* MCV-94 MCH-32.0 MCHC-34.0 RDW-13.0 Plt Ct-97* ___ 01: 10PM BLOOD WBC-11.6* RBC-3.24* Hgb-10.3* Hct-30.8* MCV-95 MCH-31.8 MCHC-33.4 RDW-13.0 Plt ___ ___ 07: 15AM BLOOD WBC-12.7* RBC-3.20* Hgb-10.2* Hct-30.1* MCV-94 MCH-31.9 MCHC-33.9 RDW-13.8 Plt ___ ___ 08: 15AM BLOOD WBC-12.7* RBC-3.15* Hgb-10.1* Hct-29.2* MCV-93 MCH-32.0 MCHC-34.6 RDW-13.7 Plt ___ ___ 11: 53AM BLOOD Glucose-155* UreaN-35* Creat-1.4* Na-139 K-3.9 Cl-94* HCO3-32 AnGap-17 ___ 05: 45AM BLOOD Glucose-171* UreaN-33* Creat-1.5* Na-135 K-3.7 Cl-96 HCO3-32 AnGap-11 ___ 04: 27AM BLOOD Glucose-136* UreaN-27* Creat-1.3* Na-133 K-3.6 Cl-97 HCO3-27 AnGap-13 ___ 12: 40PM BLOOD Glucose-124* UreaN-25* Creat-1.4* Na-134 K-4.0 Cl-96 HCO3-31 AnGap-11 ___ 06: 30AM BLOOD Glucose-119* UreaN-20 Creat-1.3* Na-132* K-3.9 Cl-99 HCO3-26 AnGap-11 ___ 01: 10PM BLOOD Glucose-103* UreaN-19 Creat-1.3* Na-134 K-4.0 Cl-100 HCO3-29 AnGap-9 ___ 07: 15AM BLOOD Glucose-92 UreaN-18 Creat-1.3* Na-136 K-3.7 Cl-99 HCO3-28 AnGap-13 ___ 08: 15AM BLOOD Glucose-96 UreaN-18 Creat-1.1 Na-135 K-3.7 Cl-99 HCO3-28 AnGap-12 ___ 11: 53AM BLOOD Calcium-10.5* Phos-4.2 Mg-1.8 ___ 05: 45AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.5* ___ 04: 27AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.7 ___ 12: 40PM BLOOD Calcium-8.6 Phos-2.7 Mg-2.4 ___ 06: 30AM BLOOD Calcium-7.9* Phos-1.8* Mg-1.8 ___ 01: 10PM BLOOD Calcium-8.1* Phos-2.0* Mg-1.9 ___ 07: 15AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.7 ___ 08: 15AM BLOOD Calcium-8.1* Phos-2.0* Mg-1.9 MICROBIOLOGY: ___ 3: 43 pm STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ 10: 04AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). IMAGING: KUB ___: IMPRESSION: 1. No evidence of small-bowel obstruction or ileus. 2. Small amount of bilateral flank subcutaneous emphysema, presumably related to insufflation during robotic surgery. CT Abdomen/Pelvis ___: IMPRESSION: 1. High-grade small bowel obstruction with a transition point in an midline ventral abdominal wall hernia. 2. 4mm left lower lobe nodule may be followed in 12 months in a high risk patient. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Simvastatin 20 mg PO DAILY 5. Aspirin EC 81 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Acetaminophen 325 mg PO Q6H: PRN pain 8. Docusate Sodium 100 mg PO BID: PRN constipation use when taking oxycodone; hold for loose stool 9. Calcium Carbonate 1500 mg PO DAILY to provide 600 mg elemental calcium; to be taken with 200 units vitamin D 10. Vitamin D 200 UNIT PO DAILY to be taken with calcium carbonate 1500 mg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN pain RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Hydrochlorothiazide 25 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. Aspirin EC 81 mg PO DAILY 6. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 7. Multivitamins 1 TAB PO DAILY 8. Simvastatin 20 mg PO DAILY 9. Calcium Carbonate 1500 mg PO DAILY 10. Vitamin D 200 UNIT PO DAILY 11. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills: *0 12. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H please complete full course of antibiotics RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> small bowel obstruction, ventral hernia <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 nausea and vomiting and found to have a small bowel obstruction within a ventral hernia. You underwent hernia repair and reduction of your bowel obstruction by general surgery. You have recovered well and the team feels that you are safe for discharge home. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecology service on ___ after presenting with nausea and vomiting on post-operative day 5 status post robotic-assisted hysteropexy and cystoscopy on ___. On initial evaluation, patient underwent KUB, which was negative for ileus and obstruction. However, despite use of antiemetics, patient continued to have nausea and vomiting and on hospital day 2 (___) decision was made to proceed with CT of the abdomen and pelvis. CT showed high grade bowel obstruction within a ventral hernia and general surgery was consulted. Patient was made NPO and a ___ tube was placed. General surgery took patient to the OR early morning on hospital day 3 (___) for reduction of incarcerated small bowel and repair of ventral hernia. Post-operatively patient did well. Her pain was controlled with IV acetaminophen. She was started on prophylactic subcutaneous heparin BID. On post-operative day 0 (___) her NG tube was discontinued and she was advanced to clears and then to regular diet without incident. Her foley was discontinued and she voided spontaneously. Daily electrolytes were obtained and patient repleted as needed. On post-operative day 1, patient developed diffuse watery diarrhea. C. difficile assay was sent and came back positive on post-operative day 2. Flagyl was started. Patient's home medications were continued. 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 on a 14 day course of flagyl for her c. difficile infection. Issues requiring follow-up: * CT showed: "4mm left lower lobe nodule may be followed in 12 months in a high risk patient."
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10617577-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> chronic pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy <HISTORY OF PRESENT ILLNESS> ___, who has a history of multiple prior abdominal surgeries, including an open appendectomy and 3 C-sections via vertical midline incisions, who started having pelvic pain following her last C-section. She had a pelvic ultrasound that showed concern for adhesive disease between the anterior uterus and the anterior abdominal wall. She desired definitive management via hysterectomy and lysis of adhesions. <PAST MEDICAL HISTORY> PMH: constipation PSH: open ruptured appy, Lsc LSO, Lsc CCY, C/S x 3. <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On day of discharge: AFVSS NAD RRR CTAB Abd: soft, appropriately tender, no r/g, incision c/d/i ___: nt, ne <MEDICATIONS ON ADMISSION> Colace, senna, oxycodone <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H pain Do not take more than 4000mg acetaminophen per day. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN pain Take with food to prevent stomach upset. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive or drink alcohol with this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID Take with oxycodone to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 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 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. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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___ underwent an uncomplicated total laparoscopic hysterectomy and cytoscopy for chronic pelvic pain on ___. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with dilaudid and acetaminophen. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. She then subsequently developed urinary retention of 220cc(likely secondary to narcotics use) and her foley was replaced overnight . Her diet was advanced without difficulty and she was transitioned to oxycodone, acetaminophen and motrin. Her foley was successfully removed without urinary retention on POD#2. 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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10617964-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Uterine Mass and abnormal vaginal bleeding. <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node sampling <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ year old who presents with heavy vaginal bleeding and clots since ___. Her LMP was over ___ year ago. Her bleeding has worsened over the past 3 weeks. She was evaluated at ___ and had an US and biopsy of tissue from protruding from the cervical os. US revealed an enlarged and heterogenous uterus, with multiple myometrial masses. There was a complex cystic mass in the central portion of the uterus measuring at least 7.5 x 4.5 cm, containing sonolucent areas and multiple septations. Follow up MRI revealed a large complex heterogeneously enhancing 11.5 cm solid and cystic mass of the uterus, highly suspicious for neoplasm, difficult to determine if arising from the endometrium or myometrium. She had another biopsy done, for which final pathology report is still pending. She currently continues to have vaginal bleeding, with abdominal cramping and she describes the bleeding now as malodorous. She has also noticed difficulty with urination as she has to strain herself to be able to urinate. She denies fever, weight change, nausea, vomiting, dizziness, feeling lightheaded, or changes in her bowel movements. <PAST MEDICAL HISTORY> OBGYNHx: Gravida 0. Menopausal symptoms of hot flashes for ___ year. Has a history of fibroids. No hx of ovarian cysts, STD's or abnormal pap smears. Last pap was in ___ and was normal. Mammogram in ___ was nml. PMH: Denies history of asthma, heart disease, diabetes, HTN, thromboembolic disease and breast cancer. PSH: Open cholecystectomy in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family hx of cancer, heart disease, DM <PHYSICAL EXAM> On initial presentation: Gen: No acute distress CV: RRR no extra heart sounds Lungs: CTAB Abd: Soft. Mass palpated 2-3 cm below umbilicus, tender on palpation. Pelvic: Normal appearing external genitalia with no lesions. On speculum exam foul smelling necrotic tissue from cervix was seen with rim of apparent normal cervix. On bimanual exam, mass palpated to be extending from internal os but exam limited due to bleeding. On discharge: Gen: comfortable, NAD CV: RRR Lungs: CTAB Abd: soft, appropriately tender to palpation, vertical midline incision cleand/dry/intact with staples in place Ext: non tender, nonedematous <PERTINENT RESULTS> ___ 07: 10AM BLOOD WBC-16.6* RBC-3.37* Hgb-8.5* Hct-27.1* MCV-81* MCH-25.3* MCHC-31.5 RDW-12.7 Plt ___ ___ 09: 40PM BLOOD WBC-15.1* RBC-3.36* Hgb-8.7* Hct-27.0* MCV-80* MCH-26.0* MCHC-32.3 RDW-12.8 Plt ___ ___ 07: 10AM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-136 K-5.0 Cl-100 HCO3-23 AnGap-18 ___ 09: 40PM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-139 K-4.6 Cl-104 HCO3-20* AnGap-20 ___ 07: 10AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.4 ___ 09: 40PM BLOOD Calcium-8.1* Phos-4.0 Mg-2.2 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 2. Ibuprofen 600 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth 6 hours Disp #*60 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not drive while taking this medication. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth 4 hours Disp #*60 Tablet Refills: *0 4. Ferrous GLUCONATE 324 mg PO DAILY RX *ferrous gluconate 325 mg (36 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> exploratory laparotomy, radical abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph node sampling, cystoscopy, omental biopsy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will beremoved at your follow-up visit.
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Ms. ___ was admitted to the gynecology oncology service after undergoing exploratory laparotomy, radical abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph node sampling, cystoscopy, 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 dilaudid and toradol. Her diet was advanced without difficulty and she was transitioned to PO percocet and ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,441
| 178
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10618000-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Nabumetone / Metformin / Latex / Omeprazole / Nifedipine / Iodine-Iodine Containing / Oxycodone / Humalog / Cyclobenzaprine / simvastatin / ibuprofen / bandaid / oxybutynin / triamterene / colchicine <ATTENDING> ___ <CHIEF COMPLAINT> " I have a growth in the stomach " <MAJOR SURGICAL OR INVASIVE PROCEDURE> BILATERAL SACROSPINOUS LIGAMENTS VAULT SUSPENSION WITH SYNTHETIC GRAFT, ANTERIOR COLPORRHAPHY, SUBURETHRAL SLING AND CYSTOSCOPY <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ gravida 3 para 3 who was referred to me by Dr. ___ consultation regarding vaginal prolapse. She is complaining of vaginal pressure and palpable prolapse that started about a year ago. She was initially concerned that this was a "growth" but was seen by Dr. ___ ___ reassured her that she was experiencing some pelvic organ prolapse. The protrusion is worse after periods of standing and gets better at night when she lies down. Mrs. ___ denies any episodes of stress incontinence but admits to urgency. She plays at the casino and drinks decaf tea with Splenda. She experiences occasional urgency incontinence episodes for which she does not wear a pad. She is voiding ___ times per day and 4 times at night. She does admit to consuming fluid leading to the night. She reports her urinary flow as "normal". She denies any recent urinary tract infection. Mrs. ___ denies any constipation. She is sexually active and does not experience any dyspareunia. She is otherwise without any other clinically significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: DIABETES TYPE II GLAUCOMA HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS VENOUS INSUFFICIENCY DEEP VENOUS THROMBOSIS DEPRESSION ANXIETY H/O COLONIC POLYPS H/O BELL'S PALSY H/O CHOLECYSTECTOMY H/O TOTAL ABDOMINAL HYSTERECTOMY PAST OB HISTORY: ___ Vaginal: 3 PAST GYN HISTORY: She is postmenopausal and denies any episodes of postmenopausal bleeding PAST SURGICAL HISTORY: TAH Cholecystectomy Umbilical hernia repair <PHYSICAL EXAM> Discharge: GENERAL: NAD in bed LUNGS: CTAB CARDIAC: RRR ABDOMEN: soft, non-distended, tender to palpations at mons, near site of exit of sling GU: foley in place Ext: wwp, non tender, pneumoboots in place. Admission: Neuro/Psych: Oriented x3, Affect Normal, NAD. Nodes: No inguinal adenopathy. Heart: No pedal edema Lungs: Normal respiratory effort. GI: Non tender lower abdomen, Non distended, No masses, guarding or rebound, No hepatosplenomegaly, No hernia. Ext: No clubbing, cyanosis, edema. Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. Cervix: absent-hysterectomy Uterus: absent-hysterectomy Adnexa: no masses non tender. <MEDICATIONS ON ADMISSION> amlodipine, chlorthalidone, fluticasone, gabapentin, novalog, lantus, lisinopril, acetaminophen, ASA and celecoxib (not taken prior to surgery), potassium chloride, pravastatin, simethicone <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q8H Do not take more than 2400mg in 24 hours. RX *acetaminophen 500 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #*30 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice daily as needed Disp #*40 Tablet Refills: *0 3. TraMADol 25 mg PO Q6H: PRN pain Do not drink or drive while taking. RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Take ___ tablet every 6 hours as needed Disp #*4 Tablet Refills: *0 4. amLODIPine 5 mg PO DAILY 5. Calcium Carbonate 500 mg PO TID 6. Gabapentin 100 mg PO BID 7. Glargine 17 Units Bedtime Insulin SC Sliding Scale using Novalog Insulin 8. Pravastatin 40 mg PO QPM <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 1. Anterior wall prolapse (cystocele). 2. Vaginal vault prolapse. 3. Stress urinary incontinence with urethral hypermobility. <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. 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 ___. Thank you!
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On ___, Ms. ___ was admitted to the gynecology service after undergoing BILATERAL SACROSPINOUS LIGAMENTS VAULT SUSPENSION WITH SYNTHETIC GRAFT, ANTERIOR COLPORRHAPHY, SUBURETHRAL SLING AND CYSTOSCOPY. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 150 mL into the hat (with a large amount missing and unmeasured) with 17 mL residual. Her diet was advanced without difficulty, and she was transitioned to PO tramadol and acetaminophen. She was then discharged home in stable condition with outpatient follow-up scheduled.
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| 196
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10619308-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> diagnostic laparoscopy evacuation of hemoperitoneum <HISTORY OF PRESENT ILLNESS> ___ yo G0 presents with sudden onset of pelvic pain s/p intercourse. ___ at max. Now ___ s/p narcotics. + radiation to R shoulder. + N/V x ___ s/p narcotics. -lightheadedness or dizziness. Pain mostly mid to R pelvis. +chills today, no fevers. <PAST MEDICAL HISTORY> POB: G0 . PGYN: PAP ___ nl. + abnl PAP ___, f/b colpo and rpt PAPs. No STIs. Paragard IUD placed ___, no F/C or significant afterwards. Primary GYN Dr ___ at ___. . PMH: denies . PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> O: 97.6 73 102/55 16 100%RA NAD, pale CTAB RRR abd soft upper, rigid lower, + guarding, mild rebound, no masses or HSM. No tympany. biman deferred. per Dr ___ not able to tolerate secondary to significant pain. ___ NE <PERTINENT RESULTS> ___ Hct 38.8 plt 335 WBC 21.2 N92.2 L 5.7 M 1.8 E0 Bas 0.3 Lactate 2.4 HCG <5 LDH 186 Na 140, Cl 105, BUN 17, glucose 138, K 4.0, HCO3 21, Creat 0.8 BCx x 2 pnd ___ ___ 13.1 PTT 22.5 INR 1.1 ___ UA nl UCG neg ___ stat rpt Hct 27.6 ___ HCT 27.5 ___ HCT 25.8 ___ Pelvic ultrasound (wet read) per Dr ___ discussion with radiology, free fluid in pelvis, nl placed IUD ___ CT (wet read) 1. Hemoperitoneum originating in the pelvis and tracking around the liver. 2. Complex right adnexal mass is not as well seen as on US, given presence of blood. This could represent ruptured ___ although this amount of hemoperitoneum is somewhat unusual. Alternatively, there could be underlying mass that has ruptured. High-density material in the region of the mass could conceivably represent active extrav - correlate with labs and vitals. 3. Appendix not seen, but because the cecum is located in RUQ, the appendix is presumably not located at the site of the hemorrhagic process. <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: *30 Tablet(s)* Refills: *0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *25 Tablet(s)* Refills: *0* 3. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ruptured hemorrhagic cyst hemoperitoneum acute blood loss anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> No heavy lifting for 6 weeks. Nothing in the vagina for 6 weeks until you see Dr. ___. No strenuous activity for 6 weeks. No driving while on narcotics. No working for 2 weeks.
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Ms. ___ was taken to the operating room from the emergency room where she underwent an uncomplicated laparoscopy with evacuation of hemoperitoneum. She was found to have a hemorrhagic cyst that was hemostatic at the time of surgery. Following surgery, she was admitted to GYN from the PACU for observation. She was followed with serial HCT and serial abdominal exams both of which were stable. She was dischaged on POD 0 in stable condition.
