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10799704-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Celebrex / Iodinated Contrast Media - IV Dye <ATTENDING> ___. <CHIEF COMPLAINT> High grade serous cancer of mullerian origin <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy, omentectomy, sigmoid colectomy and primary reanastomosis, resection of peritoneal nodules, removal of pelvic mass <HISTORY OF PRESENT ILLNESS> ___ gravida 4, para 4 with multiple medical problems including eosinophilic pneumonia, ___ disease, cognitive impairment, history of CVA and hypertension, who initially presented with a vague history of abdominal pain for the last couple of months, worse in the last month. She was seen on ___ for these symptoms and obtained an abdominal pelvic CT scan, which demonstrates a pelvic mass measuring 12.5 x 13 x 10.6 cm with solid and cystic components, probably arising from the right adnexa, although it is inseparable from the uterus. Additional soft tissue lesions were seen deep within the pelvis and perirectal fat, all concerning for metastatic disease. One of these lesions is 2.7 x 1.8 cm and an additional lesion is 2.6 x 1.5 cm. Interestingly, there was no additional foci identified outside of the pelvic mass and the deep pelvic lesions concerning for metastatic disease. A CA-125 that is elevated at 1637. During her gynecology oncology intake, she reported having abdominal discomfort intermittently. She also noted a history of about a 7 pound weight loss over the last month and fatigue and weakness, which were chronic, along with chronic shortness of breath. She was recently increased to 10 mg of prednisone daily by her pulmonologist for her history of pulmonary eosinophilia. The patient denied any difficulties with eating, drinking, urinary leakage or dysuria. No diarrhea or constipation, blood in the stools or urine, early satiety or anorexia. Otherwise, a 10-point review of systems is entirely negative. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> 1. ___ disease. 2. Cognitive impairment. 3. Pulmonary eosinophilia. 4. Depression. 5. Hyperlipidemia. 6. Hypertension. 7. Osteoporosis. 8. History of CVA. Past Surgical History: 1. Right knee surgery for a torn meniscus ___ years ago at ___. 2. Exploratory laparotomy for ? appendectomy, the patient was unable to remember exact details. Past Obstetrical History: Gravida 4, para 4, four spontaneous vaginal deliveries in ___ and ___. Past Gynecologic History: Menarche at age ___. Menopause approximately ___ years ago. Reports her periods were normal every month with no particular issues. Denies any history of abnormal Pap smears, is not currently sexually active. Denies any history of using oral contraceptive pills or hormone replacement therapies and denies any other history of gynecologic infections or gynecologic problems such as uterine fibroids or ovarian cysts. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast, ovarian, uterine or colon cancers. Mother with a history of stomach cancer and father who was a smoker with history of lung cancer. She has some siblings with heart disease. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, vertical midline incision clean/dry/intact with staples, no rebound/guarding GU: no vaginal spotting ___: nontender, nonedematous, RLE ___ strength intact, LLE quadricep strength ___, +sensory deficit on LLE <PERTINENT RESULTS> ___ 07: 05AM BLOOD WBC-6.0 RBC-3.37* Hgb-10.5* Hct-32.2* MCV-96 MCH-31.2 MCHC-32.6 RDW-14.0 RDWSD-48.4* Plt ___ ___ 06: 50AM BLOOD WBC-7.6 RBC-3.30*# Hgb-10.1* Hct-31.1* MCV-94 MCH-30.6 MCHC-32.5 RDW-14.1 RDWSD-48.5* Plt ___ ___ 08: 35AM BLOOD WBC-7.1 RBC-2.61* Hgb-8.1* Hct-25.1* MCV-96 MCH-31.0 MCHC-32.3 RDW-13.2 RDWSD-45.7 Plt ___ ___ 09: 45AM BLOOD WBC-8.4 RBC-2.90* Hgb-9.1* Hct-27.8* MCV-96 MCH-31.4 MCHC-32.7 RDW-13.2 RDWSD-46.4* Plt ___ ___ 01: 13AM BLOOD WBC-8.5 RBC-2.62* Hgb-8.1* Hct-25.4* MCV-97 MCH-30.9 MCHC-31.9* RDW-13.2 RDWSD-46.3 Plt ___ ___ 08: 15PM BLOOD WBC-8.0 RBC-2.85*# Hgb-8.9*# Hct-27.4*# MCV-96 MCH-31.2 MCHC-32.5 RDW-13.0 RDWSD-46.4* Plt ___ ___ 07: 05AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-140 K-3.2* Cl-102 HCO3-29 AnGap-12 ___ 06: 50AM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-136 K-3.9 Cl-103 HCO3-24 AnGap-13 ___ 08: 35AM BLOOD Glucose-112* UreaN-16 Creat-1.0 Na-132* K-4.4 Cl-99 HCO3-26 AnGap-11 ___ 09: 45AM BLOOD Glucose-157* UreaN-18 Creat-1.1 Na-135 K-5.2* Cl-100 HCO3-27 AnGap-13 ___ 08: 15PM BLOOD Glucose-252* UreaN-17 Creat-1.0 Na-133 K-4.8 Cl-100 HCO3-23 AnGap-15 ___ 07: 05AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.9 ___ 06: 50AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.0 ___ 08: 35AM BLOOD Calcium-8.0* Phos-3.8 Mg-1.8 ___ 09: 45AM BLOOD Calcium-8.2* Phos-4.9* Mg-1.9 ___ 08: 15PM BLOOD Calcium-7.6* Phos-5.7* Mg-1.7 ___ 07: 05PM BLOOD Type-ART pO2-237* pCO2-47* pH-7.30* calTCO2-24 Base XS--3 ___ 05: 30PM BLOOD Type-ART pO2-233* pCO2-46* pH-7.33* calTCO2-25 Base XS--1 ___ 04: 30PM BLOOD Type-ART pO2-216* pCO2-45 pH-7.36 calTCO2-26 Base XS-0 ___ 07: 05PM BLOOD Glucose-269* Lactate-1.4 Na-132* K-5.1 Cl-101 ___ 05: 30PM BLOOD Glucose-204* Lactate-1.9 Na-132* K-5.8* Cl-101 ___ 04: 30PM BLOOD Glucose-163* Lactate-1.9 Na-133 K-5.7* Cl-100 ___ 