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10622674-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Tylenol-Codeine <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> anterior and posterior colporrhaphy, TVT, cystoscopy, sacrospinus suspension <HISTORY OF PRESENT ILLNESS> The patient has had a bulge protruding from the vagina for more than ___ year. It is associated with increased urinary frequency. She is now urinating approximately every half hour throughout the day with fluid intake of approximately 40 or 50 ounces. She also complains of occasional stress incontinence with coughing or sneezing. She has urge incontinence once or twice every 2 days. She is wearing pads all the time. She has nocturia x1 or 2. She has difficulty initiating and maintaining the urine stream. The urine flow comes out intermittently. She is not sure that she is emptying her bladder. She often has to push up the prolapse in order to assist urinating. She has had occasional fecal incontinence approximately twice per month. Sometimes she has loose stools. She is not sexually active. <PAST MEDICAL HISTORY> OB HISTORY: Gravida 1, para 1, vaginal birth 1. Largest baby 7 pounds 13 ounces. PAST MEDICAL HISTORY: ILLNESSES: 1. Hypertension. 2. Heavy smoker. SURGICAL HISTORY: 1. Cholecystectomy. 2. Tonsillectomy. 3. Cataracts. 4. Lumbar injections for back pain. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No incontinence or prolapse <PHYSICAL EXAM> OFFICE PHYSICAL EXAMINATION: Well-developed, well-nourished female. Orientation and affect normal. Lungs: clear Cor: regular thythm, no murmurs Respiratory effort normal. Abdomen: Soft, nontender, no masses. Liver and spleen normal. No hernia or inguinal adenopathy. PELVIC EXAM: Vulva: Normal. Vagina: The anterior vaginal wall protrudes completely outside the introitus with bilateral paravaginal defects. The vaginal mucosa is atrophic. The cervix descends down to the hymen. The posterior wall bulges forward to 1.5 cm beyond the hymen. Fundus is 5 x 3 cm. No adnexal masses. Anus and perineum: Normal. Rectal: Sphincter tone is normal. There is a defect in the rectovaginal septum above the anal sphincter. Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <MEDICATIONS ON ADMISSION> 1. Atenolol 50 mg PO BID 2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY <DISCHARGE MEDICATIONS> 1. Atenolol 50 mg PO BID 2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 3. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *1 4. Acetaminophen 325-650 mg PO Q6H: PRN pain not to exceed 4 grams in 24 hours RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *1 5. 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 6. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain do not drink alcohol or drive <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse and stress urinary incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing anterior and posterior colporrhaphy, TVT, cystoscopy, sacrospinus suspension for pelvic organ prolapse. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid/Toradol. On post-operative day 1, her urine output was adequate and her vaginal packing and Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 300 mL with 0 mL residual. Her diet was advanced without difficulty and she was transitioned to oral oxycodone/ibuprofen/acetaminophen. Her blood pressures were controlled on her home medications. By post-operative day 1, she was tolerating a regular diet, ambulating independently, voiding spontaneously and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10627246-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / iodine / Iodinated Contrast Media - IV Dye / labatolol / carbamazepine <ATTENDING> ___. <CHIEF COMPLAINT> Postoperative pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo with infertility and endometriosis ___ s/p Hysteroscopy, biopsy, cervical dilation and cervical mapping for infertility, endometriosis, and cervical stenosis sent to be directly admitted for poor pain control and likely activation of chronic pain pathway s/p procedure. Patient had a prolonged recovery postoperatively and required Fentanyl (reacted with intense itching + nausea), Morphine, and Demerol. Was in recovery for >2.5 hours. Reported CP with normal EKG and complete recovery within minutes. <PAST MEDICAL HISTORY> GYNHx: Cycles regular Q29, LMP ___, Severe endometriosis / adenomyosis s/p multiple laparoscopies. . OBHx: ___ Daughter, C-section, PIH, +Meconium, Placental extraction difficult, ttc x 3 months (but no contraception x ___ years before), Breastfed x 2 months . PMHx: Neuropathic pain (diagnosed by neurologist), Asthma, Hx Pregnancy Induced Hypertension . SurgHx: ___ Exploratory Laparoscopy - dx Severe endometriosis, minimal treatment ___ Laparoscopy laser ablation, obliterated cul de sac, involved bowel ___ Laparoscopic bowel and bladder surgery for endometriosis ___ C-section ___ Exploratory Laparoscopy saw adhesion from C-section to abdominal wall (thick), Ovarian twisted but not necrotic, Endometriosis in the adhesion. No surgery. Lupron x 6 months ___ Laparoscopy endometriosis ablation, adhesion, untwisted left ovary, chromotubation showed tubal patency. Pain improved after this last surgery. ___ Hysteroscopy, cervical dilation and mapping, endometrial biopsy as above . Allerg: NSAIDs (swelling/anaphylaxis), Tramadol (rash), Labetolol (swelling/rash), Iodine (rash/swelling), GnRH agonist (one had a reaction, okay with another) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> AF, VSS Gen- NAD, comfortable CV- RRR Pulm- CTAB Abd- soft, NTTP, no R/G Ext- warm, perfused <PERTINENT RESULTS> ___ 05: 28PM BLOOD WBC-7.7 RBC-4.60 Hgb-13.2 Hct-39.1 MCV-85 MCH-28.8 MCHC-33.8 RDW-13.5 Plt ___ ___ 05: 28PM BLOOD Neuts-90.2* Lymphs-7.0* Monos-1.9* Eos-0.9 Baso-0 ___ 05: 28PM BLOOD Glucose-116* UreaN-11 Creat-0.8 Na-138 K-4.2 Cl-105 HCO3-22 AnGap-15 ___ 06: 17PM URINE Color-Straw Appear-Clear Sp ___ ___ 06: 17PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06: 17PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-1 <MEDICATIONS ON ADMISSION> Levothyroxine 50 mcg Folic acid Vitamin B6 Ventolin PRN Beclametasone (asthma daily inhaled steroid) <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H do not take more than 4000mg in 24 hours 2. Albuterol Inhaler ___ PUFF IH Q4H: PRN asthma 3. Apri (desogestrel-ethinyl estradiol) 0.15-0.03 mg oral DAILY 4. Docusate Sodium 100 mg PO BID: PRN constipation take while using narcotic pain medications RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *0 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY asthma 6. FoLIC Acid 1 mg PO DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Morphine Sulfate ___ 7.5-15 mg PO Q8H: PRN pain do not drink alcohol or drive while taking RX *morphine 15 mg ___ tablet(s) by mouth every 8 hours Disp #*15 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Post-operative 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 management of your pain. You were seen by the Chronic Pain Service, who recommended morphine as needed for pain control. Your pain resolved while in the hospital and it was determined that you were safe to go home. Please follow these 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. 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 acute on chronic pain control after undergoing a hysteroscopy, biopsy, cervical dilation and cervical mapping at ___ earlier in the day. . Her pain was initially controlled with IV dilaudid and PO tylenol. She was seen by the Chronic Pain service. She was transitioned to PO dilaudid, and then to PO morphine per the Pain Service recommendations. . On hospital day 2, she was determined to have good pain control and was discharged home in stable condition with outpatient follow up scheduled.
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10629690-DS-17
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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> INSERTION TANDEM & ovoids into the cervix and vagina. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ female with a history of ASC-H Pap smears on ___ and ___. She had a Nexplanon implanted in ___ and presented with a year of abnormal uterine bleeding that was thought to be related to the Nexplanon. The Nexplanon was removed in early ___, which initially caused severe vaginal bleeding for several days, but which then abated. She was seen by Dr. ___ of obstetrics and gynecology on ___. Colposcopy inadequately visualized the cervix due to bleeding, but there seemed to be acetowhite changes at 6 and 12 o'clock, with a possible raised lesion from 5 to 8 o'clock. Cervical biopsy at 6 and 12 o'clock showed HGSIL. Endocervical curettage, which was reviewed at ___, demonstrated moderately differentiated invasive squamous cell carcinoma with HGSIL. The specimen was not well oriented, and the depth of invasion could not be determined. The patient was referred to Dr. ___ of gynecologic oncology on ___, who noted a 5 to 6 cm enlarged firm cervix with no convincing extracervical extension, but with limited mobility raising concern for parametrial disease. There was friable and vascular tissue at the internal os with biopsy site changes, which bled easily with contact. Pelvic MRI at ___ on ___ demonstrated a 7.9 x 5.6 x 6.6 cm T2 hypointense cervical mass extending superiorly into the lower uterus with left posterolateral parametrial invasion. There was a 1.6 cm enlarged right pelvic sidewall lymph node and a prominent 0.5 cm left pelvic sidewall lymph node, both of which enhance and had abnormal morphology. PET-CT at ___ on ___ showed a large avid cervical mass with an SUV max of 20.1, an intensely avid 3.0 x 1.9 cm right external iliac lymph node with an SUV max of 15.2, a 0.9 cm avid left external iliac lymph node with an SUV max of 4.5, and a focus of uptake along the right pelvic side wall with an SUV max of 4.4 that was likely another involved lymph node. The patient started external beam radiation therapy to the pelvic and para-aortic lymph nodes with concurrent weekly cisplatin on ___, and has had treatment daily for approximately 5 weeks. She has the expected diarrhea, controlled with Imodium, and dysuria, urinary urgency, and frequency from radiation. Her vaginal bleeding and discharge has significantly improved. <PAST MEDICAL HISTORY> PAST MEDICAL AND SURGICAL HISTORY: 1. Anxiety. 2. Depression. OB/GYN HISTORY: G1P1 with an SVD in ___. Menarche at age ___. She is unsure when her last menstrual period was. She does have a history of treated chlamydia. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal great grandmother and maternal aunt both had breast cancer. A paternal grandmother had cervical cancer that was treated with a cone biopsy. A maternal aunt and two to three other maternal relatives had colon cancer. <PHYSICAL EXAM> Afebrile, vitals stable Gen: No acute distress CV: RRR Pulm: CTAB Abd: soft, appropriately tender, nondistended, no rebound/guarding ___: non-tender, non-edematous <PERTINENT RESULTS> ___ 11: 23PM URINE HOURS-RANDOM ___ 11: 23PM URINE UCG-NEG ___ 01: 00PM PLT COUNT-67* ___ 09: 03AM WBC-1.1* RBC-3.50* HGB-8.4* HCT-26.8* MCV-77* MCH-24.0* MCHC-31.3* RDW-18.7* RDWSD-48.0* ___ 09: 03AM PLT COUNT-54* ___ 09: 03AM AbsNeut-0.76* <MEDICATIONS ON ADMISSION> DEXAMETHASONE [DECADRON] - Decadron 4 mg tablet. 1 tablet by mouth twice daily for 3 days after chemo then stop LIDOCAINE HCL - lidocaine 2 % mucosal jelly in applicator. use topically on vagina prior to urination prior to urination as needed for pain LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth q8 hours prn as needed for nausea/anxiety/insomnia OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth once a day as needed for acid reflux - (Prescribed by Other Provider) ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth q8 hours prn as needed for nausea vomiting chemotherapy associated nausea. ICD 10 C53.9 OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every ___ hours as needed for as needed for pain PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet. 1 tablet(s) by mouth q6 hours prn nausea as needed for nausea TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 capsule(s) by mouth once a day <DISCHARGE MEDICATIONS> 1. Ciprofloxacin HCl 500 mg PO BID RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills: *0 2. Filgrastim 300 mcg SC Q24H RX *filgrastim-aafi [Nivestym] 300 mcg/0.5 mL 300 mcg subcutaneous q24h Disp #*10 Syringe Refills: *0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate PACU ONLY RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills: *0 4. Dronabinol 2.5 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> MALIGNANT NEOPLASM OF OVERLAPPING SITES OF CERVIX UTERI <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 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 nurse. * 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 ___ 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. *) Neutropenia - Given your low level of white blood cells, you were prescribed filgrastim shots. - You will be discharged home with prophylaxis antibiotics. Please take this antibiotics for 10 days. - If you develop a fever, please go to the emergency department. 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 medical optimization for pancytopenia prior to her scheduled vaginal brachytherapy. She underwent placement of a tandem and ovoid insertion on ___. Please see operative report for full details. . She received treatments from ___ until ___ or a total of 4 sessions. She was maintained on bedrest, a clear diet, and loperamide throughout this time. Her pain was controlled with a dilaudid PCA and oral acetaminophen. . She was seen by Social Work during her admission. . After removal of the implant on hospital day 3, her diet was advanced without difficulty. Her Foley catheter was removed and she voided spontaneously. She was transitioned to oral acetaminophen for her pain. . Throughout her hospital course, her pancytopenia was managed with neupogen 300 daily for bone marrow stimulation and ciprofloxacin 500 mg twice a day as antibiotic prophylaxis. She was discharge on these medications with instructions to continue ciprofloxacin for 10 days and neupogen until instructed to discontinue. . By hospital day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and she was no longer requiring pain medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10631235-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> grade 1 endometrioid adenocarcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G3P3 presenting for robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection for grade 1 endometrioid adenocarcinoma. Patient presented in ___ with vaginal spotting. EMB in ___ was insufficient. Pelvic US showed an 11.2 cm uterus with a markedly thickened endometrium with a soft tissue mass measuring 4.7 x 3.2 x 3.9 cm. There was a second mass measuring 2cm in the posterior mid uterus. The ovaries were normal. On ___ she underwent D&C/hysteroscopy. Pathology revealed a grade 1 endometrioid adenocarcinoma. On specific ROS, she complains of increased weight and abdominal bloating/pain. She denies significant changes in her bowel or bladder habits. Further ROS is positive for chest pain/SOB which she attributes to anxiety, fatigue, headaches, easy bruising, and some nausea. <PAST MEDICAL HISTORY> PMH: depression hypercholesterolemia hypothyroidism hypertension obesity PSH: D&C as above tubal ligation OB/GYN: G3P3, LMP: ___ years ago, No HRT Use, Last Pap Smear: ___, NIL, No H/O Fibroids, ovarian cysts or other GYN infections/problems Health Maintenance: Mammogram: ___, Colonoscopy: ___ years ago, Routine PCP follow up ___ History: ___ <FAMILY HISTORY> no colon ca, no ovarian, uterine or breast 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, no rebound/guarding, incision clean/dry/intact ___: nontender, nonedematous <PERTINENT RESULTS> ___ 12: 37PM BLOOD WBC-12.0*# RBC-4.14* Hgb-12.6 Hct-39.7 MCV-96 MCH-30.5 MCHC-31.8 RDW-13.0 Plt ___ ___ 06: 55AM BLOOD WBC-9.2 RBC-3.84* Hgb-11.9* Hct-36.3 MCV-95 MCH-31.0 MCHC-32.8 RDW-12.9 Plt ___ ___ 12: 37PM BLOOD Glucose-136* UreaN-17 Creat-0.8 Na-142 K-3.8 Cl-104 HCO3-27 AnGap-15 ___ 06: 55AM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-142 K-3.6 Cl-106 HCO3-29 AnGap-11 ___ 12: 37PM BLOOD Calcium-9.1 Phos-4.6* Mg-2.0 ___ 06: 55AM BLOOD Calcium-8.6 Phos-2.5*# Mg-1.9 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. hydrochlorothiazide 12.5 mg oral daily 3. Omeprazole 20 mg PO DAILY 4. Levothyroxine Sodium 137 mcg PO DAILY 5. Pravastatin 20 mg PO DAILY 6. Sertraline 100 mg PO DAILY <DISCHARGE MEDICATIONS> 1. 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 #*50 Tablet Refills: *0 2. Ibuprofen 400 mg PO Q8H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills: *0 3. hydrochlorothiazide 12.5 mg oral daily 4. Levothyroxine Sodium 137 mcg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Sertraline 100 mg PO DAILY 7. Docusate Sodium 100 mg PO BID take while using percocet, hold for loose stool RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 8. Omeprazole 20 mg PO DAILY 9. Pravastatin 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrioid adenocarcinoma fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . 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 8 weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If 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 robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV Dilaudid/IV Tylenol. Her diet was advanced without difficulty and she was transitioned to oral Percocet and ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Her electrolytes were repleted. 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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10631235-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p RA-TLH, BSO, bilateral pelvic lymphadenectomy and washings on ___ for stage IB endometrial adenocarcinoma who presents to the ED for evaluation of fever and chills. She reports that it started earlier today. She also reports nausea and emesis x3 as well as right sided abdominal pain. She also reports diarrhea x3. She denies vaginal bleeding, dizziness, chest pain, shortness of breath, leg pain, cough. She reports she had a cat bite on ___ on right leg. <PAST MEDICAL HISTORY> PMH: - depression - hypercholesterolemia - hypothyroidism - hypertension - obesity PSH: - D&C as above - tubal ligation - RA-TLH, BSO, lymph node dissection, ___ OB/GYN: G3P3, LMP: ___ years ago, No HRT Use, Last Pap Smear: ___, NIL, No H/O Fibroids, ovarian cysts or other GYN infections/problems Health Maintenance: Mammogram: ___, Colonoscopy: ___ years ago, Routine PCP follow up ___ History: ___ <FAMILY HISTORY> no colon ca, no ovarian, uterine or breast cancer. <PHYSICAL EXAM> VS: Tm-102.4 Tc-99.2 HR-93 BP-123/96 RR-20 O2-97% RA Gen: NAD CV: RRR, no murmurs Pulm: CTAB, no crackles Abd: obese, nondistended, soft, RLQ tenderness to palpation without rebound or guarding. Incisions: clean dry and intact, no erythema Ext: 8 cm right lower extremity cellulitis consistent with are of cat bite. No edema or tenderness, other than over cellulitis. Pelvic: normal appearing external genitalia, interlabial fold, urethral meatus. Speculum exam reveals well healing vaginal cuff without erythema or redness. Sutures palpated along left vaginal side wall c/w vaginal laceration repair from surgery. Vaginal cuff is intact and nontender on palpation. 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 healing well, clean/dry/intact, no erythema ___: nonedematous, posterior ___ with stable ecchymosis and mild TTP, erythema resolved, no purulent discharge, has 4 healing bite marks. <PERTINENT RESULTS> ___ abd/pelvic CT 1. Bilateral pelvic wall cystic collections may be postoperative seromas or lymphoceles. Abdominal wall fluid collections are likely seromas. 2. Non pathologically enlarged right common iliac and right external iliac lymph nodes. Recommend attention on follow up. 3. Minimal asymmetry of the vaginal stump should also be followed up on subsequent studies ___ 1: 02 am BLOOD CULTURE Blood Culture, Routine (Preliminary): PASTEURELLA MULTOCIDA. Sensitivity testing per ___ ___. BEING ISOLATED FOR SENSITIVITIES. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 4PM ___. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). SMALL PLEOMORPHIC. Blood cultures ___ no growth to date ___ UA neg ___ 07: 05AM BLOOD WBC-7.3 RBC-3.72* Hgb-11.6* Hct-34.2* MCV-92 MCH-31.1 MCHC-33.8 RDW-13.4 Plt ___ ___ 07: 20AM BLOOD WBC-8.1 RBC-3.44* Hgb-10.7* Hct-31.6* MCV-92 MCH-30.9 MCHC-33.7 RDW-13.3 Plt ___ ___ 10: 30AM BLOOD WBC-10.5 RBC-3.65* Hgb-11.6* Hct-33.8* MCV-93 MCH-31.8 MCHC-34.3 RDW-13.3 Plt ___ ___ 06: 38AM BLOOD WBC-13.0* RBC-3.43* Hgb-11.0* Hct-31.8* MCV-93 MCH-32.0 MCHC-34.5 RDW-13.4 Plt ___ ___ 02: 40PM BLOOD WBC-17.9* RBC-3.82* Hgb-11.6* Hct-34.9* MCV-91 MCH-30.2 MCHC-33.1 RDW-13.3 Plt ___ ___ 01: 02AM BLOOD WBC-14.4*# RBC-4.11* Hgb-12.6 Hct-37.8 MCV-92 MCH-30.7 MCHC-33.4 RDW-13.6 Plt ___ ___ 07: 05AM BLOOD Neuts-66.0 ___ Monos-7.2 Eos-3.4 Baso-0.5 ___ 07: 20AM BLOOD Neuts-71.7* ___ Monos-4.8 Eos-3.1 Baso-0.5 ___ 10: 30AM BLOOD Neuts-79.7* Lymphs-13.6* Monos-4.7 Eos-1.7 Baso-0.3 ___ 02: 40PM BLOOD Neuts-86.8* Lymphs-8.1* Monos-4.6 Eos-0.3 Baso-0.2 ___ 01: 02AM BLOOD Neuts-85.5* Lymphs-8.7* Monos-3.9 Eos-1.6 Baso-0.3 ___ 01: 02AM BLOOD ___ PTT-27.4 ___ ___ 07: 05AM BLOOD Glucose-90 UreaN-10 Creat-0.6 Na-142 K-4.0 Cl-103 HCO3-30 AnGap-13 ___ 07: 20AM BLOOD Glucose-93 UreaN-9 Creat-0.5 Na-141 K-3.3 Cl-104 HCO3-28 AnGap-12 ___ 10: 30AM BLOOD Glucose-104* UreaN-9 Creat-0.5 Na-142 K-3.6 Cl-105 HCO3-32 AnGap-9 ___ 01: 02AM BLOOD Glucose-110* UreaN-21* Creat-0.6 Na-142 K-3.8 Cl-101 HCO3-26 AnGap-19 ___ 01: 02AM BLOOD ALT-21 AST-21 AlkPhos-70 TotBili-0.2 ___ 07: 05AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0 ___ 07: 20AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.9 ___ 10: 30AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.9 ___ 06: 40PM BLOOD Calcium-8.5 Phos-1.7* Mg-1.7 ___ 01: 02AM BLOOD Albumin-4.4 ___ 06: 00AM BLOOD Vanco-8.9* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. lisinopril-hydrochlorothiazide ___ mg oral daily 2. Pravastatin 20 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Sertraline 100 mg PO DAILY 5. Levothyroxine Sodium 137 mcg PO DAILY 6. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain 8. Ibuprofen 400 mg PO Q8H: PRN pain 9. Docusate Sodium 100 mg PO BID <DISCHARGE MEDICATIONS> 1. Levothyroxine Sodium 137 mcg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Pravastatin 20 mg PO DAILY 4. Sertraline 100 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Ibuprofen 400 mg PO Q8H: PRN pain 7. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY 8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain 9. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 10. Ciprofloxacin HCl 500 mg PO BID Duration: 10 Days Please take until ___ RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> right calf cellilitus secondary to cat bite Pasteurella bacteremia post operative abdominal seromas <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 cellulitis and bacteremia after a cat bite. You have recovered well on antibiotics and the team feels that you are safe to be discharged home. Please follow these instructions: . Please continue antibiotics as instructed until ___ . Please continue prior post-operative instructions including: . 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 6 weeks post-operation * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . 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 * rash * onset of any concerning symptoms
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Ms. ___ is a ___ year old ___ s/p robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection on ___ who was admitted to the gynecology oncology service for fever and right lower extremity cellulitis and pasteurella bacteremia after a cat bite. She was also noted to have intra-abdominal fluid collections on CT ___ that are likely post-op seromas. She was started on IV ciprofloxacin and Flagyl. Her ___ preliminary blood cultures grew gram negative bacteremia so broad spectrum IV meropenem and vancomycin were started on hospital day 1. She defervesed since 100.4F on hospital day 1 and has been afebrile since. Infectious disease was consulted and followed her during her stay. Daily blood cultures were drawn. ___ blood cultures were positive for Pasteurella multicida. Subsequent blood cultures were no growth to date. She was improving symptomatically with resolution of leukocytosis and was transitioned to oral ciprofloxacin on hopital day 4. She remained afebrile and stable on oral antibiotics and was discharged home with a 14 day total course of antibiotics, until ___. She also reported diarrhea on hospital day 1 that resolved and C. diff labs were negative. ___ urine culture was negative. By hospital day 5, she was afebrile on oral ciprofloxicin with no leukocytosis and symptomatically improved. She was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with gynecologic oncology and infectious disease outpatient follow-up scheduled.
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10631235-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain, recurrent endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> biopsy of pelvic mass, percutaneous nephrostomy tube placement, ureteral stent placement <HISTORY OF PRESENT ILLNESS> ___ with suspected recurrence of stage IB FIGO grade 2 endometrial adenocarcinoma who presents to the ED with complaint of abdominal pain. Please see her oncology history below for details regarding her initial presentation and treatment, as well as re-presentation in ___, at which time a vaginal cuff mass was detected on imaging. She was seen in the ED on ___ with abdominal pain felt likely combination of constipation and poor utilization of po pain meds. Her pain was well controlled on a modified oral regimen and she was discharged home. She was then seen in the office by Dr. ___ on ___, where a perineal mass was biopsied and the patient continued to report adequate pain control with oral oxycodone and Tylenol. She presented this morning for her PET-CT scan, which is summarized below and was concerning for metastatic disease in her liver and mesentery. She reported increased pain and was encouraged to use her prescribed oxycodone, which did not improve her pain. She then presented to the ED for evaluation. She currently reports ___ left lower abdominal and flank pain which is constant and worsens intermittently. She has had no appetite and has not eaten since yesterday. She has had minimal spotting only with wiping and denies any heavy bleeding. She denies nausea, vomiting, chest pain or shortness of breath. She has not had a bowel movement since ___ but continues to pass flatus and has been taking Colace. ROS otherwise negative except as noted in the HPI <PAST MEDICAL HISTORY> Oncologic history: - presented with postmenopausal spotting in ___. Endometrial biopsy in ___ was nondiagnostic. Pelvic ultrasound showed a markedly thickening endometrium. Dilatation and curettage on ___ revealed grade 2 endometrioid adenocarcinoma. On ___, robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy demonstrated a 2.5 cm grade 2 endometrioid adenocarcinoma with 96% myometrial invasion, no lymphovascular invasion, 45 negative lymph nodes and negative washings. She had adjuvant vaginal cuff radiation therapy to a dose of 24 Gy in 6 fractions from ___ to ___. - Presented to ___ on ___ with complaints of lower abdominal pain and vaginal bleeding ×2 weeks. She also complained of worsening constipation. A CT scan was performed on ___ of the abdomen and pelvis as well as the chest. This showed a 2 mm nodule in the chest which was indeterminate. A 3.0 x 3.3 x 4.0 cm lobular partially enhancing mass was seen superior to the vaginal fornix on the left. There was no retroperitoneal or mesenteric lymphadenopathy there was no pelvic or inguinal lymphadenopathy. There was mild to moderate dilation of the left ureter likely secondary to mass-effect from the mass at the vaginal fornix. No hydronephrosis was detected. On physical exam a 2 cm firm friable mass was noted at 6: 00 on the perineum. There was a question of a small nodule at the left apex. Health Maintenance: Mammogram: ___, Colonoscopy: ___, Bone Density: unsure, Routine follow up with PCP ___: G3P3, LMP: ___ years ago, No HRT Use, Last Pap Smear: ___, NIL, No H/O Fibroids, ovarian cysts or other GYN infections/problems PMH: - Hypothyroidism - Hypertension - Hypercholesterolemia - Depression PSH: - Tubal ligation - D&C, hysteroscopy - RA-TLH, BSO, pLND <SOCIAL HISTORY> ___ <FAMILY HISTORY> no colon ca, no ovarian, uterine or breast 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> ___ 03: 10PM GLUCOSE-98 UREA N-22* CREAT-1.1 SODIUM-137 POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20 ___ 03: 10PM WBC-10.2* RBC-4.05 HGB-12.3 HCT-36.1 MCV-89 MCH-30.4 MCHC-34.1 RDW-12.6 RDWSD-41.3 ___ 03: 10PM NEUTS-77.6* LYMPHS-13.6* MONOS-7.6 EOS-0.1* BASOS-0.6 IM ___ AbsNeut-7.91* AbsLymp-1.38 AbsMono-0.77 AbsEos-0.01* AbsBaso-0.06 ___ 03: 10PM PLT COUNT-165 ___ 03: 01PM URINE HOURS-RANDOM ___ 03: 01PM URINE UHOLD-HOLD ___ 03: 01PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03: 01PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM ___ 03: 01PM URINE RBC-50* WBC-3 BACTERIA-NONE YEAST-NONE EPI-1 ___ 03: 01PM URINE MUCOUS-RARE <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. Nephrostomy Tube: * You have been set up with a home nurse who will help you take care of the nephrostomy tube. * If you start experiencing flank/back pain and difficulty urinating, please reconnect the tube to a bag with help from your home nurse * If you start experiencing a fever or any of the danger signs listed below, please also reconnect the tube to a bag and either call Dr. ___ (___) or go to the emergency room for evaluation of an infection. * You were prescribed oxybutynin to help with feeling urinary urgency. You currently do not have insurance coverage until ___. Please call ___ Health to let them know to backdate your previous insurance coverage for prescription medication (should take ___ hours). Afterwards, you can go to the pharmacy to fill this prescription. Please take as needed as instructed. Oxybutynin may cause urinary retention, constipation, and dry mouth. 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 for management of her abdominal pain and suspected recurrence of stage IB FIGO grade 2 endometrial adenocarcinoma. For her abdominal pain she was given IV dilaudid and acetaminophen as well as pyridium. On hospital day #1 she underwent ___ biopsy of her pelvic / vaginal cuff mass. Regarding her malignant ureteral obstruction, her creatinine was uptrending on hospital day 1 and she developed new onset hematuria. She was seen by Urology who recommended placement of left percutaneous nephrostomy tube and ureteral stent for relief of malignant urinary obstruction. During the procedure, she reportedly experience a 5 second asymptomatic asystole and recovered without incident. Vital signs were normal and she remained asymptomatic. EKG showed sinus tachycardia with prolonged QTC. She was placed on telemetry for close cardiac monitoring. UA and urine culture were negative for infection. By hospital day #4 her creatinine had normalized to her baseline of 0.5 and her percutaneous nephrostomy tube was capped. For her hypertension and hypothyroidism, her home medications were continued. On hospital day 4, she was tolerating a regular diet, pain was controlled with oral medications, and she was discharged home in stable condition with percutaneous nephrostomy tube in place and outpatient follow-up as scheduled. Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Malignant ureteral obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
| 1,694
| 348
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10635114-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> citalopram <ATTENDING> ___. <CHIEF COMPLAINT> Heavy menses <MAJOR SURGICAL OR INVASIVE PROCEDURE> Blood transfusion, FFP, vitamin K <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G2P1 with hc of 3 CVA's on coumadin who is followed by ___ clinic who presents with heavy menses. She reports that her period started last week ___ and by ___ this week, she was bleeding heaving and soaking through pads every 15mins and hence presented for further ED for further evaluation. Patient reports that this is definitely her period because her menses occured around the same time last month and was heavy but no prolonged. She denies any chest pain or shortness of breath but endorses dizziness and lightheadedness. Denies syncope. Of note, last INR was 2.9, goal is 2.0-3.0. Patient was seen by ED resident who reported heavy vaginal bleeding on exam. Patient denies any pain. <PAST MEDICAL HISTORY> GYN Hx: LMP: ___ Denies STI, abnl Pap smears, last Pap ___ NILM Diagnosed with fibroids ___ OB Hx: 1 SVD, no complications, 1 TAB Med hx: Anxiety, Carotid artery dissections, CVA x 3, HTN, Depression Surg Hx: Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> grandmother with dementia <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 Resp: no acute respiratory distress Abd: soft, nontender, no rebound/guarding Ext: no c/c/e <PERTINENT RESULTS> ___ 09: 20PM BLOOD WBC-13.3* RBC-2.78* Hgb-8.5* Hct-26.1* MCV-94 MCH-30.5 MCHC-32.5 RDW-17.8* Plt ___ ___ 10: 30AM BLOOD WBC-7.5 RBC-2.41* Hgb-7.5* Hct-21.9* MCV-91 MCH-31.0 MCHC-34.1 RDW-17.1* Plt ___ ___ 09: 45PM BLOOD WBC-8.8 RBC-2.34* Hgb-7.8* Hct-21.1* MCV-90 MCH-33.3* MCHC-36.9* RDW-17.1* Plt ___ ___ 06: 30AM BLOOD WBC-8.8 RBC-2.30* Hgb-7.4* Hct-20.8* MCV-90 MCH-32.0 MCHC-35.4* RDW-16.9* Plt ___ ___ 12: 45PM BLOOD WBC-9.9 RBC-2.55* Hgb-8.2* Hct-22.7* MCV-89 MCH-32.2* MCHC-36.1* RDW-16.9* Plt ___ ___ 12: 00AM BLOOD WBC-8.4 RBC-3.08* Hgb-9.5* Hct-26.9* MCV-87 MCH-30.7 MCHC-35.2* RDW-16.9* Plt ___ ___ 06: 30AM BLOOD WBC-9.0 RBC-3.28* Hgb-10.4* Hct-29.1* MCV-89 MCH-31.8 MCHC-35.9* RDW-17.2* Plt ___ ___ 09: 20PM BLOOD ___ PTT-41.0* ___ ___ 09: 20PM BLOOD Plt ___ ___ 10: 30AM BLOOD ___ PTT-31.1 ___ ___ 10: 30AM BLOOD Plt ___ ___ 09: 45PM BLOOD Plt ___ ___ 06: 30AM BLOOD ___ PTT-28.2 ___ ___ 06: 30AM BLOOD Plt ___ ___ 12: 45PM BLOOD Plt ___ ___ 12: 00AM BLOOD ___ PTT-27.6 ___ ___ 12: 00AM BLOOD Plt ___ ___ 06: 30AM BLOOD ___ PTT-26.4 ___ ___ 06: 30AM BLOOD Plt ___ ___ 09: 20PM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-21* AnGap-19 <MEDICATIONS ON ADMISSION> - Verapamil 180mg daily - Metoprolol 50mg QAM - Effexor 75mg daily - Warfarin 5mg/4mg alternating days <DISCHARGE MEDICATIONS> - MedroxyPROGESTERone Acetate 10 mg PO BID RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth twice a day Disp #*17 Tablet Refills: *0 - Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*120 Tablet Refills: *0 - Verapamil 180mg daily - Metoprolol 50mg QAM - Effexor 75mg daily <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Heavy vaginal bleeding, anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for monitoring of your bleeding. You received a blood transfusion and were started on Provera. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office at ___ with any questions regarding this hospitalization. If you have questions regarding follow up, you may contact Dr. ___. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * Your Neurologist (Dr. ___ has recommended that you continue taking aspirin 325mg daily until you have a follow up appointment with him. * Call the doctor for any of the concerning symptoms listed below. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service for management of her menorrhagia. . On intial presentation, she had a supratherapeutic INR of 3.2. She was given vitamin K, 1 unit of FFP, and 1 unit of pRBCs. She was also symptomatic from her anemia. . Over the course of her hospitalization, she received a total of 5 units pRBCs with improvement in her symptoms. On ___, she was started on provera BID, with excellent improvement in her vaginal bleeding. . During her admission, Hematology was consulted regarding re-initiation of her warfarin. They recommended holding her warfarin and consultation with the Neurology team. The inpatient Neurology team was consulted, who recommended a CTA head/neck. Based on her studies, the inpatient Neurology team as well as her primary Neurologist recommended that her anticoagulation be held until stabilization of her bleeding, with planned re-initiation during outpatient follow up. . She was maintained on her home medications for her hypertension and anxiety. . On ___, the patient was discharged home in stable condition on aspirin and provera with outpatient follow up scheduled.
| 1,481
| 260
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10639037-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Menorrhagia, cervical elongation <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy with completion of colpotomy and vaginal cuff closure Cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 1, para 1. Last menstrual period, ___. The patient has been under the care of Dr. ___ ___, Dr. ___ and Dr. ___. The patient had consulted with Dr. ___ because of her menorrhagia. She was placed on norethindrone acetate and has been amenorrheic since ___ although, she has had intermittent break through bleeding due to occcasional inconsistency with pill taking. She had a negative endometrial biopsy on ___, which showed proliferative endometrium. She was seen by Dr. ___ Dr. ___ she felt that her uterus was dropping. After her evaluations, she was diagnosed with cervical elongation. She elected for definitive surgical therapy for her history of menorrhagia/breakthrough bleeding. She also wants to discontinue this hormonal therapy secondary to her decreased mood but is afraid to do so because of her history of menorrhagia. <PAST MEDICAL HISTORY> PMH: Gastritis, anemia, hyperlipidemia PSH: Knee surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with hypertension and status post stroke, deceased at age ___. Father with heart disease, died at ___. <PHYSICAL EXAM> Upon discharge General: NAD, A&Ox3 Cardiac: RRR, S1&S2, no m/r/g Pulm: CTAB Abdomen: +BS, nondistended, mild tenderness to palpation in periumbilical region. Incisions C/D/I Extremities: no edema, no calf tenderness to palpation <PERTINENT RESULTS> N/A <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*75 Tablet Refills: *0 2. Ferrous Sulfate 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every 12 hours Disp #*60 Capsule Refills: *0 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every 4 - 6 hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic pain Menorrhagia Cervical elongation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted into the GYN service after your surgery. You have done well and the team feels like you're safe to be discharged 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 3000mg 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 they are still on after 7 days, 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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___ G1P1 who was admitted after a total laparascopic hysterectomy with completion of colpotomy and vaginal cuff closure and cystoscopy. Please refer to op note for full details of the procedure. She was stable post-operatively and complained of some shoulder soreness bilaterally and left arm numbness. On POD1 she was ambulatory and doing well with good PO intake and resolution of shoulder soreness and Left arm numbness. She was discharged on POD1 after meeting appropriate post op milestones with adequate follow up in place.
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10640398-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Aloe / Shellfish Derived <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Patient is a ___ y/o nulligravida who presents with 1 week of intermittent LLQ abdominal pain worsening over the last 3 days. Pain initially started a month ago and patient thought it was due to robutussin with codeine she was taking for a URI. It lasted the 3 days she was taking the medication then stopped. It recurred 1 week ago while she was taking amoxicillin for URI and she again assumed it was due to that. However it persisted and has been getting worse, ___ in intensity yesterday. She took aleve which helped a little. No exacerbating factors. No change with food or BMs, last several days ago. Pain is sharp and constant located in the midline and LLQ. It does not radiate. She has had some nausea and vomited once yesterday after drinking water but has been tolerating food, mostly cheerios. . Here in the ED got 4mg of morphine at ___ and at 0030. Pain is mild ___. Also got Zofran. Denies nausea and has been drinking juice. . (-) F/C, dysuria, hematuria, constipation, diarrhea, hematuria, hematochezia <PAST MEDICAL HISTORY> Gyn: - All gyn care provided by PCP at ___ - No abnormal pap smears. Up to date - No history of STDs - Not currently sexually active. last activity was several months ago with her then boyfriend. - Uses condoms - Has history of "small cysts " on her ovaries that resolved on their own PMH: - "Retains water" -> HCTZ. Denies HTN PSH: Denies All: Denies <SOCIAL HISTORY> ___ ___ History: Denies breast, ovarian, endometrial cancer <PHYSICAL EXAM> On GYN evaluation: VS 96.7 (1627) 100.4 ___ 100.0 (0231) HR 104 BP 132/89 RR 16 02 99% RA Gen: Seated comfortable on stretcher. Moves with ease with no evidence of discomfort. CV: RRR Lungs: CTAB Abd: Soft, mild tenderness in mid lower abdomen and LLQ, no rebound or guarding, (+) BS Pelvic: - Moderate white discharge, no foul odor, no cervical or vaginal lesions - BME No CMT, denies adnexal tenderness bilaterally, no uterine tenderness, small midline uterus. Ext: No edema, nontender <PERTINENT RESULTS> Labs on admission: 24.8 ___ 13.8 373 40.4 N: 88.3 L: 7.5 M: 3.4 E: 0 Bas: 0.7 ALT: 32 AP: 73 Tbili: 1.2 Alb: 4.6 AST: 23 Lip: 21 137|98|7 <113 3.5|28|0.8 Lactate: 1.2 UCG: Negative Leuk Neg Bld Sm Nitr Neg Prot 30 Ket 10 RBC 2 WBC 3 Bact Mod Yeast Epi 4 UCx: < 10,000 organisms GC/CT negative Blood culture x 3 NGTD Further labs during hospitalization: - ___ 10: 55AM BLOOD WBC-17.4* RBC-4.44 Hgb-12.7 Hct-37.8 MCV-85 MCH-28.7 MCHC-33.7 RDW-13.8 Plt ___ - ___ 06: 20AM BLOOD WBC-13.7* RBC-3.81* Hgb-11.0* Hct-32.6* MCV-85 MCH-28.9 MCHC-33.9 RDW-13.9 Plt ___ - ___ 05: 00PM BLOOD Glucose-113* UreaN-7 Creat-0.8 Na-137 K-3.5 Cl-98 HCO3-28 AnGap-15 Imaging: ___ CT pelvis 1. Complex cystic lesion in the left adnexa. Due to its size and acute pain in the LLQ, please consider pelvic ultrasound to evaluate for torsion. 2. Diverticulosis. ___ Pelvic US 1. Large complex cystic lesion with diffuse low level echoes and septations in the left adnexa, most characteristic of an endometrioma. Follow-up pelvic ultrasound is recommended in ___ weeks. Discussed with Dr. ___ at 8 pm by phone on ___. 2. Small heterogeneous lesion near uterine fundus, most likely a fibroid. 3. No evidence of ovarian torsion noted, however, ultimately, US cannot entirely exclude the diagnosis (particularly intermittent torsion). <MEDICATIONS ON ADMISSION> HCTZ 25mg daily <DISCHARGE MEDICATIONS> 1. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. Disp: *14 Tablet(s)* Refills: *0* 2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp: *42 Tablet(s)* Refills: *0* 3. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abdominal pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call our office if you develop worsening abdominal pain, nausea, vomitting, or temperature > 100.4
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Ms. ___ was admitted due to concerns for ovarian torsion. She was monitored with serial abdominal exams and kept NPO until her pain improved to the point of not requiring any medications. Her white count and fever curve improved on levofloxacin and metronidazole. An infection workup was unremarkable, and her pain was attributed to a potentially infected endometrioma versus hemorrhagic cyst, less likely a tubo-ovarian abscess or diverticulitis given quick clinical improvement. The suspicion for intermittent torsion was low as her pain improved steadily on antibiotics and did not recur. She was discharged on hospital day 2 with instructions to continue a 2 week course of antibiotics and to follow up closely with the OB/Gyn Residents' practice and with plans for repeat imaging to evaluate for interval changes.