07: 05PM BLOOD Hgb-8.4* calcHCT-25 ___ 05: 30PM BLOOD Hgb-10.3* calcHCT-31 ___ 04: 30PM BLOOD Hgb-10.7* calcHCT-32 ___ 07: 05PM BLOOD freeCa-1.11* ___ 05: 30PM BLOOD freeCa-1.08* ___ 04: 30PM BLOOD freeCa-1.11* <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Losartan Potassium 25 mg PO DAILY 2. BusPIRone 20 mg PO BID 3. Alendronate Sodium 70 mg PO QMON 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. Carbidopa-Levodopa (___) 1.5 TAB PO TID 6. Simvastatin 40 mg PO QPM 7. Sucralfate 1 gm PO BID 8. Omeprazole 20 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Escitalopram Oxalate 20 mg PO DAILY 11. PredniSONE 10 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q8H: PRN Pain - Mild Please do not take more than 4000mg in 24 hours RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours. Disp #*60 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice per day. Disp #*60 Tablet Refills: *1 3. Enoxaparin Sodium 40 mg SC Q24H Start: after discharge RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe Refills: *0 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q3H: PRN Pain - Moderate ___ cause sedation. Do not take with alcohol or while driving RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp #*50 Tablet Refills: *0 5. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 17 powder(s) by mouth once or twice daily. Disp #*30 Gram Refills: *1 6. Alendronate Sodium 70 mg PO QMON 7. Aspirin 81 mg PO DAILY 8. BusPIRone 20 mg PO BID 9. Carbidopa-Levodopa (___) 1.5 TAB PO TID 10. Escitalopram Oxalate 20 mg PO DAILY 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Losartan Potassium 25 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. PredniSONE 10 mg PO DAILY 15. Simvastatin 40 mg PO QPM 16. Sucralfate 1 gm PO BID <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> high grade serous cancer of mullerian origin <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy, omentectomy, sigmoid colectomy and primary reanastomosis, resection of peritoneal nodules, removal of pelvic mass. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural of bupivacaine and dilaudid PCA. In PACU, her BP was noted to be ___. Patient as asymptomatic with HR in the ___. She received hydrocortisone x1, albumin x1 and 1 unit of packed RBC. She was transferred to an inpatient floor and BPs were ___ on POD1. On POD 2, there was concern for mental status change. She was having visual hallucinations and was disoriented to the location. Of note, per her family, disorientation to time and place is her baseline and she often has hallucinations at home. Acute Pain Service was consulted to titrate her epidural medicine down. They discontinued her dilaudid PCA and she was continued on bupivacaine epidural and IV Tylenol. Workup including EKG, electrolytes and urinalysis were within normal limits. Her CBC showed a hematocrit of 25.1 and she was consented to receive 1 unit of packed RBC. Her hematocrit trended as follows during her stay. Preop Hct 39 -> 2 units pRBC (intraoperatively/PACU) -> 27.8 POD1 -> 25.1 POD2 -> 1 unit pRBCs ___ ___ -> 31.1 x2 (stable upon discharge). Her epidural was capped and pulled on POD#3 and she was transitioned to PO tylenol and oxycodone. Her diet was advanced slowly without difficulty and she was tolerating a regular diet by POD#4. On post-operative day #4, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Physical therapy was consulted to assess for disposition and complaint of left leg heaviness, differential including concern for injury from intraoperative leg placement vs. result of epidural placement (less likely) vs. baseline deficit. Patient complained of left leg heaviness and demonstrated decreased sensation particularly in the anterior and lateral aspects of the left thigh and anterior left lower leg on physical exam. Physical therapy agrees next best step is discharge to rehabilitation. For her ___ disease, she was continued on her home dose of carbidopa-levidopa. For her pulmonary eosinophilia, she was continued on fluticasone. Of note, she was on prednisone 10mg daily for management of her pulmonary eosinophilia. She received a stress does of steroids intraoperatively and was then started on a steroid taper of 50mg then 25mg before returning to her home dose of 10mg daily. For her depression, she was continued on her buspirone and escitalopram. For her hyperlipidemia, she was re-started on her simvastatin one tolerating a regular diet. For her hypertension and history of CVA, she was continued on losartan and aspirin. For her osteoporosis, her alendronate was held and she will restart this medication on an outpatient basis. She began passing gas on post-operative day #4 but had not yet had a bowel movement at the time of discharge. She had a JP drain in her RLQ. The output was monitored closely. She is discharged with the drain in place, with instructions for daily care and removal once the output is <50cc/day or once she starts having bowel movements. By post-operative day #5, she was tolerating a regular diet, voiding spontaneously, ambulating with assistance from ___ and a walker, and pain was controlled with oral medications. She was then discharged to rehab in stable condition with outpatient follow-up scheduled.