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10641228-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> nausea/vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G6P2032 at ___ who presents with persistent nausea and vomiting, unable to tolerate PO. On evaluation here, she denies ctx, VB, LOF. Endorses active fetal movement. She also denies any F/C, no diarrhea. No sick contacts. PNC: - ___ ___ by ___ trimester US - Labs Rh pos/Abs neg/Rub I/Trep equivocal -> RPR NR/VZV immune/HBsAg neg/HIV neg /GBS unk - Screening: CF carrier per patient report, Hgb electrophoresis normal ___, low risk ERA - FFS normal, anterior placenta - GLT 143 (early) -> could not tolerate GTT - U/S none since follow up survey ___ - Issues: *) failed GLT, unable to tolerate GTT *) Hyperemesis - booking weight 277.8 (___), last weight 258.8 on ___, multiple triage visits - home Rx zofran and compazine *) subchorionic hematoma noted on ___ and ___ PUS *) BMI ___ - s/p early GLT (see above), declined referral to nutrition *) VZV nonimmune [ ] PP vaccination *) No call quantiferon gold (positive verbal TB screen) *) treated for bacteriuria w/ Amoxicillin ___ <PAST MEDICAL HISTORY> OBHx: ___ - h/o ectopic pregnancy x 1 - TAB x 2 - SVD x 2 GynHx: - denies abnormal Pap or cervical procedures - denies fibroids/endometriosis/cysts - h/o trichomoniasis PMH: denies PSH: denies Meds: unisom, zofran, compazine, PNV All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, no edema FHR: present at a normal rate <PERTINENT RESULTS> ___ 01: 26PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 01: 26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100* GLUCOSE-NEG KETONE-150* BILIRUBIN-SM* UROBILNGN-4* PH-6.5 LEUK-NEG ___ 01: 26PM URINE RBC-1 WBC-7* BACTERIA-FEW* YEAST-NONE EPI-2 ___ 01: 26PM URINE HYALINE-2* ___ 01: 26PM URINE MUCOUS-MANY* ___ 01: 24PM GLUCOSE-91 UREA N-4* CREAT-0.4 SODIUM-141 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19* ___ 01: 24PM estGFR-Using this ___ 01: 24PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-2.0 ___ 01: 24PM WBC-9.0 RBC-3.75* HGB-11.5 HCT-34.9 MCV-93 MCH-30.7 MCHC-33.0 RDW-12.7 RDWSD-42.7 ___ 01: 24PM NEUTS-64 ___ MONOS-5 EOS-0* BASOS-0 ATYPS-9* AbsNeut-5.76 AbsLymp-2.79 AbsMono-0.45 AbsEos-0.00* AbsBaso-0.00* ___ 01: 24PM RBCM-WITHIN NOR ___ 01: 24PM PLT SMR-NORMAL PLT COUNT-375 <MEDICATIONS ON ADMISSION> unisom Zofran Compazine PNV <DISCHARGE MEDICATIONS> 1. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *2 2. Ondansetron 4 mg PO Q8H RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills: *2 3. Promethazine 25 mg PR Q6H: PRN nausea and vomiting RX *promethazine 25 mg 1 suppository(s) rectally Q6hr Disp #*50 Suppository Refills: *1 4. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hyperemesis gravidarum <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with nausea and vomiting, hyperemesis gravidarum. You received IV fluids, anti nausea medications, and you were able to tolerate a regular diet. You were also seen by the nutrition team. You felt better after the IV fluids and medicine, and your lab tests were reassuring. 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 Please eat small meals every ___ hours that are bland and easily tolerated, such as rice, toast, bananas, apple sauce. Please drink the ensure clear drinks ___ times a day for additional nutritional support. Please take the medications for nausea as prescribed. Please attend your infusion appointments, your first appointment is on ___. Please take: Ondansetron 40 mg every 8 hours Famotidine 20 mg twice daily Promethazine (Compazine) 25 mg as needed when experiencing extreme nausea
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Ms. ___ was admitted to the hospital for nausea and vomiting of pregnancy. The patient had an anion gap attributed to dehydration; this resolved on repeat evaluation. She received IV Pepcid, Zofran, Compazine, Phenergan and IV fluids. She was transitioned to oral Pepcid, Zofran, and PR Compazine with symptomatic improvement. By hospital day 2, she was tolerating oral intake and was deemed stable for discharge. She was scheduled for outpatient pheresis for weekly IV fluid administration.
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10641592-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / iodine <ATTENDING> ___ <CHIEF COMPLAINT> vaginal prolaps <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Vaginal colpectomy. 2. Tension-free vaginal tape (TVT) Exact sling. 3. High perineorrhaphy. 4. Cystoscopy x2. <HISTORY OF PRESENT ILLNESS> The patient is a ___, gravida 4, para 1, who was referred to Dr. ___ by Dr. ___ vaginal prolapse. The patient was complaining of pressure and bulging that was affecting her ability to walk and have bowel movement. Her symptoms had been present for approximately ___ years, and they had become worse over the past 5 months. She reported daily incontinent events even with minimal exertion such as walking. She was examined and was found to have a third-degree cystocele, a second-degree vault prolapse, and a positive empty supine stress test, suggestive of intrinsic sphincter deficiency. The patient was referred for multichannel urodynamic testing, which confirmed that she had stress urinary incontinence, ureteral hypermobility and unstable detrusor. The patient was counseled extensively regarding our evaluation. She elected to proceed with surgical management. The risks, benefits, and alternatives to her management were discussed with the patient. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Anxiety/Depression 2. GERD 3. Chronic back pain PAST SURGICAL HISTORY 1. TAH BSO ___ 2. ___ (? vaginal sling Dr. ___ 3. Appendectomy 4. Cholecystectomy 5. Parathyroid lobe excision 6. Melanoma excision x 2 <FAMILY HISTORY> FAMILY HISTORY Her family history is unremarkable for Breast/Ovarian or Colon cancer. <PHYSICAL EXAM> On day of discharge General: NAD CV: RRR LUNGS: CTABl ABD: soft, nondistended, appropriately tender, +BS EXT: NE, NT <MEDICATIONS ON ADMISSION> 1. conjugated estrogens [Premarin] 0.625 mg tablet 60 Tablet 1 tablet(s) by mouth twice a day 2. conjugated estrogens [Premarin] 0.625 mg/gram Cream insert 1 gram per vagina weekly 3. diclofenac sodium 50 mg tablet,delayed release (___) 1 tablet,delayed release (___) by mouth once a day as needed for pain 4. esomeprazole magnesium [Nexium] 40 mg capsule,delayed ___ 60 Tablet 1 capsule,delayed ___ by mouth twice a day 5. ketoconazole 2 % Shampoo 1 Bottle use topically once a day 6. lorazepam 1 mg tablet 1 (One) tablet(s) by mouth at bedtime 7. olmesartan [Benicar] 20 mg tablet 30 Tablet 1 tablet(s) by mouth daily 8. oxybutynin chloride 10 mg tablet extended release 24hr 30 Tablet ___ MD 1 Tablet(s) by mouth once a day ___ hr before breakfast Current List of Over the Counter Medications Medication Dispense Prescribed By Take B complex-folic acid [Balanced B-100] 0.4 mg tablet 30 Tablet ___ NP 1 (One) tablet(s) by mouth once a day cholecalciferol (vitamin D3) 2,000 unit capsule 30 Capsule ___ NP 1 (One) capsule(s) by mouth once a day fish oil-vit E-fat acid5-___ [Flax, Fish & Borage Oil] 400 mg-5 unit capsule 1 (One) capsule(s) by mouth once a day glucosamine sulfate 500 mg tablet 30 Tablet ___ NP 1 (One) tablet(s) by mouth once a day salmon oil-omega-3 fatty acids [Salmon Oil-1000] 1,000 mg-200 mg capsule 1 (One) capsule(s) by mouth once a day sennosides [senna] 8.6 mg tablet 120 Tablet ___ NP 1 to 2 tablet(s) by mouth twice a day <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 2. olmesartan 20 mg Oral daily 3. OxycoDONE (Immediate Release) 5 mg PO Q3H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 4. Polyethylene Glycol 17 g PO DAILY: PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth once a day Disp #*30 Packet Refills: *0 5. Lorazepam 0.5 mg PO ONCE anxiety Duration: 1 Dose 6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID: PRN GERD RX *aluminum-magnesium hydroxide [MAG-AL] 200 mg-200 mg/5 mL ___ mL by mouth QID: PRN Disp #*1 Bottle Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> stress urinary incontinence, cystocele, prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing vaginal colpectomy, tension-free vaginal tape (TVT) Exact sling, high perineorrhaphy, and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: Instilled 300 mL, voided 250 mL with some leaking, then scanned for 17mL residual. Her diet was advanced without difficulty and she was transitioned to tylenol and oxycodone. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10643918-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo P3 who presented to the ED with heavy VB x one month. She stateed she was amenorrheic for one year and then started bleeding heavily one month ago. She presented to ___ on ___ for this, had an EMB which showed proliferative endometrium and was prescribed provera 10mg daily. She reported that the bleeding had not improved since starting provera and she in fact thought it worsened. She reported soaking through a pad every 30 min to one hour and was dizzy with ambulation. She also felt palpitations when climbing up two flights of stairs in her home. Denied CP, SOB, abdominal pain. <PAST MEDICAL HISTORY> GYNHx: LMP ___, continuous until now amenorrhea x ___ year, cycles were regular prior to that Q month, reports h/o menorrhagia currently not sexually active, has not been x ___ years, no partner denies h/o STIs or abnormal Paps reports having had Pap done at ___ on ___ (but no report in OMR) OBHx: G1- SVD, full term, no complications G2- SVD, full term, no complications, twins PMH: denies PSH: open cholecystectomy, open appendectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> denies FH of uterine, ovarian, breat, colon ca, no FH of clotting disorders <PHYSICAL EXAM> VS- 98.9 118/67 99 18 100%RA appears comfortable, in NAD RRR CTA B abd soft nontender nondistended SSE on arrival (per ED resident): large amount of clot evacuated from vagina with active bleeding from os SSE on my exam: small clot at external os, normal external genitalia, normal cervix, normal vaginal walls without lesions or lacerations, slow trickle from os, blood staining on perineum and inner thighs bimanual: slightly enlarged about 12 week size uterus, retroverted, nontender to palpation, no adnexal masses palpable, no CMT <PERTINENT RESULTS> ___ 03: 20PM BLOOD WBC-8.9 RBC-2.89*# Hgb-8.0* Hct-24.4* MCV-84 MCH-27.8 MCHC-33.0 RDW-16.5* Plt ___ ___ 09: 00AM BLOOD WBC-8.4 RBC-3.50* Hgb-9.8* Hct-29.4* MCV-84 MCH-27.9 MCHC-33.2 RDW-16.1* Plt ___ ___ 03: 20PM BLOOD Neuts-69.7 ___ Monos-3.9 Eos-1.0 Baso-0.5 ___ 04: 23PM BLOOD ___ PTT-23.2 ___ ___ 09: 00AM BLOOD ___ ___ 03: 20PM BLOOD Glucose-106* UreaN-15 Creat-0.7 Na-139 K-4.6 Cl-107 HCO3-23 AnGap-14 ___ 03: 20PM BLOOD HCG-<5 <MEDICATIONS ON ADMISSION> Provera 10mg daily <DISCHARGE MEDICATIONS> 1. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. Disp: *60 Tablet(s)* Refills: *2* 2. Mononessa (28) 0.25-35 mg-mcg Tablet Sig: Take as directed Tablet PO once a day: Take two pills daily for the first pack, skip the sugar pills. Take one pill daily starting with the second pack, you can take the sugar pills with this pack. Please give instructions in ___. Disp: *1 Pack* Refills: *6* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Dysfunctional uterine bleeding Blood loss anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for heavy bleeding that has improved. You are being discharged on oral contraceptive pills to help control the bleeding. Risks of oral contraceptive pills include blood clots in your legs and lungs, but this is uncommon and you do not have any risk factors for this. . For the first pack of pills, take two pills daily (one in the morning and one at night) until you have finished the first 21 pills. Do not take the sugar pills (7 different color pills at the end of the pack). Start the second pack of pills and take only one pill daily. You can take the sugar pills in this pack. You should have a period when taking the sugar pills. You can follow up with ___ to discuss long term management of your heavy bleeding. . Stop taking the medroxyprogesterone that you were prescribed at ___. . Take iron twice daily. If you are constipated, you can take colace. . If you have bleeding that soaks through a large pad in less than an hour for more than two hours, this is too much bleeding and you should call your doctor.
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Ms. ___ was evaluated by ultrasound which revealed: IMPRESSION: Endometrial cavity markedly distended with blood. No definite internal vascularity is seen within the endometrial canal. Assessment of the endometrium itself is limited due to the presence of endometrial blood. No uterine masses noted otherwise, and ovaries are normal. Her bleeding was thoguht to be anovulatory in nature. Given that she was symptomatic (dizzy with ambulation) and her Hct dropped from 32 to 24 in ten days with pelvic u/s showing enlarged uterus full of blood, she was transfused 2u PRBC and admitted for observation overnight. She was kept NPO and given IV fluids in case there was a need for urgent D&C. She was also given 20mg Provera and started on 20mg BID. By the following morning, her post-transfusion hematocrit was 29.4 and she felt much improved. She was discharged to home with on oral contraceptive pills and follow-up at ___.
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10643918-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Hysteroscopy, Dilation & Curettage, Novasure endometrial ablation <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ YO P3 who presented to the ED with heavy vaginal bleeding. She was discharged from the GYN service on ___ after a 1 day admission for the same complaint. Please see discharge summary from ___ for details of admission and treatment. She reported that she has been taking her prescribed pills, 2 tabs BID for 1 week, then 3 tabs BID for the last 2 days. Discharge medications note that she was to take the OCP Mononessa, 2 pills QD for first pack and 1 pill QD for the ___ pack. Bleeding initially slowed down but then became heavy again over the last 2 days. She has been soaking 1 pad every 30 mins and now is dizzy with a headache and lower abdominal cramping. She denies syncope, CP, palpitations. <PAST MEDICAL HISTORY> GYNHx: LMP ___, continuous until now amenorrhea x ___ year, cycles were regular prior to that Q month, reports h/o menorrhagia currently not sexually active, has not been x ___ years, no partner denies h/o STIs or abnormal Paps reports having had Pap done at ___ on ___ Endometrial biopsy at ___ ___ - Disordered proliferative endometrium. OBHx: G1- SVD, full term, no complications G2- SVD, full term, no complications, twins PMH: denies PSH: open cholecystectomy, open appendectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> denies FH of uterine, ovarian, breast, colon ca, no FH of clotting disorders <PHYSICAL EXAM> Physical examination on admission VS- 97.8 95 128/63 16 100% appears comfortable, tired in NAD RRR CTA B abd soft nontender nondistended SSE on arrival (per ED resident): moderate amount of clot evacuated from vagina with active bleeding from os SSE on my exam: small clots x 4 at in posterior fornix, normal external genitalia, normal cervix, normal vaginal walls without lesions or lacerations, slow trickle from os, blood staining on perineum and inner thighs bimanual: 12 week size uterus, retroverted, nontender to palpation, no adnexal masses palpable, no CMT <PERTINENT RESULTS> ___ 09: 50PM BLOOD Neuts-62.9 ___ Monos-6.1 Eos-2.9 Baso-0.9 ___ 09: 50PM BLOOD WBC-9.7 RBC-2.87* Hgb-7.8* Hct-24.0* MCV-84 MCH-27.2 MCHC-32.6 RDW-16.1* Plt ___ ___ 01: 10PM BLOOD WBC-8.1 RBC-3.53* Hgb-9.8*# Hct-29.4* MCV-84 MCH-27.7 MCHC-33.2 RDW-15.5 Plt ___ ___ 09: 50PM BLOOD ___ PTT-21.8* ___ ___ 01: 10PM BLOOD ___ PTT-23.0 ___ ___ 01: 10PM BLOOD ___ ___ 09: 50PM BLOOD Glucose-96 UreaN-18 Creat-0.7 Na-139 K-4.8 Cl-107 HCO3-22 AnGap-15 <MEDICATIONS ON ADMISSION> 1. Iron 325 mg BID 2. Mononessa (28) 0.25-35 mg-mcg Tablet Take two pills daily for the first pack, skip the sugar pills. Take one pill daily starting with the second pack, you can take the sugar pills with this pack. <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: do not take more than 4 pills in 24hr. Disp: *30 Tablet(s)* Refills: *0* 2. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: do not take more than 4000mg acetaminophen (APAP) . Disp: *20 Tablet(s)* Refills: *0* 3. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal bleeding <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. * Narcotic medications can cause constipation. Please take a stool softener, such a colace, stay hydrated, and consume fiber. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecology service. Her HCT had dropped form 29.4 at discharge to 24.0 on readmission. It was decided to transfuse 2 units given her symptomatic anemia. Her post-transfusion hematocrit was 29.4 The patient desired more definitive management of her bleeding. The options, risks, and benefits were discussed with her and she chose hysteroscopy, Dilation & Curettage, Novasure endometrial ablation. The procedure was uncomplicated, please see operative note for details. She had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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10643918-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopy converted to open total abdominal hysterectomy <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ Para 2 who had a history of menorrhagia. She had an endometrial biopsy performed ___ ans subsequently developed pelvic pain. She desired definitive management of both pain and bleeding via hysterectomy and was appropriately counseled about the risk/benefits. <PAST MEDICAL HISTORY> PMH: Depression, Menorrhagia, Pre-diabetes PSH: HSC D&C ___, Endometrial ablation ___, Open Appe, Open CCY, b/l tubal ligation <SOCIAL HISTORY> ___ <FAMILY HISTORY> denies FH of uterine, ovarian, breast, colon ca, no FH of clotting disorders <PHYSICAL EXAM> Upon discharge No acute distress RRR no m/r/g CTAB ABD S/appropriately tender to palpation, no rebound or guarding. Phanestiel incision C/D/I EXT NT/NE <PERTINENT RESULTS> ___ 06: 15AM BLOOD WBC-12.5*# RBC-3.46*# Hgb-9.5*# Hct-28.3*# MCV-82 MCH-27.6 MCHC-33.7 RDW-14.3 Plt ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*100 Tablet Refills: *0 RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth every 12 hours Disp #*50 Capsule Refills: *0 RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 3. Omeprazole 20 mg PO DAILY 4. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H: PRN pain Do not drive or combine with alcohol. Do not take >4000mg acetaminophen in 24 hours. RX *hydrocodone-acetaminophen 5 mg-500 mg ___ tablet(s) by mouth every 6 hours Disp #*45 Tablet Refills: *0 5. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours. Disp #*5 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 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 GYN service after undergoing the procedure listed below. You have done well after surgery and the team feels that you're safe to be discharged 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 6 weeks * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted into the GYN service following her Laparoscopy, which was converted to an open hysterectomy. Please refer to operative report for full details of the procedure. Her case was complicated by large EBL. However, she had an uncomplicated recovery and was discharged home on postoperative day #2 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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10646437-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Ibuprofen <ATTENDING> ___ <CHIEF COMPLAINT> ___ yo with menorrhagia and anemia secondary to symptomatic uterine fibroids and ovarian cysts. <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy left salpingostomy bilateral ovarian cystectomy right pyosalpinx drainage blood transfusion <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 0 with a known fibroid uterus, history of menorrhagia, and significant anemia. The patient has been seen multiple times with increased bleeding. On ___, she presented with increased bleeding and was admitted and treated with Lo/Ovral taper. The patient then received test dose of Lupron in ___. After normal endometrial biopsy in ___, she received the Depo Lupron. The patient has had irregular bleeding while on Lupron. Her hematocrit is stable, last check was on ___, and it was 28. The patient comes today prior to her operative procedure on ___, and we discussed the fact that although she has been on Lupron for several months, there has not been a great improvement in her hematocrit and that delaying surgery any further would probably not benefit her. Of note, on ___, she had a hematocrit of 34, and now, it is 28. The patient originally had thought that she wanted definitive therapy in the form of a supracervical hysterectomy. After much discussion, the patient has decided to have removal of her uterine fibroids only. After much discussion, she is well aware of the fact that she is young and that the likelihood of other fibroids growing is certainly increased, and this also increases the chances of the possibility of returning to the operating room or having some other form of fibroid treatment. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 11. She cycles every 14 days and she states that she is in constant pain from uterine cramping. She is sexually active at present. She has been active in the past and at present with a female partner. She denies ever having a sexual experience that made her physically or emotionally uncomfortable. Fertility control, not applicable. Her last Pap was on ___ with my nurse practitioner. Therefore, no need to update it today. PAST MEDICAL HISTORY: Positive for migraine headaches, anemia, abnormal vaginal bleeding, superficial thrombophlebitis, sleeping difficulties, depression, and anxiety. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Significant for hypertension, diabetes, stroke. Negative for any female cancers <PHYSICAL EXAM> GENERAL: This is a well-developed, well-nourished woman in no apparent distress. Weight 258, height 5 feet 8 inches, blood pressure 110/80. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Conjunctivae pale. NECK: Supple, without thyromegaly. LYMPH: Lymph system negative. BACK: Negative CVAT. ABDOMEN: Soft, nondistended. Negative hepatosplenomegaly. Uterus was palpated one fingerbreadth below the umbilicus. PELVIC: Normal female external genitalia. Vaginal vault, normal-appearing discharge. Cervix without cervical motion tenderness. Uterus approximately 18 cm in maximal vertical dimension. Adnexa impossible to evaluate secondary to large pelvic abdominal mass. <PERTINENT RESULTS> HCT (pre-op) 28 -> (post-op/transfusion) 30.6 -> 24.6 -> 23.7 -> 27.5 The patient had an ultrasound done on ___, which showed a fibroid uterus, which measured 15.3 x 9 x 11.3 cm. The largest fibroid measured 9.5 x 8.1 x 8.7 cm. There was no free fluid or hydronephrosis. <MEDICATIONS ON ADMISSION> prilosec <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: maximum daily Tylenol (acetaminophen) is 4000mg, each Percocet contains 325mg Tylenol (acetaminophen). Disp: *50 Tablet(s)* Refills: *0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* 3. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day: HOLD until done with antibiotics. Disp: *60 Tablet(s)* Refills: *2* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp: *42 Tablet(s)* Refills: *0* 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp: *28 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine fibroids tubo-ovarian abscess bilateral ovarian cysts blood loss anemia <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, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit.
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Despite being on Lupron the patient had significant pre-operative anemia and was counselled that she would likely require a blood transfusion if she proceeded with myomectomy. Because she was noted to have tubular structures in the R and L adenexa she was also consented on possible ovarian cystectomies. Intra-operatively the EBL was 1800 and the patient required 2 units of packed red blood cells. Although there was no evidence of infection pre-operatively, intra-operatively she was noted to have a tubovarian abscess so ___ drain was placed and IV Cipro and Flagyl were started. She was transferred from the PACU to the surgical care floor in stable condition, on IV antibiotics, with the JP drain and a Foley catheter in place. Her post-op HCT was 30.6. Given the extensive nature of her surgery she was started on a Dilaudid PCA for pain control. On POD1 she tolerated sips but did not ambulate or eat a regular diet so she continued to use the PCA for pain, the Foley catheter stayed in place, and she remained with pneumoboots in place. She denied any symptoms of anemia. On POD2 she began to tolerate a regular diet without nausea or vomiting so the PCA was stopped and oral pain medications were started. However, she had some vomiting in the afternoon so she ate only crackers and soda for the rest of the day and her PCA was started again. Her Foley catheter was discontinued and she began to ambulate. By the evening the PCA was stopped again and she was able to tolerate a regular diet. The IV antibiotics were replaced with oral medications. On POD3 she was ambulating, passing flatus, her pain was well controlled on PO pain meds and she was tolerating a regular diet. She was complaining of some lightheadedness when standing but her vital signs were stable and she was not orthostatic. Her HCT was 23.7. She remained in the hospital one more night until her symptoms resolved and her hematocrit improved. On POD4 her HCT was 27.5, she denied symptoms of anemia, and she was discharged home in stable condition.
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10647030-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine <ATTENDING> ___ <CHIEF COMPLAINT> "It comes all the way out and rubs on my clothes" <MAJOR SURGICAL OR INVASIVE PROCEDURE> total vaginal hysterectomy, anterior colporrhaphy, Monarch sling <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 2 Para 0020 who presented for vaginal prolapse. She is complaining of vaginal bulging whihc have been gradually getting worse over the past ___ years. She now reports episodes of complete procidentia. She reports no current incontinence events (rare SUI). 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 interrupted flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ also admits to some vaginal pressure or palpable prolapse. She also denies any constipation. She is sexually active and does not experience dyspareunia. She admits to vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST OB HISTORY G___ Vaginal: 2 PAST GYN HISTORY She denies having Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV She denies having an abnormal Pap test She denies having an abnormal Mammogram Her last colonoscopy was in ___ She is [Postmenopausal] since ___ She denies post-menopausal bleeding. PAST MEDICAL HISTORY: 1. Hypothyroidism 2. CREST 3. Arthritis PAST SURGICAL HISTORY 1. Breast biopsy 2. Vein surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Ovarian or Colon cancer. + MGM Breast Cancer <PHYSICAL EXAM> on discharge: AF VSS Gent: NAD, AxO CV: RRR Resp: CTAB, no crackles Abd: soft, nontender GU: no vaginal bleeding Ext: calves nontender <PERTINENT RESULTS> ___ Final pathology pending at the time of this discharge summary <MEDICATIONS ON ADMISSION> levothyroxine, hydroxychloroquine <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID Please take to prevent constipation while you are taking narcotics. Hold for loose stools. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 2. Ibuprofen 400 mg PO Q8H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills: *1 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not take more than 4000 mg of acetaminophen in 24 hours. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*45 Tablet Refills: *0 4. TraMADOL (Ultram) 50 mg PO Q6H: PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*45 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine prolapse, stress urinary incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to gynecology service after undergoing the procedures listed below. You have recovered well and the team feels that you are safe for discharge home. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing an uncomplicated total vaginal hysterectomy, anterior colporrhaphy, and Monarc sling for pelvic organ prolapse. Please refer to Dr. ___ report for details of the operation. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV medications. On post-operative day 1, she was ambulatory and her urine output was adequate so her foley was removed and she underwent the following voiding trial: -Instill 300cc, voided 300cc, PVR 50cc -Instill 300cc, voided 300cc, PVR 0cc She therefore passed her voiding trial and the foley was not replaced. Her diet was advanced without difficulty and she was transitioned to oral percocet and ibuprofen. By the afternoon of 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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10648545-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Labial Abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> Incision and Drainage of right labial abscess <HISTORY OF PRESENT ILLNESS> ___ yo G1 presented to ED with several days of labial pain and swelling, found to have suspected vulvar abscess. Reported it started as a small blemish, tried to "squeeze" without success and rapidly developed into large and painful mass. Denies fevers at home, CP or SOB. No abdominal pain or abnormal discharge. In ED was I&D'd by resident and wick placed. No formal procedure note to review but by report drained "7cc fluid" or "a lot of prurulent fluid". During this time patient was briefly hypotensive ___, tachycardic to 120s and t max reported to be 100.4 (on dashboard highest 100.1). <PAST MEDICAL HISTORY> Ob/gyn hx: G0, denies h/o abnl Pap, menses regular, using condoms, one male partner ___: denies PSHx: denies Meds: none All: NKDA <SOCIAL HISTORY> Soc: grad student at ___, presents with husband, denies t/e/d <PHYSICAL EXAM> Upon admission at ED: 97.6 HR 85 92/56 RR 14 100% RA verbally tmax 101.4 at unknown time tmax recorded on ED dashboard 100.1 at 2055 BP as low as ___ and at one point triggered for hypotension intermittent tachycardia up to 120s but improving - NAD on exam, non-toxic, A&Ox3 - RRR - CTAB - abd soft, NT, ND, no R/G - right vulva with 3-4 cm laceration, somewhat superficial at superior and inferior aspects but centrally deep with wick in place, not probed - surrounding labial tissue markedly erythematous, edematous but without skin changes or air pockets to suggest cellulitis or gangrene. moderately tender to palpation Upon discharge: Upon discharge: VSS, AF Gen: NAD A&O x 3 Resp: no visible respiratory distress, speaking in full sentences Abd: soft, NT ND Ext: moving all 4 extremities Incision: right vulva with a 3cm wound incision, clean, dry, dressing intact, mild erythema, no purulent drainage <PERTINENT RESULTS> ___ 11: 56PM ___ COMMENTS-GREEN TOP ___ 11: 56PM LACTATE-0.9 ___ 09: 34PM LACTATE-0.9 ___ 09: 20PM GLUCOSE-81 UREA N-4* CREAT-0.5 SODIUM-139 POTASSIUM-3.0* CHLORIDE-110* TOTAL CO2-20* ANION GAP-12 ___ 09: 20PM estGFR-Using this ___ 09: 20PM WBC-9.7 RBC-3.54* HGB-11.5* HCT-32.0* MCV-91 MCH-32.4* MCHC-35.8* RDW-11.8 ___ 09: 20PM NEUTS-92.9* LYMPHS-4.3* MONOS-2.0 EOS-0.6 BASOS-0.2 ___ 09: 20PM PLT COUNT-201 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain do not take more than 4g/24hrs RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hrs Disp #*20 Tablet Refills: *0 2. Ibuprofen 800 mg PO Q8H: PRN pain take with food, do not take more than 2400mg in 24 hrs RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hrs Disp #*30 Tablet Refills: *0 3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 4. HYDROmorphone (Dilaudid) 2 mg PO Q6H: PRN pain use before dressing changes. RX *hydromorphone 2 mg 1 tablet(s) by mouth every 12 hours Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ Diagnosis: Labial Abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You have been admitted to the Gynecology service for a labial abscess. Your infection has been drained, and you were started on IV antibiotics. You did have some episodes of low blood pressure, but you have recovered well. We have determined that you are in a good condition for discharge. Please follow-up with us as scheduled. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) until the lesion is healed * 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 until lesion is healed * Please leave the wick dressing on your wound and change it twice daily. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or purulent drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * Or anything that concerns you To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the Gynecology service after an incision & drainage for a right labial abscess on ___. She was also triggered for hypotension and tachycardia in the ED. *) Labial Abscess She was started on vancomycin and Unasyn upon admission. She was hemodynamically stable, with a normal white count and no signs of SIRS. We trended her fever curve. The patient had a tmax of 101.3 on ___, but remained afebrile thereafter. She was transitioned to po Bactrim once she had been afebrile for 24 hrs. Her labial wound was dressed with ___ wick dressing, wet-to-dry, twice a day. We set up home care to assist with dressing changes, and we instructed her friend to assist with dressing changes as well. The patient's pain was controlled. By hospital day 3, Ms. ___ was tolerating a regular diet, voiding spontaneously, ambulating independently, and her pain was minimal. She was then discharged home in stable condition, to continue her Bactrim outpatient, BID dressing changes at home, as well as a follow-up with Dr. ___ next week on ___.
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10652543-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> prednisone <ATTENDING> ___ <CHIEF COMPLAINT> elevated BP, swelling <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 26w2d presents with worsening extremity edema. She reports intermittent headaches over the last few days, but none currently. Denies visual changes, ctx, VB, LOF. +FM. Upon review of record she had elevated BP at 10 wks of 144/70. Also has other document elevated BPs in OMR, prior to pregnancy. Urine dips previously neg for protein, in the office <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ - Labs ___ - Screening declined, survey only - FFS normal - GLT neg - Issues *) smoker *) Obesity: BMI 51 OBHx: - G1: current GynHx: - Denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - Hypothyroidism - Anxiety - Obesity: BMI 51 PSH: LSC CCY <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> (on admission) VS in the ED- T-98.0 HR-104 BP-160/106 RR-20 O2-98% VS in triage- BPs 130-150s/80s Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender, obese Ext: no calf tenderness, DTRs 2+ b/l Toco flat FHT 150/moderate varability/-accels/-decels, AGA (on day of discharge) afebrile, VSS. BPs 130s-140s/70s-80s Gen: NAD Pulm: normal work of breathing Abd: gravid, soft, nontender Ext: bilateral 2+ edema, symmetric. unchanged from prior. <PERTINENT RESULTS> ___ 03: 50PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-1 ___ 03: 50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 09: 45PM CREAT-0.4 ___ 09: 45PM ALT(SGPT)-22 LD(LDH)-158 ___ 09: 45PM URIC ACID-4.7 ___ 08: 07PM URINE pH-7 Hours-24 Volume-4400 Creat-33 TotProt-6 Prot/Cr-0.2 ___ 08: 07PM URINE 24Creat-1452 24Prot-264 TAUS: EFW 1025g (58th %ile); BPP ___. Breech presentation. <MEDICATIONS ON ADMISSION> 1. BusPIRone 7.5mg po TID 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Liothyronine Sodium 10 mcg PO TID 4. Loratadine 10 mg PO DAILY 5. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. BusPIRone 15 mg PO BID RX *buspirone 15 mg 1 tablet(s) by mouth twice daily Disp #*28 Tablet Refills: *0 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Liothyronine Sodium 10 mcg PO TID 4. Loratadine 10 mg PO DAILY 5. Lorazepam 0.5 mg PO HS: PRN anxiety RX *lorazepam 0.5 mg 1 tablet by mouth once daily at bedtime Disp #*14 Tablet Refills: *0 6. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the ___ service for blood pressure monitoring and evaluation for pre-eclampsia. Your blood pressure remained within an acceptable range and you were not found to have any signs or symptoms of pre-eclampsia. You were also seen by psychiatry who recommended slight modifications to your anxiety medications. Your doctors feel ___ are safe to go home with outpatient followup. Please follow these instructions: - please keep all outpatient appointments as scheduled - please continue taking all medications as prescribed
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Ms. ___ was admitted to the antepartum service for evaluation for superimposed pre-eclampsia. She has known chronic hypertension and did not meet diagnostic criteria for superimposed pre-eclampsia during her hospitalization. She had an elevated initial urine protein:creatinine ratio but had a normal 24hr urine protein collection and did not require medication to maintain her blood pressures below 160/105. All fetal testing was reassuring. Maternal Fetal Medicine was consulted and did not recommend betamethasone unless she meets criteria for superimposed pre-eclampsia. She had a normal growth ultrasound and MFM recommended q4 week growth scans. She also had anxiety and was seen by psychiatry, who recommended some changes to her home medications. Social work was unable to see her while admitted but she will follow up with social work as an outpatient. On hospital day 3 she was discharged home in good condition with outpatient followup scheduled. She will also see pyschiatry and social work as an outpatient to continue to manage her anxiety.
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10652543-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> high blood pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo G2P0 @ 32+6 presents from office with elevated BP to systolic of 160s and repeat of 176/100. Denies a history of chronic hypertension. Upon chart biopsy, she has a BP of 140/70 on ___ and 144/70 at 10 wga. She had a prior antepartum admission where she did not rule in for PEC after a P: C of 1.2 but a 24-hour urine of 264. ROS: Denies headache, visual changes, RUQ or epigastric pain. Denies fever, chills, other abdominal pain, abdominal trauma, dysuria, vaginal discharge. Denies CTX, vaginal bleeding, DFM, LOF. <PAST MEDICAL HISTORY> PNC: ___ ___ by LMP c/w ___ TM US -Labs: A+/ab-/RI/RPRNR/HBsAg-/HIV-/GBS unk -Glucose screening: normal -Genetics screening: declined -FFS: normal -US ___: EFW 1025g (58%), post placenta, ___ BPP Issues: 1. Anxiety d/o with hospital admission in ___ for panic attacks- s/p buspirone, stable now on zoloft, followed by Dr. ___ (psychiatrist) 2. Hypothyroid- on levothyroxine 3. Obesity/cHTN- BMI 52, followed with normal growth US PObHx: SAB x1 PGynHx: denies abnl pap or STI PMHx: hypothyroid, cHTN, anxiety, obesity PSHx: cholecystectomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> on admission VS 150-162/80-104 HR 82-103 General: NAD Cardiac: RRR Pulm: CTAB Abdomen: soft, obese, NT, gravid Pelvic: deferred Ext: NT, no erythema, 1+ ___ edema b/l NST: 130, mod var, +accels, no decels TOCO: flat BPP: VTX, ___, AFI: 12.4 <PERTINENT RESULTS> ___ 05: 42PM BLOOD WBC-11.1* RBC-4.06* Hgb-12.2 Hct-36.6 MCV-90 MCH-30.0 MCHC-33.2 RDW-14.6 Plt ___ ___ 05: 42PM BLOOD Creat-0.6 ___ 05: 42PM BLOOD ALT-20 ___ 05: 42PM BLOOD UricAcd-5.5 ___ 05: 42PM URINE Color-Straw Appear-Clear Sp ___ ___ 05: 42PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 05: 42PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 ___ 08: 00PM URINE pH-6 Hours-24 Volume-2910 Creat-60 TotProt-9 Prot/Cr-0.2 ___ 05: 42PM URINE Hours-RANDOM Creat-27 TotProt-28 Prot/Cr-1.0* ___ 08: 00PM URINE 24Creat-1746 24Prot-262 ___ 8: 08 pm ANORECTAL/VAGINAL CULTURE Site: CERVIX Source: Cervical. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP. Please contact the Microbiology Laboratory (___) immediately if sensitivity testing to clindamycin is required on this patient's isolate. <MEDICATIONS ON ADMISSION> Zoloft 25 mcg daily, Ativan 0.5mg qHS prn insomnia/anxiety, levothyroxine 75 mcg daily, liothyronine 10 mcg TID, PNV <DISCHARGE MEDICATIONS> 1. Labetalol 400 mg PO TID RX *labetalol 200 mg 2 tablet(s) by mouth every eight (8) hours Disp #*84 Tablet Refills: *1 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Prenatal Vitamins 1 TAB PO DAILY 4. Sertraline 25 mg PO HS 5. Liothyronine Sodium 10 mcg PO TID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital with elevated blood pressures. Your urine collection indicated that you do not have preeclampsia. It is now safe for you to be discharged home. You were started on Labetalol for blood pressure control for chronic hypertension. Please take your medication as prescribed and monitor your blood pressures at home. Please call Dr. ___ ___ for the following: blood pressure greater than 160/105, less than 120/80. Heart rate less than 60.
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Ms. ___ is a ___ yo G2P0 at 32w6d with chronic HTN admitted for evaluation of possible superimposed pre-eclampsia. Upon presentation in OB Triage, patient was initially given 200mg labetalol PO for severe range pressures without improvement. She was given an additional one time dose of 400mg labetalol with good response and no further severe range BPs. She was continued on labetalol 400mg TID with close BP monitoring on the antepartum service. She remained asymptomatic and had normal HELLP labs except for a P:C of 1.0. A 24 hour urine protein was collected that was normal at 262mg. Her fetal monitoring was reassuring with BPP ___, AFI 9.8. She was seen by ___ with normal growth scan 7505g 72% and recommendation for follow-up growth scan in 3 weeks. She was betamethasone complete ___. She was also seen by social work and NICU during her hospital stay. Her blood pressures was controlled in the non-severe range and she remained asymptomatic without evidence of pre-eclampsia features. She was discharged home in stable condition on hospital day 5 with precautions and follow-up instructions given.