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| 841
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10799704-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Celebrex / Iodinated Contrast Media - IV Dye <ATTENDING> ___ <CHIEF COMPLAINT> Rectal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ F who presented to the ___ for evaluation for rectal bleeding. At that time, she was ___ s/p exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy, omentectomy, sigmoid colectomy and primary reanastomosis, and resection of peritoneal nodules who was in rehab for limited mobility, LLE DVT. Patient was discharged from hospital post-op to ___ Rehab in ___ on ___. At the time of her discharge, she was able to ambulate with a walker and assistance but was having deficits in her LLE. She was discharged on lovenox 40mg daily for prophylaxis. While in rehab, she was diagnosed with a LLE DVT. She was started on lovenox 65mg BID and Coumadin daily on ___ her Coumadin was being titrated currently with goal INR ___. Her most recent INR was 2.1 on ___. Per phone discussion with RN ___ at ___ (where patient was staying), patient was able to ambulate to bathroom with walker/assist at rehab and currently getting rehab services. Also per phone discussion RN at ___, who reviewed the patient's record, patient had been having soft twice daily bowel movements for the past several days. However, today, she was noted to have blood in her stool. Unfortunately the documentation at the ___ center did not specify further details or how much. Patient was taking Colace BID and Miralax QD. She was also prescribed senna, dulcolax PR, and fleet enema prn but per RN review of chart did not receive any of these medications at rehab. Patient denied any abdominal pain, CP/SOB, N/V, F/C, dizziness. Reported that she had not noticed blood in her stools but was told that she had blood in her stool. She did not know how much or what the color of the blood was. In the ___, VS were normal. Hct 34.8 which was stable from prior. Per exam by Dr. ___ resident), patient had mild RLQ tenderness but otherwise benign abdominal exam, with no focal masses, induration, ecchymoses, or peritoneal signs. On digital rectal exam, noted to have brown stool with specks of bright red blood, + guaiac. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> 1. ___ disease. 2. Cognitive impairment. 3. Pulmonary eosinophilia. 4. Depression. 5. Hyperlipidemia. 6. Hypertension. 7. Osteoporosis. 8. History of CVA. Past Surgical History: 1. Right knee surgery for a torn meniscus ___ years ago at ___. 2. Exploratory laparotomy for ? appendectomy, the patient was unable to remember exact details. 3. Exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy, omentectomy, sigmoid colectomy and primary reanastomosis, resection of peritoneal nodules. (___) Past Obstetrical History: Gravida 4, para 4, four spontaneous vaginal deliveries in ___ and ___. Past Gynecologic History: Menarche at age ___. Menopause approximately ___ years ago. Reports her periods were normal every month with no particular issues. Denies any history of abnormal Pap smears, is not currently sexually active. Denies any history of using oral contraceptive pills or hormone replacement therapies and denies any other history of gynecologic infections or gynecologic problems such as uterine fibroids or ovarian cysts. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast, ovarian, uterine or colon cancers. Mother with a history of stomach cancer and father who was a smoker with history of lung cancer. She has some siblings with heart disease. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 06: 50AM BLOOD WBC-4.5 RBC-3.04* Hgb-9.7* Hct-30.3* MCV-100* MCH-31.9 MCHC-32.0 RDW-14.4 RDWSD-52.2* Plt ___ ___ 07: 00AM BLOOD WBC-4.4 RBC-3.10* Hgb-9.8* Hct-30.9* MCV-100* MCH-31.6 MCHC-31.7* RDW-14.3 RDWSD-51.5* Plt ___ ___ 05: 20PM BLOOD WBC-6.9 RBC-3.39* Hgb-10.7* Hct-34.8 MCV-103*# MCH-31.6 MCHC-30.7* RDW-14.6 RDWSD-53.6* Plt ___ ___ 05: 20PM BLOOD Neuts-83.0* Lymphs-11.0* Monos-4.3* Eos-0.7* Baso-0.6 Im ___ AbsNeut-5.75 AbsLymp-0.76* AbsMono-0.30 AbsEos-0.05 AbsBaso-0.04 ___ 06: 50AM BLOOD ___ PTT-52.4* ___ ___ 07: 00AM BLOOD ___ PTT-48.6* ___ ___ 05: 20PM BLOOD ___ PTT-61.6* ___ ___ 06: 50AM BLOOD Glucose-95 UreaN-19 Creat-0.8 Na-142 K-3.6 Cl-106 HCO3-30 AnGap-10 ___ 07: 00AM BLOOD Glucose-92 UreaN-21* Creat-0.8 Na-142 K-3.4 Cl-105 HCO3-29 AnGap-11 ___ 05: 20PM BLOOD Glucose-116* UreaN-23* Creat-1.0 Na-142 K-4.1 Cl-104 HCO3-29 AnGap-13 ___ 06: 50AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.1 ___ 07: 00AM BLOOD Calcium-8.2* Phos-4.2 Mg-2.1 <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Losartan Potassium 25 mg PO DAILY 2. BusPIRone 10 mg PO BID 3. Alendronate Sodium 70 mg PO 1X/WEEK (___) 4. Docusate Sodium 100 mg PO BID 5. Polyethylene Glycol 17 g PO BID: PRN constipation 6. Fluticasone Propionate NASAL 2 SPRY NU BID 7. Carbidopa-Levodopa (___) 1.5 TAB PO TID 8. Enoxaparin Sodium 65 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 9. Simvastatin 40 mg PO QPM 10. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate 11. Sucralfate 1 gm PO BID 12. Omeprazole 20 mg PO DAILY 13. Aspirin 81 mg PO DAILY 14. Escitalopram Oxalate 20 mg PO DAILY 15. Warfarin 5 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Alendronate Sodium 70 mg PO 1X/WEEK (___) 2. Aspirin 81 mg PO DAILY 3. BusPIRone 10 mg PO BID 4. Carbidopa-Levodopa (___) 1.5 TAB PO TID 5. Docusate Sodium 100 mg PO BID 6. Enoxaparin Sodium 65 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 7. Escitalopram Oxalate 20 mg PO DAILY 8. Fluticasone Propionate NASAL 2 SPRY NU BID 9. Losartan Potassium 25 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate 12. Polyethylene Glycol 17 g PO BID: PRN constipation 13. Simvastatin 40 mg PO QPM 14. Sucralfate 1 gm PO BID <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Rectal bleeding likely secondary to hemorrhoids <DISCHARGE CONDITION> Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecological oncology service at ___ because of blood in your stool after your recent surgery for ovarian cancer. You have recovered well and the team thinks it is safe for you to leave the hospital. You are being discharged to Care One at ___. Information on your hospital issues are detailed below: *) Rectal Bleeding likely due to hemorrhoids - Do not put anything in the rectum (suppository, enema, etc) for 3 months, unless advised otherwise by your doctor. - Trace amounts of blood around the stool is likely due to hemorrhoids and is not worrisome at this time. During your hospital stay, there was no change in bleeding. - Due to your recent surgery, your anticoagulation medicine, Coumadin, was stopped due to concern for further bleeding. - Please continue to take Lovenox 65mg BID. - Please call your doctor at ___ if you notice heavy bleeding from your rectum or vagina. *) DVT - Please continue taking lovenox for your DVT. - You will likely need this medicine for 3 months. *) Pain control - Please continue taking Tylenol, ibuprofen and oxycodone for post-operative pain control *) Chronic medical problems - Your medications were unchanged during this hospital visit. - Please continue taking busprione, aspirin, Colace, Flonase, alendronate, miralax, carbidopa-levodpa, escitalopram, losartan, omeprazole, prednisone, simvastatin, sucralfate. Please take your medications as prescribed and monitor for signs of To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Rehab stay will be less than 30 days.