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10652831-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> RLQ pain, nausea, vomitting <MAJOR SURGICAL OR INVASIVE PROCEDURE> laproscopic right ovarian cystectomy <HISTORY OF PRESENT ILLNESS> ___ G0 with known right ovarian cyst presenting to the ED with ___ hours of acute onset right lower quadrant pain. Patient reports that she was diagnosed with an ovarian cyst 6 months ago at ___. She is unsure how big the cyst was then. She was discharged home without intervention. She had no pain since then until earlier tonight when she developed acute onset right lower quadrant pain that she describes as constant and makes her crawl into fetal position. This pain was associated with nausea and several episodes of emesis. Only probing by providers has made the pain worse. She has received 10mg IV morphine in OR with some relief in pain, although it is still there. No unusual vaginal discharge/dysuria/fever/chills/recent sick contacts/dizziness. <PAST MEDICAL HISTORY> GYN hx: LMP ___. Has not ever seen a Gynecologist. No hx of STI or abnormal Pap. Sexually active with one male partner. Uses the ___. Hx of ovarian cyst as described above. OB Hx: GO PMH: denies PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On day of admission <PHYSICAL EXAM> Gen: NAD, uncomfortable only with abdominal exam Abd: soft, ND, diffuse TTP in lower abdomen, no rebound, +voluntary guarding. Spec: scant menstrual blood in vaginal vault. No vaginal discharge. Cervix appears normal. BME: Small nontender uterus. +right adnexal fullness that is tender. No CMT. Left adnexa wnl. On day of discharge: <PERTINENT RESULTS> ___ 11: 00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11: 00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG ___ 11: 00AM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 ___ 11: 00AM URINE MUCOUS-RARE ___ 06: 10AM WBC-14.3* RBC-4.25 HGB-11.6* HCT-36.0 MCV-85 MCH-27.3 MCHC-32.2 RDW-14.5 ___ 06: 10AM NEUTS-75.2* ___ MONOS-5.1 EOS-1.4 BASOS-0.2 ___ 06: 10AM PLT COUNT-300 ___ 10: 20PM GLUCOSE-98 UREA N-10 CREAT-0.9 SODIUM-140 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18 ___ 10: 20PM estGFR-Using this ___ 10: 20PM URINE HOURS-RANDOM ___ 10: 20PM URINE HOURS-RANDOM ___ 10: 20PM URINE UCG-NEGATIVE ___ 10: 20PM URINE GR HOLD-HOLD ___ 10: 20PM WBC-11.9* RBC-5.02 HGB-13.3 HCT-42.7 MCV-85 MCH-26.5* MCHC-31.1 RDW-14.3 ___ 10: 20PM NEUTS-75.2* ___ MONOS-3.6 EOS-2.2 BASOS-0.5 ___ 10: 20PM PLT COUNT-363 ___ 10: 20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10: 20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 10: 20PM URINE RBC->182* WBC-3 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 10: 20PM URINE MUCOUS-RARE <MEDICATIONS ON ADMISSION> ___ <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4-6 HOURS Do not drive. Do not exceed 4000mg tylenol (acetominophen) in 24 hours. Take w/food. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN pain. Take with food. Do not take more than prescribed. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *2 3. 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 #*50 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> R ovarian cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * 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. ___ is an ___ yo G0 admitted with R lower quadrant pain, nuasea and vomitting with acute onset in the setting of a 7.3cm ovarian cyst, negative urine pregnancy test, LMP of 2 days ago, mild leukocytosis. After being admitted for observation overnight her pain did not improve and the decision was made to proceed to the operating room for diagnostic laparoscopy to r/o ovarian torsion and for ovarian cystectomy. On HD#1 she underwent an uncomplicated R ovarian cystectomy. Of note, her ovary was not torsed when visualized intraoperatively. Please see operative report for further details. She then was easily transitioned to po pain medication, voided, ambulated and was felt to be safe for discharge with outpatient follow-up.
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10653674-DS-15
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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> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G2P2 who presented to triage on postpartum day 8 after vaginal delivery on ___ after PPROM at 34 weeks EGA. Her prenatal coruse was complicated by elevated BPs 110-140/70-92. She had PEC labs on admission to L&D which were WNL. Her blood pressures were 140s/90s, she therefore did not receive a pre-eclampsia diagnosis or magnesium in labor or postpartum. . Her postpartum course was uncomplicated and she was discharged to home in good condition. She was seen at an OSH on ___ for RLQ pain which has since resolved, however, her BP was noted to be 180/90 and she was referrred to gyn triage. On presentation, she had elevated BPs to 180s/100s, which improved with nifedipine and she discharged home on nifedipine CR 30 daily. . She returned to ___ triage ___ for a BP check and was 150s-160s/80s. At that time, her labs were concerning for hemoconcentration vs dehydration and she was discharged home on nifedipine CR 30 BID and a 24h urine collection. She returned on ___ for BP check, having completed 12h of urine collection (2350 ___ - 1130 ___. She denied HA/visual changes/RUQ or epigastric pain. Leg swelling diminishing. No SOB/CP/palps. No other complaints. Lochia minimal. <PAST MEDICAL HISTORY> OB Hx: G1 SVD @41wga -> PP depression G2 SVD @34wga after PPROM, with GDMA2 (IVF pregnancy) . GYN Hx: s/p cervical cone bx x2, denies fibroids, +infertility . PMH: denies . PSH: cervical cone x2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> T 98.2 HR 109 -> 90 RR 20 BP 149/97 137/91 135/82 140/90 151/94 147/88 144/89 Physical exam: A&O, NARD RRR CTAB abd soft ND +BS FFBU, no TTP ext WWP, trace tibial edema, no calf pain <PERTINENT RESULTS> ___ 07: 25PM BLOOD WBC-6.9 RBC-4.62 Hgb-12.9 Hct-40.8 MCV-88 MCH-28.0 MCHC-31.7 RDW-14.1 Plt ___ ___ 12: 27PM BLOOD WBC-6.1 RBC-4.92 Hgb-13.5 Hct-43.3 MCV-88 MCH-27.6 MCHC-31.3 RDW-13.8 Plt ___ ___ 05: 42AM BLOOD WBC-5.8 RBC-5.24 Hgb-14.5 Hct-45.5 MCV-87 MCH-27.6 MCHC-31.8 RDW-14.1 Plt ___ ___ 06: 02AM BLOOD WBC-5.9 RBC-4.78 Hgb-13.1 Hct-41.4 MCV-87 MCH-27.4 MCHC-31.6 RDW-13.6 Plt ___ ___ 12: 27PM BLOOD ___ PTT-23.6 ___ ___ 07: 25PM BLOOD Creat-0.8 ___ 12: 27PM BLOOD UreaN-15 Creat-0.8 ___ 05: 42AM BLOOD Creat-0.7 ___ 06: 02AM BLOOD Creat-0.7 ___ 07: 25PM BLOOD ALT-86* AST-35 ___ 12: 27PM BLOOD ALT-70* AST-26 ___ 05: 42AM BLOOD ALT-58* ___ 06: 02AM BLOOD ALT-39 ___ 07: 25PM BLOOD UricAcd-3.9 ___ 05: 42AM BLOOD UricAcd-4.7 ___ 06: 02AM BLOOD UricAcd-4.6 ___ 12: 29PM URINE 24Creat-872 24Prot-187 ___ 07: 25PM URINE Hours-RANDOM Creat-40 TotProt-14 Prot/Cr-0.4* ___ 12: 29PM URINE pH-7 Hours-24 Volume-___ Creat-42 TotProt-9 Prot/Cr-0.2 ___ 08: 37PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG <MEDICATIONS ON ADMISSION> ibuprofen, Tylenol, nifedipine 30CR BID <DISCHARGE MEDICATIONS> 1. nifedipine 30 mg Tablet Extended Release Sig: One tablet QAM, two tablets QHS Tablet Extended Release PO One tablet QAM, two tablets QHS. Disp: *90 Tablet Extended Release(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> -Postpartum preeclampsia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> -Call with headache, visual changes, abdominal pain. -See discharge instructions
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Ms. ___ was admitted for treatment of likely postpartum preeclampsia given hypertension, proteinuria, and newly elevated LFTs. She completed a 24 hour course of magnesium therapy for seizure prophylaxis. Her blood pressure was controlled with nifdeipine CR 30 qAM and 60qPM, which she tolerated well. Her blood pressure remained under good control and her ALT and CR trended down durng the course of her admission. Please see laboratory results section for more details. She was discharged to home on ___ in good condition with appropriate follow-up.
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10653822-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic assisted vaginal hysterectomy, right oophorectomy, and cystoscopy <HISTORY OF PRESENT ILLNESS> ___ YO G4P2 who presented with irregular and heavy bleeding. She has decided after several months that she would like to go ahead with definitive treatment and have a hysterectomy. Pt has had endometrial biospy which was benign, and declines hormonal or conservative treatment at this time. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Fibroids. 2. Glaucoma. 3. Obesity. PAST SURGICAL HISTORY 1. D&C. 2. LEEP: About ___ years ago. 3. SVD. 4. laparoscopic salpingectomy for ectopic <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: Pulmonary embolism after fall, early menopause. Deceased. Father: colon cancer, DM. Living. Sis: Living. ___: Living. Children: A&W. <PHYSICAL EXAM> BP: 118/80. Weight: 228.6. BMI: 41.5. LMP: ___. Pleasant female, NAD Head and Neck: mucosa moist, oropharynx clear, normal dentition No thyromegaly, normal neck Chest: CTA, no wheezes, rales, or rhonchi Heart: RRR, no murmurs noted Abdomen: soft, obese, NT, no CVAT or masses, no inguinal lymphadenopathy Ext Gen: normal female, no lesions discharge or blood Cx: parous, no CMT, no lesion or blood Ut: 9 cm, ant, NT, mobile Adn: NE, NT Rectal: normal tone, no masses Extr: no edema, calf tenderness. <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> Colace Fe <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID patient may refuse RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Tablet Refills: *2 2. Ibuprofen 600 mg PO Q6H: PRN Pain when taking po RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain hold for sedation. when taking po. do not administer more than 4000mg acetaminiphenin 24 hrs RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Please continue to take an iron supplement twice a day until your follow-up visit with Dr. ___ * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 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. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ underwent an uncomplicated laparoscopic-assisted vaginal hysterectomy, right oophorectomy, and cystoscopy; see operative report for details. She had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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10655635-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, right salpingo-oopherectomy and cystoscopy <HISTORY OF PRESENT ILLNESS> Pt. has h/o fibroids & ___. Fibroids have become progressively more symptomatic, with heavy bleeding and bloating type pain and pressure, to the point of needing ED care last month, at which time she was diagnosed with a UTI also. Her last period ___ was better, but pt is unable to work usually during her period and would like definitive treatment. Pt. also reports fibroid symptoms have worsened. Belly stays distended and hard beginning on the ___ day of last period. For the past 3mo, pain has increased to entire abdomen. Also, darker blood during periods for past 6mo. Pt. reports headaches and dizziness before periods. Denies urinary/GI symptoms. <PAST MEDICAL HISTORY> PMH: none PSH: Tubal ligation (___), C-Section (___) PGynHx: h/o pap with ___ and ___, fibroids as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> Hypertension <PHYSICAL EXAM> On admission: Pleasant female, NAD Head and Neck: mucosa moist, oropharynx clear, normal dentition. No thyromegaly, normal neck Chest: CTA, no wheezes, rales, or rhonchi Heart: RRR, no murmurs noted Extr: no edema, calf tenderness. 1+ DTR ___: No hepatosplenomegally,no rebound or guarding, no CVAT *Abnormal: Tender, midline mobile masse palpable to 3 cm below umbilicus, corresponds with pt's description of where her abdomen is enlarged Vulva: Nl hair pattern, no lesions. Vagina: No lesions, well supported, Cystocele absent, Rectocele absent. Cervix: deviated anteriorly, No CMT, no lesions, no discharge, Pap done. Uterus: approx 16 weeks size, slightly tender, consistent with mass felt abdominally Adn: not palpable due to large uterus <PERTINENT RESULTS> ___ 08: 36AM BLOOD WBC-7.1 RBC-3.85* Hgb-11.2* Hct-32.9* MCV-86 MCH-29.0 MCHC-33.9 RDW-13.6 Plt ___ <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine fibroids and right adnexal lesion s/p total abdominal hysterectomy, right salpingo-oopherectomy and cystoscopy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after undergoing a total abdominal hysterectomy and removal of right ovary for uterine fibroids and a right ovarian lesion. You have done well post-operatively and are ready to be discharged home. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a total abdominal hysterectomy, right salpingo-oopherectomy and cystoscopy for a symptomatic fibroid uterus with a right adnexal lesion. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oral percocet and motrin for pain control. Her hematocrit decreased appropriately from 37.5 preoperatively to 32.9 on post-op day #1. 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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10664937-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Cefaclor <ATTENDING> ___. <CHIEF COMPLAINT> Fibroid uterus, menorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy and cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G0010 with fibroid uterus and long standing menorrhagia who desires definitive management with hysterectomy. She has tried Mirena IUD twice, had D&C/hysteroscopy for planned myomectomy but was unable to resect fibroid due to location. Her second mirena IUD expelled at the beginning of ___ during her period, which was very heavy. She has a history of blood transfusion for blood loss anemia related to her periods for a HCT of 19.6 in ___. All consents were obtained prior to surgery. <PAST MEDICAL HISTORY> Gyn Hx: regular menstruation monthly; hx of abnl pap, s/p LEEP ___ last pap ___ normal; s/p tubal ligation PMH: anemia d/t heavy vaginal bleeding PSH: tubal ligation, Hysteroscopy, Appendectomy, LEEP <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father-abused ___ Sister - s/p hysterectomy for fibroids; MGM - breast CA at age ___. <PHYSICAL EXAM> physical exam on discharge: VS: T 97.6 BP 98/50 HR 68 RR 18, O2 sat 98%RA Gen: NAD, comfortable Card: RRR, no murmus Lungs: CTAB Abd: soft, ND, NT, no rebound, no guarding; laparoscopic incision C/D/I Ext: C/C/E, NT <PERTINENT RESULTS> Pathology: uterus and cervix pathology report pending at time of discharge. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain: do not take more than 3 pills in 24 hrs. Disp: *40 Tablet(s)* Refills: *0* 2. famotidine Oral 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 4. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Narcotic medications can cause constipation. Please take a stool softener, such a colace, stay hydrated, and consume fiber. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 3 months * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * 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 after undergoing total laparoscopic hysterectomy and cystoscopy for symptomatic fibroid uterus. The surgery was uncomplicated. Intraoperative finding included 10 wk size uterus with exophytic fibroid. Please see operative note by ___ complete details. She received routine post-operative care. Ms. ___ was discharged on post-operative day #1 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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10665682-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> uterovaginal prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Vaginal Hysterectomy, sacrospinous ligament fixation, anterior repair, posterior repair, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ G4P2 who presents for a presoperative visit due to uterovaginal prolapse. Patient with stage 4 uterovaginal prolpase, previously managed with a pessary. In ___ she presented with obstructive ___ secondary to stage 4 prolapse. She was admitted, pessary was placed and her creatinine improved. She was counseled regarding options for management with a plan for surgery. However, per the notes in the chart, the pt was apprehensive about surgery and desired to proceed with pessary. She was followed in our clinic for pessary changes intermittently until ___. She was then lost to follow up until ___ at which time she was unsure if her pessary was still retained. On examination the pessary was found to be retained and removed. The vagina was copiously irrigated. There were mild erosions noted. The pessary was left out due to erosions. An endometrial biopsy was performed at that time which revealed benign strips of inactive endometrium. . Patient represented for evaluation on ___ and had complete uterovaginal prolapse with erosions. At that time a ring with support was placed and patient was started on vaginal estrogen. At that time she was also found to have ___ likely secondary to obstruction from prolapse, which has since resolved. Patient presents today with sister, ___, who is her health care proxy. Reports has been doing well with pessary and vaginal estrogen since last visit. Reports voiding without difficulty. Denies any further vaginal bleeding. ROS: otherwise neg. <PAST MEDICAL HISTORY> PObHx: G4P2 - SVD x 2 (___), uncomplicated - TAB x 2 PGynHx: Menopausal around age ___, no bleeding until 8.5 months ago Last Pap documented in ___, neg Pap, no HR HPV done Unsure if she has had a Pap since that time Denies Hx abnormal Paps Denies history of STIs, gynecological diagnoses such a fibroids, endometriosis Not currently sexually active Pelvic organ prolapse as above, unsure if pessary still in place Per record, in ___ h/o stage 4 prolapse and ureteral kinking causing ___ -> Cr improved with pessary Problems (Last Verified ___ by ___, MD): SCHIZOPHRENIA HYPOTHYROIDISM H/O ANEMIA Surgical History (Last Verified ___ by ___, MD): Surgical History updated, no known surgical history. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 05: 06PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05: 06PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ 05: 06PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 05: 06PM URINE Mucous-RARE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. PATHOLOGIC DIAGNOSIS: 1. Uterus and cervix (156g): Leiomyoma (2.2 cm). Atrophic endometrium. Unremarkable cervix and serosa. 2. Vaginal mucosa, excision: Unremarkable squamous mucosa. <MEDICATIONS ON ADMISSION> levoxyl 50 mcg daily, olanzapine 20 mg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4000mg acetaminophen per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID take with oxycodone to prevent constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*50 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain take with food to prevent stomach upset RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 4. Levothyroxine Sodium 50 mcg PO DAILY 5. OLANZapine 20 mg PO DAILY <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> pelvic organ prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. The team feels as though you have recovered well and are ready to be discharged. You are going to be transferred to a short term rehabilitation center until a living situation is set up for you long term. . Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. . General instructions: * Take your medications as prescribed. * Take a stool softener such as colace to prevent constipation. * 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. 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, sacrospinous ligament fixation, anterior repair, posterior repair, cystoscopy. Please see the operative report for full details. Immediately post-op, her pain was controlled with IV Dilaudid/Toradol, which was then transitioned successfully to PO oxycodone, ibuprofen, acetaminophen, and flexeril on post-operative day 1. Her diet was also advanced without difficulty and she did not experience nausea or vomiting. . On post-operative day 1, she was tolerating a regular diet without nausea or vomiting. Her foley was removed, but she failed 2 voiding trials. She was meeting all other milestones by postoperative day 2. On postoperative day 2, it was noted that she had difficulty with ambulation. Physical therapy was consulted who recommended inpatient physical therapy. There was a significant confrontation with the patient's sister, who desired her to be discharged home against medical advice. However, the patient desired ___ rehab as advised by physical therapy. Ultimately the patient was kept in the hospital due to placement issues. She was followed by social work, elder services as well as the complex case manager for assistance with disposition. Psychiatry was also consulted given her history of schizophrenia and complex psychosocial issues. . Her foley was again removed on postoperative day 2 and she voided until postoperative day #4 where it was found that she again was retaining. Her foley was reinserted and she was started on macrobid prophylaxis. Her foley remained in place until POD#10 when she successfully passed her voiding trial. . On hospital day #15, after a multidisciplinary meeting, placement was found for the patient at a short term rehab facility with a plan for assistance from social work and elder services with long term placement.