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Ms. ___ was admitted to the gynecologic oncology service due to concern for rectal bleeding. Her hospital course is detailed as follows. Upon admission to ___, patient's lovenox and Coumadin were held. It was thought that the bleeding could be secondary to small bleeding at her sigmoid anastomotic site that was exacerbated by dual anticoagulation agents. On admission, her hematocrit was 34.8 compared to 32.2 on discharge the week prior. On hospital day #1, she was restarted on her therapeutic dose of lovenox and continued to be monitored for signs of bleeding. Patient remained stable with normal vital signs and no signs of heavy bleeding. For HD#1, she had a total of six small bowel movements, 3 with small amounts of blood. On hospital day #2, she continued having regular bowel movements with trace amounts of blood noticed around the stools which was felt to be stable. Colorectal surgery was consulted who felt that anastomotic bleeding was unlikely to present with small amounts of bleeding and that patient was most likely displaying signs/symptoms of hemorrhoids. Further work-up of hemorrhoids will require outpatient follow-up with colorectal surgery to determine if banding is appropriate. With regards to her DVT, she was restarted on her therapeutic dose of lovenox. Physical therapy was consulted but unable to see the patient during her stay. For her ___ disease, she was continued on her home dose of carbidopa-levidopa. For her pulmonary eosinophilia, she was continued on fluticasone and prednisone. For her depression, she was continued on her buspirone and escitalopram. For her hyperlipidemia, she was re-started on her simvastatin one tolerating a regular diet. For her hypertension and history of CVA, she was continued on losartan and aspirin. For her osteoporosis, her alendronate was ordered for her weekly dosage. By hospital day 2, she was having minimal amounts of rectal bleeding, tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged to rehab in stable condition with outpatient follow-up scheduled.
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10802063-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> motor vehicle accident <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P1 @ ___ s/p MVA at approximately 1545 in which she was the unrestrained driver and hit her head cracking the windshield. Denies LOC. Was driving approx. 40mph. Denies trauma to belly. Denies abdominal pain, cramping/ctx, LOF, VB. +FM, but less than usual. ___ per pt ___. Receives prenatal care at ___. E___. Missed most recent PNV, and not sure when most recent visit was. On suboxone for hx of substance abuse, ___. Denies current drug, ETOH use. Reported to nurse that she last used opiates 2months ago. Occasionally smokes cigarettes and endorses past MJ use. Reports otherwise nl prenatal care and is having a boy. Pt does not know blood type. <PAST MEDICAL HISTORY> POb: TAB x 1 PMH: denies other than substance abuse PSH: denies other than TAB <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 98.8, HR 100, BP 117/83, RR 17, 100% O2 on RA rpt HR 93 RR 22 BP 115/73 100% O2 RA Abrasion on forehead, alert and oriented x 3, does not appear to be intoxicated ABDOMEN: soft, NDNT, gravid FAST exam wnl FHR 160s TAUS by myself: posterior placenta, FHR wnl, + active FM, grossly normal fluid No vaginal bleeding Ext NT, no edema CXR wnl <PERTINENT RESULTS> ___ WBC-10.8 RBC-4.42 Hgb-12.1 Hct-35.5 MCV-80 Plt-213 ___ WBC-10.1 RBC-3.96 Hgb-10.9 Hct-31.9 MCV-81 Plt-180 ___ WBC-13.5 RBC-4.14 Hgb-11.3 Hct-32.9 MCV-80 Plt-206 ___ ___ PTT-26.1 ___ ___ ___ PTT-28.3 ___ ___ PTT-28.4 ___ ___ BLOOD FetlHgb-0 ___ Glu-86 BUN-5 Cre-0.5 Na-133 K-3.6 Cl-103 HCO3-21 ___ ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG <MEDICATIONS ON ADMISSION> Wellbutrin ER 150mg daily Suboxone (prescribed by Dr. ___ at ___) Visteril prn <DISCHARGE MEDICATIONS> no medication changes. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 33 weeks gestation s/p motor vehicle accident <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for observation after an MVA. You were evaluated by the Emergency You had no evidence of abruption or preterm labor. You underwent close fetal monitoring and all testing was reassuring. You received a course of betamethasone for fetal lung maturity (second dose given at noon on ___
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___ y/o G2P0 admitted at 33w1d for observation after an MVA. Pt was initially evaluated and cleared by the emergency department. She then was transferred to labor and delivery where she underwent prolonged monitoring. She had no evidence of preterm labor or abruption. Her cervix was closed/50%. CBC and coagulation studies were stable and KB was negative. Her fetal tracing was notable for rare spontaneous decels. MFM was consulted and performed an ultrasound which revealed no sonographic evidence of abruption, appropriate fetal growth, and reassuring testing. She received a course of betamethasone for fetal lung maturity (complete ___ and the NICU was consulted. The fetal decelerations resolved and subsequent NSTs were reactive. She was discharged to home in stable condition on ___. . Of note, Ms ___ was continued on her Wellbutrin and Suboxone as she had been taking. Social services met with the patient during this admission.