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10666130-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Procidentia <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ colpocleisis <HISTORY OF PRESENT ILLNESS> ___ is a ___ woman who comes to the office accompanied by her daughter who served as a ___. She has longstanding pelvic organ prolapse that has been using a pessary for some years now. She, however, developed postmenopausal bleeding. An endometrial biopsy, which was done recently, was negative. The pessary was taken out in ___ because of the bleeding and has been out since then. The patient reports that it is quite uncomfortable for her. She has difficulty with defecation and urination. She has to strain to get the urine out. She does have urinary incontinence consistent with stress incontinence. She also has urinary frequency, voiding every hour and she gets up at night. She urinates several times. She also describes urge incontinence. She wears ___ pad, which she changes more than five times a day. She denies recurrent bladder infections, kidney stones or hematuria. She has occasional constipation. No fecal incontinence. She is not sexually active. <PAST MEDICAL HISTORY> Hypertension Pulmonary Fibrosis Glaucoma <SOCIAL HISTORY> ___ <FAMILY HISTORY> Hypertension <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: 20AM ___ PTT-33.8 ___ ___ 11: 12AM WBC-11.2*# RBC-4.05 HGB-12.2 HCT-37.8 MCV-93 MCH-30.1 MCHC-32.3 RDW-13.8 RDWSD-46.8* ___ 11: 12AM PLT COUNT-282 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 2. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY 3. Diltiazem Extended-Release 300 mg PO DAILY 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Citalopram 10 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Celecoxib 100 mg oral BID <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID Do not take more than 4000mg acetaminophen in 24 hours RX *acetaminophen 325 mg 2 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills: *2 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*40 Capsule Refills: *2 3. Ibuprofen 400 mg PO Q8H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills: *2 4. Diltiazem Extended-Release 300 mg PO DAILY 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 6. Celecoxib 100 mg oral BID 7. Citalopram 10 mg PO DAILY 8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY 11. Vitamin D 1000 UNIT PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> procidentia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ , You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. 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 LeFort colpocleisis and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV pain medications. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 200 mL with 43 mL residual. Her Foley catheter was removed. Her diet was advanced without difficulty and she was transitioned to oral pain meds. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10667153-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> bleeding abruption vs PTL <MAJOR SURGICAL OR INVASIVE PROCEDURE> monitoring <HISTORY OF PRESENT ILLNESS> CC: PTC/VB HPI: ___ G3P0020 at 34+6, developed abd cramping last night, today around noon noted dark red spotting on underwear. Went to see OB at ___, was found to be 2cm dilated and having some CTX on Toco. Sent to L&D for further evaluation. Since then she has noted some additional dark brown spotting and continues to have constant cramping. This is the first episode of bleeding during pregnancy. Pt denies recent intercourse or abdominal trauma. Denies LOF. +AFM. Pt feels she may be a little dehydrated, hasn't had much fluids today and urine is yellow. Denies fever, N/V/D, dysuria. <PAST MEDICAL HISTORY> PNC: -___: ___ -Labs: A+/Ab-/HBsAg-/RPRNR/RI/HIV-/GBS pend (sent today from Triage) -Screening: Abnormal ERA elevated risk T21 1: 260, NIPT no results due to low fetal fraction -FFS: WNL, low lying placenta, resolved 22 weeks -Glucola: passed -Issues: hx of ___ trimester loss (incompetent Cx, current pregnancy followed with cervical lengths q2weeks until 28weeks, last measurement ___, HSV outbreak 33 weeks (none currently, plan to start Acyclovir at 36 weeks), breech presentation confirmed ___ with bedside U/S, obesity (BMI at initial OB = 36) OBHx: -___ SAB, 20 weeks, incompetent Cx, ?requiring blood transfusion in ___ -___ TAB 5 weeks -current GynHx: abnormal pap ___, colposcopy neg, hx Chlamydia, hx bilateral ovarian cysts, hx of HSV (no outbreak in ___ year, new outbreak 33 weeks, now resolved) PMH: denies PSH: denies Meds: PNV KNDA SHx: ___ <FAMILY HISTORY> see above <PHYSICAL EXAM> <PHYSICAL EXAM> -VS: T 98.8, HR 103, RR 18, BP 124/80 -Gen: NAD -Abd: obese, gravid, soft, NT -SSE: scant, mucousy brown blood in vault, no active bleeding -SVE: ___ exam performed at 16: 00 (unchanged from exam in office at 12: 00) -NST: baseline 140, mod var, +accels, no decels, reactive -Toco: ctx q2-4min, pt comfortable, unaware <PERTINENT RESULTS> ___ 04: 00PM WBC-11.7* RBC-4.07 HGB-11.9 HCT-35.5 MCV-87 MCH-29.2 MCHC-33.5 RDW-13.2 RDWSD-41.7 ___ 04: 00PM PLT COUNT-182 ___ 04: 00PM FIBRINOGE-UNABLE TO ___ 03: 30PM URINE HOURS-RANDOM ___ 03: 30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 03: 30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03: 30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM ___ 03: 30PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE EPI-2 ___ 03: 30PM URINE MUCOUS-RARE <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> PNV <DISCHARGE DISPOSITION> Home Facility: ___ <DISCHARGE DIAGNOSIS> Preterm labor <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call if leaking, bleeding, baby not moving, contractions and abdominal. Call if leaking, bleeding, baby not moving, contractions and abdominal.
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Pt admitted. No cervical change. No contractions on NST. Does not sound like prior delivery was secondary to abruption. CBC, ___, PTT stable from admission. She did have an US on the day of discharge to look for hematoma.
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10668956-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine / IV Dye, Iodine Containing Contrast Media / Augmentin / morphine <ATTENDING> ___. <CHIEF COMPLAINT> "Abdominal Pain" <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparascopic Right Cystectomy <HISTORY OF PRESENT ILLNESS> ___ yo G___ who presented to ___ ED with abdominal pain. Her pain started 5 days ago. It was intially gradual and dull but since night before presentation at 11pm it had been sharp and intermittent in the right lower quadrant with associated nausea and vomiting (2 episodes since midnight). She endorses anorexia, last ate ___ crackers at 4pm yesterday. Unclear why she didn't eat dinner night before presentation. She has a history of ovarian torsion in the past and believes this feels similar. In ED, unable to obtain IV access. Given subq dilaudid for pain control. <PAST MEDICAL HISTORY> T2 Diabetes Mellitus Asthma HTN Migraines Obesity Past Surgical History: Laparascopic appendectomy (done for endometriosis) Laparascopic cholecystectomy (done for endometriosis) Laparascopic fulgaration of endometriosis x2 Laparascopic left ovarian de-torsion/cystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> None on file <PHYSICAL EXAM> Physical Examination was performed by Dr. ___ VS: 99.1 112 129/84 16 97% Gen: No acute distress Card: Regular rate and rhythm -> not tachycardiac on exam Resp: Clear to auscultation bilaterally Abd: Soft, obese, diffusely tender, maximally in supra-pubic and right lower quadrant. No rebound or guarding. Active bowel sounds. Speculum: Parous os without exudate. Gonorrhea/Chalmydia collected. Bimanual: Cervical motion tenderness present, right adnexal tenderness. Remainder of exam limited by body habitus. Extremities: Non-tender, 1+ edema bilaterally <PERTINENT RESULTS> Pelvic Ultrasound: Transabdominal and transvaginal examinations were performed, the latter for better evaluation of the endometrium and adnexa. The uterus measures 9.2 x 3.3 x 6.5 cm. There is a 1 cm posterior fibroid. The endometrium is normal in echotexture measuring 12 mm. Arising off the right ovary is 5.9 cm cyst which is anechoic with good through transmission and no solid echogenic components. The right ovary in total measures 5.9 x 5.8 x 4.9 cm. Venous and arterial waveforms could be identified within the right ovary. The left ovary, which by report has previously undergone torsion, measures 3.8 x 2.7 x 3 cm. Follicles are present within the left ovary. However, neither venous, nor arterial waveforms could be identified within the left ovary. This may be technical as the left ovary was positioned deep in the pelvis posterior to the uterus. Trace fluid is present in the pelvis. The patient was tender in both the right and left adnexa, but was more tender in the right adnexa. IMPRESSION: 1. Enlarged right adnexal cyst measuring 5.9 cm. Although flow was present in the right ovary, torsion is not excluded as this correlated to the site of patient's pain. 2. Normal-sized left ovary, however, neither venous nor arterial waveforms could be identified. This lack of flow may be positional, but given the history of previous torsion in this ovary torsion is not entirely excluded. 3. Fibroid uterus. Normal endometrium. Cultures negative for Gonorrhea and Chlamydia <MEDICATIONS ON ADMISSION> - Metoprolol - Metformin - Advair - Albuterol - Tompamax - Singulair 20 - Imitrex - Toradol - Phenergan - Percocet ___ q4prn <DISCHARGE MEDICATIONS> 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 2. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation DAILY (Daily). 4. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp: *30 Tablet(s)* Refills: *0* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *30 Capsule(s)* Refills: *0* 7. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *40 Tablet(s)* Refills: *1* 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp: *30 Tablet, Delayed Release (E.C.)(s)* Refills: *2* 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrioma Chronic pain <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 - Please keep your follow up appointment with Dr. ___ -- 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. Nothing in your vagina x 2 weeks (no sex, no tampons)
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Ms ___ was admitted into the gynecology service for rule out of ovarian torsion but was found to have a very concerning abdominal examination with significant guarding but no rebound tenderness. The decision was made to proceed with a diagnostic laparascopy, which resulted into a right cystectomy for simple cyst and endometrioma. After surgery, Ms ___ pain was unchanged in terms of quality, location and severity. She was actively requesting all her pain medicines around the clock and would also ask for more pain medicines in between dosages. She was receiving IV dilaudid and toradol. She was also complaining of nausea and reported vomiting. She found it difficult to try to eat anything by mouth for fear of vomiting. For her nausea, she was receiving IV zofran and phenergan. She was also placed on intravenous protonix. Due to her history of chronic pain and recurrent laparascopy procedures, chronic pain was curbsided and they felt that she should follow up with them as an outpatient. On hospital day 3, Ms ___ expressed some frustration about her inadequate pain control and was encouraged to eat so that she could be switched to oral narcotics, which are more slow onset but are longer acting. She then began to eat some bland food like crackers and toasts. Of note, her blood sugars were followed while in hospital and she was placed on an insulin sliding scale while off her metformin. She did okay on oral pain medications and was discharged on hospital day 4 with bearable pain, ambulating and voiding without difficulty. She was also set up with outpatient chronic pain appointment.
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10668956-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine / IV Dye, Iodine Containing Contrast Media / Augmentin / morphine <ATTENDING> ___. <CHIEF COMPLAINT> ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> NONE <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p laparascopic ovarian cystectomy ___ complicated by prolonged post-op course for nausea and ___ control re-presented to ED with nausea and 2 days of ___. Described fever at home but none documented in ED. <PAST MEDICAL HISTORY> T2 Diabetes Mellitus Asthma HTN Migraines Obesity Past Surgical History: Laparascopic appendectomy (done for endometriosis) Laparascopic cholecystectomy (done for endometriosis) Laparascopic fulgaration of endometriosis x2 Laparascopic left ovarian de-torsion/cystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> None on file <PHYSICAL EXAM> O: 99.3 96 127/90 17 100% RA Patient tearful RRR CTAB ABD: soft, tender to deep palpation on right side of umbilicus, no rebound or guarding, incision sites appear c/d/i, non distended EXT: NT <PERTINENT RESULTS> ___ 02: 00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 11: 10PM GLUCOSE-194* UREA N-18 CREAT-0.8 SODIUM-137 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-19* ANION GAP-19 ___ 11: 10PM ALT(SGPT)-32 AST(SGOT)-20 ALK PHOS-72 TOT BILI-0.3 ___ 11: 10PM LIPASE-63* ___ 11: 10PM WBC-9.9 RBC-4.64 HGB-14.7 HCT-39.3 MCV-85 MCH-31.6 MCHC-37.3* RDW-13.3 ___ 11: 10PM NEUTS-60.3 ___ MONOS-5.1 EOS-4.3* BASOS-0.4 ___ 11: 10PM PLT COUNT-310 <MEDICATIONS ON ADMISSION> Metoprolol 100mg bid Metformin 1000 mg bid Advair once daily Albuterol q4hrs prn Tompamax 100 mg daily Singulair 20 mg daily Imitrex 6mg prn HA Toradol 40mg po q8hrs prn Phenergan 25mg q6hrs prn nausea Percocet ___ tabs q4hrs prn ___ <DISCHARGE MEDICATIONS> lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for ___. Disp: *20 Adhesive Patch, Medicated(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Abdominal ___ Nausea Vomiting <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please continue to take your ___ medications and anti-nausea medications until your appointment with the ___ Clinic.
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This ___ yo G5P1 was admitted on ___ for nausea and ___ x2 days on POD ___ s/p ovarian cystectomy. ED workup was negative for identifiable intrabdominal pathology- afebrile, WBC 9.9, CT a/p negative for ileus/SBO/hernia/other source of ___. Patient known to have chronic ___ previously attributed to endometriosis and is scheduled for outpatient follow-up with APS. In ED and on arrival to floor patient refusing to attempt PO ___ medicine or antiemetics and wishes to go home to take PO there. Was given zofran and phenergan, and 1x IV dilaudid and 1x toradol with some improvement. Per patient, nausea follows ___ and the cycle was exacerbated with long wait in ED. Patient discharged to home with previous PO ___ meds and antiemetics, to follow-up with APS this week.
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10669777-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfonamides <ATTENDING> ___. <CHIEF COMPLAINT> syncopal episode, motor vehicle accident <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ brought in by ambulance to the ED after MVA at 0930 on ___. She was a restrained single driver. She last remembers being at a stoplight and then woke up and had crashed into a pole. Estimated to be going 35mph per EMS records. She has some bruising from her seatbelt but does not know if she hit her belly. She denies any vaginal bleeding, CTX, LOF. +AFM. Pt reports a benign pregnancy although she was being followed by Dr. ___ at ___ for fibroids. She was being worked up for palpitations and had just finished using her Holter monitor yesterday. She has a cardiologist at ___ who has been following her for years for her palpitations. She has not been on any medications for years although she has been on meds in the past and had episodes of syncope in her teens. PVCs were noted in her cardiac monitoring in the ED. <PAST MEDICAL HISTORY> PNC: - ___ ___ - Labs: O+/Ab-/others unavailable - spontaneous pregnancy - Abnl First Tri screen ___ DS, ___ tri 13, 18), declined Amnio - nl FFS - followed for fibroids which have been tender whole pregnancy, last measured ___: LUS/cervical fibroid (4.9 x 4.6 x 4.6cm), ant fibroid (4.1 x 3.1 x 3.1 cm), ant near umbilicus (3.8 x 2.4 x 3.6 cm) - ___ CL 5.1 - 5.6 cm - ___ EFW 857g (55%) - Plan for c/s given location of fibroid (may need classical) PGYNhx: - fibroids - ovarian cysts s/p mini-lap and LSC x3 - denies abnl pap, STIs - s/p 4 IVF, h/o of infertility - h/o UTIs PMH: - PVCs has been on atenolol and diltiazem in the past; Dr. ___ at ___ is cardiologist PSH: - T&A age ___ - lithrotripsy (transurethral) - mini-lap for ovarian cystectomy - LSC x4 for ovarian cystecetomies and LOA around L ovary <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> PE: 98.6 78 18 117/66 NAD, bruise L shoulder and across chest where seatbelt was RRR, no murmurs CTAB soft, diffusely tender but most on R side and lower left - seems tender in all areas - usually tender in areas of fibroids at baseline NT, NE FHT: 140, AGA, no decels TOCO: q2min, irritability (pt does not feel) SVE: LCP TAUS: VTX, ant fundal placenta, AFI 12.3, BPP ___ <PERTINENT RESULTS> ___ 02: 56PM BLOOD WBC-14.6* RBC-3.76* Hgb-11.3* Hct-33.2* MCV-88 MCH-30.1 MCHC-34.2 RDW-14.6 Plt ___ ___ 02: 56PM BLOOD ___ PTT-31.1 ___ ___ 02: 56PM BLOOD ___ ___ 02: 56PM BLOOD UreaN-7 Creat-0.5 Na-140 K-3.7 Cl-108 ___ 02: 56PM BLOOD Amylase-72 ___ 02: 56PM BLOOD Calcium-8.1* Phos-3.1 Mg-1.7 ___ 02: 56PM BLOOD TSH-1.9 ___ 02: 56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03: 05PM BLOOD Lactate-1.0 ___ 06: 30AM BLOOD WBC-12.6* RBC-3.54* Hgb-10.7* Hct-31.7* MCV-90 MCH-30.2 MCHC-33.7 RDW-14.1 Plt ___ ___ 06: 30AM BLOOD ___ PTT-31.0 ___ ___ 06: 30AM BLOOD ___ Cardiac Echo ___: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: frequent ventricular premature contractions; preserved ventricular function. <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> syncope pregnancy status post traua/motor vehicle accident arrythmia <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Stay well hydrated throughout the duration of your pregnancy. Call your physician for lightheadedness, dizziness, fainting, chest pain, shortness of breath, palpitations, contractions, vaginal bleeding, leakage of fluid. NO DRIVING.
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The patient was transferred from the ED to L&D on ___ after a cardiac echo had been performed. She was monitored on L&D for ~6 hours without any clinical evidence of abruption; maternal laboratory evaluation was normal, and fetal assessment via U/S and FHT were reassuring. The recommendation for the patient was continuous telemetry due to the concern for cardiogenic syncope and arrhythmia; however, this monitoring was not possible on L&D. The pt was therefore transferred to the antepartum floor for further monitoring. She was kept on telemetry overnight, with runs of PVCs noted every 3 beats. She remained asymptomatic. Repeat abruption labs on HD#2 were normal. Consultation was obtained with the cardiology service, who recommended outpatient follow-up. The patient was discharged home on HD#2.
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10673897-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> vaginal bleeding, dizziness <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G3P3 with known fibroid uterus presents with heavy vaginal bleeding for past two weeks and new weakness for past several days, worsened overnight where feels to weak to walk. Denies any episodes of syncope, chestpain, shortness of breath, fever, chills, dysuria, abdominal pain, constipation, diarrhea. Reports bleeding has slowed over past 24 hours. Reports at it heaviest was soaking many many pads a day. Reports not taking any iron or other medications for anemia/menorrhagia. Previously had IV iron infusions, last ___. Last ultrasound done on ___ when patient presented to ED for increasing pelvic pain which showed a dominant fibroid distorting endometrial cavity, 9.6 x 9.3 x 10.0 cm, mild interval growth from prior ultrasound. Patient has been evaluated and counseled extensively previously regarding fibroids and is scheduled for abdominal myomectomy on ___ with Dr ___. For workup for surgery had negative endometrial biopsy on ___. Patient adamantly refuses blood transfusion at this time. <PAST MEDICAL HISTORY> Obstetric History: G3P3 - G1: c-section - G2: VBAC - G3: VBAC with ?postpartum tubal ligation Gynecologic History: - Previously normal cycles however increasingly heavy, and lasting longer over past several months, LMP 2 weeks prior, unsure exact date. - h/o endometrial polyp - known fibroid uterus with dominant fibroid distorting endometrial cavity 9.6 x 9.3 x 10.0 cm - Denies h/o abnormal Pap test. Last Pap ___ neg - Remote h/o chlamydia which was treated and h/o genital HSV per OMR records. <PAST MEDICAL HISTORY> - asthma (no hospitalizations or intubations) - depression, anxiety, PTSD from h/o abuse - GERD - hemorrhoids Past Surgical History: - laparoscopic appendectomy - c-section - ?postpartum tubal ligation (pt had surgery on her tubes after her last child, although she was not sure if it was done to prevent her from having children or help her to become pregnant) - hysteroscopy, D&C, polypectomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> on day of discharge: afebrile, vital signs wnl Gen: well appearing, NAD CV: RRR Resp: CTAB Abd: soft, nondistended, nontender, uterine fundus palpable at umbilicus Ext: no tenderness or edema <PERTINENT RESULTS> ___ 03: 23AM BLOOD WBC-5.2 RBC-3.04* Hgb-6.3*# Hct-21.8* MCV-72* MCH-20.6* MCHC-28.7* RDW-20.0* Plt ___ ___ 12: 00PM BLOOD WBC-5.9 RBC-3.04* Hgb-6.3* Hct-21.2* MCV-70* MCH-20.7* MCHC-29.7* RDW-20.1* Plt ___ ___ 03: 23AM BLOOD ___ PTT-25.6 ___ ___ 03: 23AM BLOOD Glucose-114* UreaN-13 Creat-0.6 Na-140 K-4.2 Cl-106 HCO3-24 AnGap-14 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Ferrous Sulfate 325 mg PO DAILY 2. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*45 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID Take while on iron RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 4. Seasonique (L norgest&E estradiol-E estrad) 0.15 mg-30 mcg (84)/10 mcg (7) oral daily <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroids, severe anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the hospital for heavy vaginal bleeding and anemia. While hospitalized you received IV iron. Your bleeding slowed down and the team feels it is safe for you to be discharged. Please take all of your medications as prescribed.
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On ___, Ms. ___ was admitted to the gynecology service for blood loss anemia due to uterine fibroids and monitoring of bleeding. Upon arrival, she was no longer actively bleeding. Her Hct remained stable at 21 over 9 hours. After extensive counseling, the patient declined a blood transfusion and instead received a dose of IV iron. She was counseled regarding the need for close outpatient follow-up, continuing to take iron and OCPs to better control her bleeding prior to any surgery. She was discharged the following day in stable conditions with outpatient follow-up.
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10673897-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic fibroid uterus, suicidal ideation <MAJOR SURGICAL OR INVASIVE PROCEDURE> EUA, extensive lysis of adhesions, total abdominal hysterectomy, bilateral salpingectomy and cystoscopy <HISTORY OF PRESENT ILLNESS> ___ gravida 3, para 3 with a known fibroid uterus, who has a history of heavy bleeding and significant anemia in the past, she has had a hematocrit as low as 21%, requiring hospitalization. Since that time, the patient has had improved bleeding while on IM Depo-Provera. She is scheduled for TAH, BS tomorrow. . She presented to the ED overnight with suicidal ideation. She was seen by pyschiatry and ___ was put in place. She has multiple stressors including abnormal uterine bleeding, domestic violence, and possible impending homelessness. . Her bleeding today is minimal. Hematocrit 33.6. Denies symptoms of anemia. <PAST MEDICAL HISTORY> OB-GYN Hx: G3P3. C/S x 1. VBAC x 2. Known fibroid uterus. Most recent PUS on ___ with 14 X 9.6 X 8.7 cm uterus and 10.0cm fibroid distorting endometrium. Admitted to GYN service in ___ with anemia (hct 21), refused blood products. She was admitted again on ___ with anemia and received 3 units PRBCs. Patient scheduled for TAH, BS on ___. Patient has persistent high-risk HPV, although on ___, her Pap was negative for intraepithelial lesion or malignancy. Remote h/o chlamydia which was treated and h/o genital HSV per OMR records. . PMH: - Anemia (Hct ranging from 21.8 to 30.3 over the past 2 months). Patient has received IV iron infusions and transfusions - Asthma - Depression, anxiety, PTSD from h/o abuse - GERD . PSH: - Laparoscopic appendectomy - c-section - postpartum tubal ligation - hysteroscopy, D&C, polypectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of anemia or gynecologic disease. <PHYSICAL EXAM> On day of discharge: Afebrile, VSS NAD, Comfortable Lungs CTAB CV RRR Abdomen soft, NT, ND. Incision c/d/i with steristrips in place. Ext: no erythema or edema <PERTINENT RESULTS> ___ 03: 35PM BLOOD WBC-6.5 RBC-4.40 Hgb-12.4 Hct-35.6* MCV-81* MCH-28.1 MCHC-34.7 RDW-15.3 Plt ___ ___ 10: 30PM BLOOD Neuts-59.7 ___ Monos-4.0 Eos-3.6 Baso-0.3 ___ 10: 30PM BLOOD WBC-6.6 RBC-4.23 Hgb-11.9* Hct-33.6* MCV-79* MCH-28.2 MCHC-35.5* RDW-16.0* Plt ___ ___ 03: 00AM BLOOD WBC-6.6 RBC-3.25* Hgb-8.8*# Hct-26.8* MCV-82 MCH-27.2 MCHC-33.0 RDW-15.5 Plt ___ ___ 09: 00AM BLOOD WBC-7.4 RBC-3.28* Hgb-9.1* Hct-26.5* MCV-81* MCH-27.8 MCHC-34.5 RDW-15.5 Plt ___ ___ 10: 30PM BLOOD Glucose-110* UreaN-16 Creat-0.8 Na-143 K-4.3 Cl-106 HCO3-27 AnGap-14 ___ 10: 30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09: 58PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM ___ 09: 58PM URINE Color-RED Appear-Cloudy Sp ___ ___ 09: 58PM URINE RBC->182* WBC-91* Bacteri-MOD Yeast-NONE Epi-0 . Time Taken Not Noted Log-In Date/Time: ___ 11: 57 pm URINE Site: NOT SPECIFIED 61620G. **FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. <MEDICATIONS ON ADMISSION> ALBUTEROL SULFATE - albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization. 1 treatment inhaled via nebulizaiton every four (4) hours prn ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. ___ puffs inhaled every four hours TERCONAZOLE - terconazole 0.8 % vaginal cream. 1 applicator per vagina before bed FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth once a day NEBULIZER ACCESSORIES [ADULT AEROSOL MASK] - Adult Aerosol Mask. as directed prn Disp #1 adult neb mask with tubing & chamber <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H do not take more than 4000mg acetaminophen in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 2. Multivitamins 1 TAB PO DAILY 3. Simethicone 40-80 mg PO QID: PRN gas pain RX *simethicone 80 mg 1 by mouth four times a day Disp #*50 Tablet Refills: *0 4. HYDROmorphone (Dilaudid) 2 mg PO Q3H: PRN pain do not drink alcohol or drive while taking RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours Disp #*37 Tablet Refills: *0 5. Ibuprofen 600 mg PO Q6H pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 6. Docusate Sodium 100 mg PO BID take this medication when using narcotic pain medications RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service for monitoring of her suicidal ideation in consultation with Psychiatry. Per Psychiatry, she was placed under a ___ but did not require a sitter. She was also followed by Social Work and seen by the community resource specialist given that much of her psychological stress was related to her housing situation. . She underwent her previously scheduled hysterectomy and bilateral salpingectomy on ___. Please see the operative report for full details. . Immediately post-op, her pain was controlled with a dilaudid PCA, toradol, and oral acetaminophen. On post-operative day 2, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oral oxycodone, ibuprofen, and acetaminophen. . By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. On post-operative day 4, she was cleared by Psychiatry. She was discharged home in stable condition on post-oeprative day 5 with outpatient follow-up scheduled in one week.
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10674457-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> positive hCG in setting of Mirena IUD <MAJOR SURGICAL OR INVASIVE PROCEDURE> Methotrexate administration <HISTORY OF PRESENT ILLNESS> ___ G4P2 presents with vaginal bleeding, abdominal pain, and positive pregnancy test. She reports having vaginal bleeding for ~17 days. She has had a Mirena IUD for ___ years. She had positive home pregnancy test in the past few days. She continues to have mild bleeding, approximately 1 full pad/day. She also reports left abdominal intermittent crampy pain, which has now resolved during her ED stay. She has not taken any pain meds. No trauma, no pain with intercourse. No fever/chills, sick contacts, CP, SOB, nausea/emesis, diarrhea/constipation. She went to OSH ED earlier today where labs notable for WBC 7.8, H/H 9.6/___.6, plt 315. HCG 581.7. TVUS there showed no evidence of intra-uterine gestation or extra-uterine gestation. IUD seen in uterus. 5 mm cystic focus in endometrium could either represent early gestational sac or pseudo-gestation sac or focal free fluid. 2.3 cm complex structure in left ovary, ectopic cannot be excluded. Small amount of free pelvic fluid, possibly hemorrhage. <PAST MEDICAL HISTORY> OBHx: -G1 ___ SVD term -G2 SAB -G3 SVD term -G4 current GynHx: LGSIL in ___ colpo normal, biopsies normal Mirena IUD placed in ___ PMH: hypothyroidism during prior pregnancy PSH: breast implants ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On discharge: VSS General: NAD, comfortable CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, mildly tender to palpation in the LLQ without slight rebound but no guarding (unchanged) GU: pad with minimal spotting Extremities: no edema, no TTP <PERTINENT RESULTS> ============ LABS ============ ___ 10: 40PM BLOOD WBC-8.2 RBC-3.54* Hgb-9.6* Hct-29.5* MCV-83 MCH-27.1# MCHC-32.5 RDW-13.4 RDWSD-40.9 Plt ___ ___ 10: 40PM BLOOD Neuts-69.5 ___ Monos-6.2 Eos-0.7* Baso-0.1 Im ___ AbsNeut-5.67 AbsLymp-1.90 AbsMono-0.51 AbsEos-0.06 AbsBaso-0.01 ___ 02: 03AM BLOOD WBC-8.8 RBC-3.59* Hgb-9.6* Hct-29.5* MCV-82 MCH-26.7 MCHC-32.5 RDW-13.4 RDWSD-40.2 Plt ___ ___ 02: 03AM BLOOD Neuts-66.9 ___ Monos-6.3 Eos-0.6* Baso-0.2 Im ___ AbsNeut-5.87 AbsLymp-2.26 AbsMono-0.55 AbsEos-0.05 AbsBaso-0.02 ___ 10: 40PM BLOOD Glucose-83 UreaN-15 Creat-0.7 Na-139 K-4.2 Cl-102 HCO3-21* AnGap-16 ___ 10: 40PM BLOOD ALT-10 AST-12 AlkPhos-52 TotBili-0.4 ___ 10: 40PM BLOOD HCG-628 ============ IMAGING ============ Pelvic ultrasound ___: 1. Findings concerning for left tubal ectopic pregnancy, with small amount of blood in the cul de sac. 2. Blood clot in the endometrial cavity <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> Ferrous sulfate supplements OTC <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> left tubal ectopic pregnancy with Mirena IUD in situ <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 an ectopic pregnancy in your left fallopian tube. You were stable and there was no sign that the tube had ruptured. You were treated with methotrexate, a medication that works by stopping cells from dividing. Please refer to your hand-out for more information on what symptoms you may experience and what activities and medications to avoid during this time. Please present immediately to an Emergency Room if you have any of the following, since they may be signs of rupture: - severe or diffuse abdominal pain that does not respond to medication - heavy vaginal bleeding - lightheadedness or dizziness or fainting You will need to have labs drawn 3 days and 6 days after you receive the methotrexate to follow the pregnancy hormone level. Please call the clinic phone number with any questions.
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Ms. ___ is a ___ year old G4P2 with a history of anemia and Mirena IUD in place since ___ who was diagnosed with a left tubal ectopic pregnancy and admitted to the Gynecology service for observation and treatment. On presention, she was hemodynamically stable. Her exam was notable for moder tenderness in the left greater than right lower quadrants with minimal rebound but no guarding. She had a small amount of blood on pelvic exam. HCG was 628. Her hematocrit was 29.5 and stable on re-check. The etiology of anemia is thought to be secondary to iron deficiency anemia and subacute blood loss. Pelvic ultrasound showed finding concerning for a left tubal ectopic pregnancy and a small amount of free fluid. There was low concern for ruptured ectopic pregnancy and she remained stable with no to minimal abdominal tenderness on exam. The decision was made to proceed with methotrexate. She received 85 mg of methotrexate (50 mg/m2) on ___ after being consented and receiving the appropriate counseling. For her anemia, she was recommended to continue iron supplements. She was discharged on hospital day 1 in stable condition and with follow-up scheduled.
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10674457-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> worsening LLQ in setting of ectopic pregnancy s/p methotrexate on ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G4P2 with a suspected left ectopic pregnancy in setting of a Mirena IUD s/p methotrexate on ___ who presents with worsening LLQ pain. She presented to ___ for evaluation and was transferred to ___ for further evaluation. Patient reports the pain is similar to pain when she initially presented. Describes the pain as worse than menstrual cramps. Only takes ___ Tylenol for pain management at home. Reports only using a pad per day for vaginal bleeding. Has been bleeding since ___. Reports some dizziness in the setting of pain. Denies lightheadedness, shortness of breath or chest pain. <PAST MEDICAL HISTORY> OBHx: -G1 ___ SVD term -G2 SAB -G3 SVD term -G4 current GynHx: LGSIL in ___ colpo normal, biopsies normal Mirena IUD placed in ___ PMH: hypothyroidism during prior pregnancy PSH: breast implants ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> ADMISSION ___ 2318 BP: 102/66 RR: 18 ___ 2318 Temp: 98.8 PO BP: 96/54 R Lying HR: 77 O2 sat: 98% O2 delivery: Ra Gen: NAD Resp: breathing comfortably Back: no CVA tenderness Abd: soft, mildly tender to palpation, non-distended, no rebound or guarding Pelvic: small amount of blood in vaginal vault, IUD strings visualized at external os, attempted to pull IUD strings but meeting some resistance and patient unable to tolerate further attempt due to discomfort DISCHARGE Vital signs and Ins/Outs all within normal limits. General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, diffusely tender to palpation without rebound or guarding--pain worst in LLQ. Distractible GU: pad with minimal/moderate spotting Extremities: no edema, no TTP <PERTINENT RESULTS> ___ 04: 10PM BLOOD WBC-6.8 RBC-2.81* Hgb-7.6* Hct-23.6* MCV-84 MCH-27.0 MCHC-32.2 RDW-13.8 RDWSD-42.2 Plt ___ ___ 04: 10PM BLOOD Neuts-76.1* Lymphs-18.4* Monos-4.9* Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.16 AbsLymp-1.25 AbsMono-0.33 AbsEos-0.00* AbsBaso-0.02 ___ 12: 10AM BLOOD WBC-5.8 RBC-2.90* Hgb-7.9* Hct-24.2* MCV-83 MCH-27.2 MCHC-32.6 RDW-13.9 RDWSD-42.4 Plt ___ ___ 07: 05AM BLOOD WBC-3.8* RBC-2.69* Hgb-7.3* Hct-22.3* MCV-83 MCH-27.1 MCHC-32.7 RDW-14.1 RDWSD-41.9 Plt ___ ___ 04: 10PM BLOOD ___ PTT-27.7 ___ ___ 04: 10PM BLOOD Glucose-91 UreaN-6 Creat-0.4 Na-143 K-3.3 Cl-105 HCO3-25 AnGap-13 ___ 04: 10PM BLOOD ALT-7 AST-10 AlkPhos-51 TotBili-0.4 ___ 04: 10PM BLOOD Lipase-15 ___ 04: 10PM BLOOD Albumin-3.6 ___ 04: 10PM BLOOD HCG-364 ___ 04: 17PM BLOOD Lactate-0.7 Pelvic Ultrasound ___: The uterus measures approximately 8-9 cm in sagittal dimension. Previously seen echogenic avascular material within the endometrial canal is not seen on the current study. As seen on the CT from outside hospital on ___, 2 days prior, the IUD is malpositioned and extends into the myometrium. The right ovary measures 2.2 x 1.5 x 1.1 cm and is unremarkable. The left ovary measures approximately 2.1 x 2.2 x 2.0 cm. In the left adnexa, there is a large region of heterogeneity, measuring at least 6.8 x 3.9 x 3.1 cm, related to the patient's known ectopic pregnancy, likely representing combination of blood products/hematoma and evolving ectopic pregnancy. This region is less vascular than on the prior ultrasound from ___. Small to moderate amount of complex free fluid is also seen, consistent with hemoperitoneum. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Cephalexin 500 mg PO Q12H Duration: 7 Days Take for entire 7 days RX *cephalexin 500 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> left ectopic pregnancy and possible malpositioned IUD <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for observation for your pain. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * 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
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Ms. ___ is a ___ year old G4P2 recently diagnosed with a left tubal ectopic pregnancy in the setting of a Mirena IUD status post methotrexate on ___ who was readmitted to the Gynecology service on ___ with abdominal pain. On presentation, she was hemodynamically stable, her exam was notable for only mild abdominal tenderness without peritoneal signs and a small amount of vaginal bleeding. Her hematocrit was 23.6, down from 29.5 when last checked on ___, but remained stable on re-check the next day. Her hCG quant fell appropriately from 628 on ___ to 364 on admission. A pelvic ultrasound showed small to moderate hemoperitoneum and a large region of heterogeneity in left adnexa consistent with evolving ectopic pregnancy. Also, the IUD was noted to be malpositioned and likely embedded into the posterior myometrium. Attempted removal of the IUD was unsuccessful. Urine culture was positive for E coli, so she was started on a 7 day course of cephalexin. Her pain, attributed to both the malpositioned IUD and the resolving ectopic pregnancy, was initially controlled with oral acetaminophen and IV morphine. Her vitals and exam remained stable overnight, and there was no indication for urgent surgical intervention. She no longer required morphine for pain. She was discharged on hospital day 2 in stable condition with outpatient follow-up scheduled.
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10678524-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Aspirin / Tetracycline / Erythromycin Base / Sulfa (Sulfonamide Antibiotics) / Augmentin / doxycycline <ATTENDING> ___ <CHIEF COMPLAINT> thickened endometrium <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophrectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ woman who I met for the first time in ___ when she presented in consultation regarding a history of an abnormal Pap smear and high-grade dysplasia. In ___, she underwent a LEEP excision of the cervix with a deep margin and high-grade dysplasia was noted. The margins were negative and followup surveillance Pap smears for ___ years returned without any abnormality. From a Pap smear and cervical dysplasia standpoint, she has done well. She recently had a pelvic ultrasound because of the concern for an inability to appreciate the ovaries. This imaging study revealed a normal-sized uterus measuring 4.7 x 2.7 x 4.1 cm. An endometrial lining of 6 mm was identified and there was a small amount of fluid within the endometrial cavity. Also identified and highlighted by the small amount of fluid was a 6 x 7 x 5 mm round echogenic nonvascular lesion. The possibility of this endometrial lesion representing a cancer was raised. The left ovary was seen. The right ovary was not seen easily. The patient was brought to the operating room for attempted hysteroscopy D&C. Because of the scar tissue from the LEEP excision of the cervix, the endocervical canal was unable to be dilated. The cervix was notably flushed with the vaginal apex and no dimple was identified. An ultrasound was attempted, but was unable to be performed. The patient presents here for discussion of treatment options. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: The patient has a history of IBS of the colon, Htn and hypercholesterolemia. Her last colonosopy was in ___ and was reportedly normal. SHe is upto date on MMG's her last was ___. She denies history of asthma, mitral valve prolapse,thromboembolic disorder. PAST SURGICAL HISTORY: Tonsils ___, Appendectomy ___, GB ___, Radical resection of left thigh melanoma ___. OB/GYN HISTORY: She is a gravida 0, para 0 woman. She denies history of fibroids, cysts, pelvic infections, or abnormal Pap smears beyond the one noted above. She has been Post-menapausal 'for years.' <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports that her mother had breast cancer at ___ cancer, Her father had glioblastoma ___ and bladder 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 <MEDICATIONS ON ADMISSION> atorvastatin 10', lisinopril-HCTZ ___, lorazepam 0.5prn, metformin 500', asa 81 <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID Do not exceed 4,000mg in 24 hours. RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H: PRN pain Do not drink alcohol or drive. RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4 hours Disp #*15 Tablet Refills: *0 4. Atorvastatin 10 mg PO QPM 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Lisinopril 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> thickened endometrium, ** final pathology pending ** <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 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-oophrectomy, cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with oral acetaminophen, oxycodone and IV morphine. Her diet was advanced without difficulty. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. For her type II diabetes, her metformin was held and she was placed on an insulin sliding scale and her blood sugars were monitored. For her hypertension, her home medications were held, as her blood pressures were low/normal range. 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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