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10805921-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Carcinomatosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, mini-laparotomy, tumor debulking, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ who presented with complaints of 1 week of new abdominal pain worse in the epigastrium. A CT scan was performed and reviewed at ___ showing a small amount of ascites in the pelvis, nodularity of the omentum in the pelvis, normal Gynecologic anatomy and no adenopathy. She was hospitalized at ___ for an expedited workup and underwent a chest CT which did not show any evidence of thoracic malignancy. She underwent a pelvic ultrasound which demonstrated a small uterus with a 2 mm endometrial stripe. The patient also underwent an EGD and colonoscopy which were both normal. The ovaries were unremarkable. There was a trace amount of free fluid. On ___, she underwent a CT-guided biopsy of the omentum. Final pathology demonstrated high-grade carcinoma. Stains were positive for CK7, PAX8, and estrogen receptor. They were negative for CK20, WT1, P53, TTF1 and CDX2. Staining profile supported a gynecologic origin. She was counseled regarding the possibility of a primary peritoneal carcinoma and the recommendation for surgical evaluation. The risks, benefits and alternatives were thoroughly discussed and an informed signed consent was obtained prior to proceeding to the operating room. <PAST MEDICAL HISTORY> GERD ___ esophagus asthma gallstone pancreatitis s/p hospitalization ___, CCY ___ chronic LUQ pain Hepatic hemangioma <SOCIAL HISTORY> ___ <FAMILY HISTORY> father with DM, HTN, grandparents with heart disease, unknown age <PHYSICAL EXAM> General: NAD, A&Ox3 CV: RRR, no m/r/g RESP: CTAB, no respiratory distress, normal work of breathing Abd: soft, appropriately tender, no rebound or guarding Extremities: no calf tenderness, wwp, pboots on and active bilaterally <PERTINENT RESULTS> ___ 06: 50AM BLOOD WBC-6.4 RBC-2.92* Hgb-8.2* Hct-25.6* MCV-88 MCH-28.1 MCHC-32.0 RDW-16.4* RDWSD-52.0* Plt ___ ___ 06: 50AM BLOOD Glucose-85 UreaN-8 Creat-0.7 Na-144 K-3.9 Cl-108 HCO3-27 AnGap-9* ___ 06: 50AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8 ___ 02: 00PM BLOOD ___ <MEDICATIONS ON ADMISSION> Albuterol Monteleukast Omeprazole <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H Do not exceed 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*60 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*30 Capsule Refills: *2 3. Enoxaparin Sodium 40 mg SC DAILY Duration: 1 Dose Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 syringe SC daily Disp #*28 Syringe Refills: *0 4. HYDROmorphone (Dilaudid) 1 mg PO Q4H: PRN Pain - Severe do not drive while taking this medication RX *hydromorphone 2 mg half tablet(s) by mouth q4hr Disp #*40 Tablet Refills: *0 5. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*60 Tablet Refills: *0 6. Albuterol Inhaler 2 PUFF IH Q4H: PRN shortness of breath 7. Montelukast 10 mg PO DAILY 8. Omeprazole 20 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Carcinomatosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. 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 GYN oncology service after undergoing a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omentectomy, abdominal exploration, tumor debulking via mini laparotomy, and cystoscopy for carcinomatosis with biopsy-proven malignancy of gynecologic origin. Her postoperative course was uncomplicated. Her pain was initially controlled with an epidural, and she was subsequently transitioned to oral gabapentin, acetaminophen, Dilaudid, ibuprofen. Her Foley catheter was removed and she voided spontaneously. Her diet was advanced and she tolerated a regular diet. By postoperative day 3, she was tolerating a regular diet without nausea, ambulating independently, voiding spontaneously, and requiring only oral pain medications. She was discharged home with close follow-up.
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10807486-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> elevated BP in office <MAJOR SURGICAL OR INVASIVE PROCEDURE> spontaneous vaginal delivery <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ G3P0 at ___ who presents to OB triage for PIH evaluation after she was seen for her regular prenatal visit and found to have elevated BP's. She has a BP cuff at home and normally runs around 140/90 when she checks it. She has had several 24 hour urine collections that have slowly been increasing. Last week the collection was 205. She reports increased lower extremity edema but denies any visual blurriness, headache or right upper quadrant pain. She denies vaginal bleeding, leakage of fluid or uterine contractions. Reports good fetal movement. <PAST MEDICAL HISTORY> PNC: ___: ___ by LMP *)Labs: A+/Ab-/RPRNR/RI/HBsAg-/HIV- *)US: normal FFS, R anterior placenta OB Hx: TAB x 2, last TAB complicated by endometritis for which she was admitted to ___ and given IV abx GYN Hx: Remote h/o abn pap, s/p colpo with benign bx, normal followup. Denied STI's. PMH: Asthma, Migraines, h/o chronic HTN- last on meds ___ years prior to pregnancy PSH: D&E X 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) T 98.3, HR 74, R 20, BP 148/95, 149/87, 136/87, 143/91 GENERAL: NAD ABDOMEN: Gravid, NT EXT: 2+ edema b/l to knees, NT FHT: Reactive NST with ___ 135/mod/+accels/ no decels BPP: ___ (-2 sustained breatheing, fetus did have several episodes of 2 breaths) R anterior placenta, vertex presentation and AFI 12.5 <PERTINENT RESULTS> ___ WBC-6.8 RBC-4.04 Hgb-12.6 Hct-36.4 MCV-90 Plt-191 ___ WBC-8.3 RBC-3.98 Hgb-12.5 Hct-35.3 MCV-89 Plt-198 ___ WBC-8.5 RBC-4.10 Hgb-12.9 Hct-36.3 MCV-89 Plt-196 ___ ___ PTT-24.4 ___ ___ ___ PTT-27.1 ___ ___ Creat-0.6 ALT-45 UricAcd-5.2 ___ Creat-0.6 ALT-40 AST-29 UricAcd-5.3 ___ Creat-0.7 ALT-31 AST-21 UricAcd-5.3 ___ TSH-4.6 Free T4-0.71 ___ URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD ___ URINE Hours-RANDOM Creat-25 TotProt-20 Prot/Cr-0.8 ___ URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE Hours-RANDOM Creat-65 TotProt-17 Prot/Cr-0.3 <MEDICATIONS ON ADMISSION> PNV levoxyl Colace <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *30 Capsule(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. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *30 Tablet(s)* Refills: *0* 4. Micronor (28) 0.35 mg Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* 5. Hospital- Grade Breast Pump Sig: One (1) Device five times a day: Indication: Infant in NICU on respiratory assistance to ill to feed. Disp: *1 Device* Refills: *0* 6. labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp: *90 Tablet(s)* Refills: *2* 7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Nothing in the vagina for 6 weeks (No sex, douching, tampons) No driving while taking percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Take your labetalol as prescribed
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It was discussed with patient in Ob triage that although previous PIH evaluations were negative, including recent 24 hr urine of 205mg on ___, her ongoing elevated BP, now with P/C 0.8 and new ALT elevation of 45 raised concern for preeclampsia. The decision was made to proceed with induction of labor. Risks and benefits were discussed. The ___ as started with cytotec as her SVE was unfavorable. After 3 cytotec, her cervix was changed to ___ and Ms. ___ was thought to not be in labor. At this time, the decision was made to hold the induction to collect a 24 hour urine. She was transferred to 6S for this testing. The following day, the decision was made to begin the induction again with pitocin. She did not require anti-hypertensives in labor. She had a vaginal delivery of liveborn male on ___ without complication. She was treated with magnesium sulfate for seizure prophylaxis postpartum. Her blood pressures were up to 150-160/90-100 on PPD#2, therefore, she was started on po Labetolol. Her blood pressures were well controlled on Labetolol 300mg tid prior to discharge. . She also has hypothyroidsim and took 75mcg levoxyl MTWThF in pregnancy. A TSH on ___ was elevated with low T4, therefore her dose was increased to 88mcg MTWThF. . Ms ___ was discharged home in stable condition on PPD#3 and will have close outpatient followup.
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10808255-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ongoing vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> hysteroscopy, dilation & curettage <HISTORY OF PRESENT ILLNESS> ___ is a very pleasant ___ year-old G3P3 who presents today with her daughter to discuss possible surgical intervention for vaginal bleeding that has been present since ___. Yesterday, she felt dizzy, similar to prior episodes where she was anemic, and was seen in triage where her hct was 30. She was sent home to start bid progesterone with no change in her bleeding - approximately 3 pads this morning already. She has a history of abnormal uterine bleeding and was previously seen at ___. She was seen at ___ ___ ___ when her HCT was 18.3. She received one unit of pRBCs with HCT increase to 22, and she then refused the second unit of blood. She then was seen in Dr. ___ and a pelvic ultrasound in ___ showing a 7.9cm uterus with multiple fibroids up to 2cm in size with 2 small cysts in the left ovary. An EMB that day showed secretory endometrium in the background of disodered proliferative endometrium. She was seen by Dr. ___ in the office on ___ at which time, she prolapsing polypoid tissue in the os which was removed and final path demonstrated an cervical polyp. She has been consented for HSC PPY but has also discussed hysterectomy for definitive treatment. She reports that she has had continued vaginal bleeding every since ___, without a single day without bleeding or with just spotting. She is fatigued but denies cp/sb/palp. She is actively bleeding. <PAST MEDICAL HISTORY> Obstetric History: G3P3 - SVD x 3 Gynecologic History: - Menarche ___ - Menses previously qmonth - Denies h/o abnormal Pap test. Last ___ neg - Denies h/o STIs or pelvic infections - h/o fibroids <PAST MEDICAL HISTORY> - hypertension - anemia - asthma Past Surgical History: - bilateral tubal ligation <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of ovarian, uterine, cervical, breast, or colon cancer <PHYSICAL EXAM> On day of admission: General: well appearing female in no apparent distress, alert and oriented HEENT: normocephalic, atraumatic, anicteric sclera Neck: supple, FROM, no thyromegaly or nodules Lymphatic: no palpable neck lymphadenopathy Back: no CVA tenderness Lungs: clear to auscultation bilaterally, good inspiratory effort, no wheezing/rales/rhonchi CV: regular rate and rhythm, no murmurs/rubs/gallops Abd: soft, +bowel sounds, non-tender, non-distended, no R/G Extremities: no clubbing/cyanosis/edema Pelvic: Skin- grossly normal external female genitalia SSE- nl cervix at ML, no unusual blding/lesions/discharge normal vaginal vault BME- small nontender AV uterus, no adnexal masses or tenderness Pelvic MS ___- no obturator or levator muscle tenderness Rectovaginal Exam: deferred On day of discharge: AFVSS Gen: well appearing, NAD CV: RRR, no murmurs or gallops Resp: CTAB, good air movement Abd: soft, nondistended, nontender GU: minimal bleeding on pad Ext: no erythema, tenderness, edema <PERTINENT RESULTS> ___ 01: 15PM BLOOD WBC-5.1 RBC-3.28* Hgb-9.9* Hct-30.4* MCV-93# MCH-30.3# MCHC-32.6 RDW-21.7* Plt ___ ___ 12: 20PM BLOOD WBC-7.0 RBC-3.38* Hgb-10.4* Hct-31.4* MCV-93 MCH-30.7 MCHC-33.0 RDW-21.3* Plt ___ ___ 06: 15PM BLOOD WBC-5.0 RBC-3.10* Hgb-9.4* Hct-29.1* MCV-94 MCH-30.3 MCHC-32.4 RDW-21.5* Plt ___ ___ 06: 30AM BLOOD WBC-3.8* RBC-2.63* Hgb-8.2* Hct-24.6* MCV-94 MCH-31.2 MCHC-33.3 RDW-21.6* Plt ___ ___ 03: 00PM BLOOD Plt Smr-NORMAL Plt ___ ___ 01: 15PM BLOOD Neuts-61.5 ___ Monos-5.0 Eos-3.5 Baso-0.3 ___ 06: 15PM BLOOD ___ PTT-29.2 ___ ___ 06: 30AM BLOOD ___ PTT-29.7 ___ ___ 06: 15PM BLOOD ___ ___ 01: 15PM BLOOD Glucose-124* UreaN-14 Creat-0.6 Na-142 K-4.1 Cl-107 HCO3-23 AnGap-16 ___ 06: 15PM BLOOD Glucose-80 UreaN-8 Creat-0.5 Na-139 K-4.4 Cl-106 HCO3-20* AnGap-17 ___ 06: 30AM BLOOD Glucose-97 UreaN-8 Creat-0.6 Na-141 K-4.3 Cl-110* HCO3-26 AnGap-9 ___ 06: 15PM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8 ___ 06: 30AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.0 <MEDICATIONS ON ADMISSION> albuterol, provera, lisinopril <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler ___ PUFF IH Q6H: PRN shortness of breath 2. MedroxyPROGESTERone Acetate 10 mg PO BID 3. Lisinopril 40 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> menorrhagia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You were admitted overnight for observation. 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 > 100.4 * 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 ___. Dr. ___ will call you about scheduling your hysterectomy. Please call Dr. ___ IMMEDIATELY if you start to have heavy bleeding again.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing hysteroscopy and dilation and curettage. Please see the operative report for full details. Given her h/o heavy bleeding and an intra-op EBL of 100cc, the decision was made to admit her overnight to monitor for ongoing bleeding and trend her CBC. Immediately post-op, her pain was controlled with tylenol and torodol. On post-operative day 0, her urine output was adequate so her foley was removed and she voided spontaneously. By post-operative day 1, she was advanced to a regular diet and transitioned to motrin and tylenol for pain control. She was voiding spontaneously, ambulating independently, and pain was controlled with oral medications. Serial CBCs were drawn showing a stable hematocrit and platlet count and she had no further bleeding over a 24 hour period. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10810471-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lactose <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic aspiration of left ovarian cyst, biopsy of cyst wall, lysis of adhesions <HISTORY OF PRESENT ILLNESS> ___ yo G0 presents to ED for r/o torsion. Noted onset of pain ~8 days ago when she presented to an outside hospital (___) ___ with sudden onset LLQ pain where CT showed 5.6 cm hemorrhagic cyst of left ovary. Next day US showed 8.9 x 5.8 x 6.9cm left ovarian cyst with 4.7 x 5.6 x 4.8 cm solid component. Cystectomy was recommended but that MD could not perform so was referred to Dr ___ f/u. She has had ongoing severe pain over the past few days, increased from prior, unresponsive to tylenol #3 and has been unable to work. Saw Dr ___ earlier on day of presentation for urgent visit for ongoing pain where exam was felt to be worsened and sent in for operative eval. Per pre-op exam ___, mass palpable but overall no acute findings on exam. Reports new nausea, no emesis. No fevers, abnl discharge or bleeding, no bowel or bladder sx. <PAST MEDICAL HISTORY> Ob/gyn hx: G0, h/o abnl Pap with nl f/u, no h/o STDs, prior cysts. menses regular q28 days with moderate dysmenorrhea, no prior h/o pelvic pain. sexually active with one male partner, uses condoms only. LMP ___, no intercourse since. PMHx: IBS, lactose intolerance, anxiety PSHx: anal fissure, wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On the day of discharge: AFVSS Gen: thin, fatigued, well-appearing, NAD CV: RRR Pulm: CTAB Abd: soft, thin, non-distended, appropriately tender to palpation, no rebound or guarding, normoactive bowel sounds GU: pad with minimal spotting Ext: no calf tenderness, no edema <PERTINENT RESULTS> ___ 09: 03PM BLOOD WBC-9.1 RBC-4.98 Hgb-15.0 Hct-42.8 MCV-86 MCH-30.1 MCHC-35.0 RDW-12.3 Plt ___ ___ 09: 03PM BLOOD Neuts-61.3 ___ Monos-4.4 Eos-1.4 Baso-0.6 ___ 09: 18PM BLOOD ___ PTT-35.2 ___ ___ 09: 03PM BLOOD Glucose-79 UreaN-13 Creat-0.6 Na-137 K-3.7 Cl-99 HCO3-26 AnGap-16 ___ 08: 39PM URINE UCG-NEGATIVE ___ 1: 10 am FLUID,OTHER PELVIC WASHINGS. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. <MEDICATIONS ON ADMISSION> Zoloft (alternates 50 & 75mg daily), Lorazepam 0.25mg (then quarters this dose) QHS, Clindex for IBS <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID You may buy this at a pharmacy. You should use a stool softener while you are taking narcotics. RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 2. Acetaminophen ___ mg PO Q6H: PRN pain Do not take >4000mg acetaminophen in 24 hrs. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Prescription previously provided by Dr. ___. 4. Sertraline 50 mg PO DAILY 5. Ibuprofen 600 mg PO Q6H Take with food to avoid GI upset. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Complex left ovarian cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the gynecology service after undergoing the procedures listed below. You have recovered well and the team feels that you are now ready to be discharged home. General instructions: * Take your medications as prescribed. * We recommend that you take the tylenol and ibuprofen every 6 hours for pain for at least the first few days after surgery, and the oxyocodone up to every 4 hours as needed for pain. You should gradually need less and less pain medicine as your pain improves. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 2 weeks. * Leave your steri-strips 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 from the emergency department after presenting with acutely worsening abdominal pain, nausea and an enlarging left adnexal mass, concerning for torsion. She was taken to the operating room urgently and underwent diagnostic laparoscopy converted to operative laparoscopy with lysis of adhesions, aspiration of left ovarian cyst and cyst wall biopsy. Intra-operative findings were consistent with endometriosis and a large left adnexal mass but no torsion. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with PO ibuprofen, acetaminophen, oxycodone and IV dilaudid as needed. Her foley was removed in the OR and she was able to void spontaneously. Her diet was advanced without difficulty and she was tolerating a regular diet by the afternoon of post-operative day #1. By the afternoon of hospital day #2 , she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10810800-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Transfer for pyelonephritis <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ y/o G9P5 at 22+3 weeks, with a history of preterm birth, on progesterone this pregnancy, transferred from ___ with pyelonephritis. She initially presented with two weeks of back pain with intermittent tactile fevers/chills at home. She also noticed urinary frequency, and urine with a hazy/dark appearance. She was admitted to ___ from ___. On admission, she was afebrile. She had a +UA and flank pain. Labs were notable for a WBC of 13.1. She was started on IV ceftriaxone (last given 0753, ___. She received oxycodone for pain. FHR was in the 140's. Urine culture prelim Gram negative rods (___). Here, she states she has severe right flank pain with movement. Denies hematuria. No VB. Mild, intermittent contractions (none current). No LOF. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP, c/w first trimester U/S - Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg - Genetics: NT ERA LR ___ - FFS: low ling placenta, normal anatomy, cervix 4cm - GLT: not yet completed - Issues: -> history of preterm delivery at 26wks with PPROM/PTL, on Makena this pregnancy (last ___, but unable to tolerate injections, so switched to vaginal progesterone (has not been taking, as did not know how to insert) GYNHx: - Denies h/o STDs - Abnormal Pap testing: denies - contraception prior to pregnancy: none - No known history of fibroids, endometriosis OBHx G1: ___ - SVD @ 38wks - ___ GIRL "Myasia" 6#9oz G2: ___ - SVD @ 37wk 1d - IOL IUGR, ___ GIRL "Sevaja" 5#12oz G3: ___ - SVD @ 36wks with PTL, ___ BOY ___ 6#8oz G4: ___ - SVD @ 35wks with PTL, ___ GIRL ___ 5#8oz, doing well G5: ___ - SVD @ 26wks with PPROM/PTL after 6d, ___ ___ BOY "Achilles" 2#4oz, doing well G6: ___ - SAB @ 8wks, desired D&C @ ___ G7: ___ - SAB after PPROM @ 16wks, vaginal delivery at ___ G8: ___ - SAB @ 5wks, no documented IUP G9: current PMH: HbS trait, denies hypertension, diabetes, asthma PSH: D+C <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> Admission <PHYSICAL EXAM> -======= Vitals: ___ 16: 32BP: 110/68 (78) ___ ___: 88 ___ 16: 38Temp.: 98.2°F Gen: A&O, comfortable Heart: RRR Pulm: CTAB Abd: soft, gravid, mild suprapubic tenderness Right CVAT SVE: deferred given h/o low lying placenta SSE: difficult to visualize cervix, no visible dilation (Dr. ___ FHR: 120's-130's Discharge <PHYSICAL EXAM> -======= 24 HR Data (last updated ___ @ 335) Temp: 97.5 (Tm 98.2), BP: 108/69 (107-111/69-73), HR: 80 (71-88), RR: 18 (___), O2 sat: 98% (96-100), O2 delivery: RA, FHR: 140-150 (120-150) Gen: NAD Resp: no evidence of respiratory distress Abd: soft, gravid, non-tender Back: Mild right CVAT Ext: no edema, non-tender <PERTINENT RESULTS> Admission Labs: -=== ___ 09: 45AM BLOOD WBC-7.5 RBC-3.10* Hgb-8.7* Hct-26.2* MCV-85 MCH-28.1 MCHC-33.2 RDW-12.9 RDWSD-39.4 Plt ___ ___ 09: 45AM BLOOD Neuts-83.7* Lymphs-7.9* Monos-7.0 Eos-0.8* Baso-0.1 Im ___ AbsNeut-6.24* AbsLymp-0.59* AbsMono-0.52 AbsEos-0.06 AbsBaso-0.01 ___ 09: 45AM BLOOD Plt ___ ___ 09: 15AM URINE Color-Straw Appear-Clear Sp ___ ___ 09: 15AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-SM* ___ 09: 15AM URINE RBC-1 WBC-6* Bacteri-FEW* Yeast-NONE Epi-1 ___ 09: 15AM URINE Mucous-RARE* ___ 05: 43PM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG Imaging: ========= cMFM Ultrasound (___): Biometry consistent with dates. Normal amniotic fluid volume. Cervical length within normal limits. No evidence of placenta previa or low-lying placenta by TV ultrasound. Renal Ultrasound ___: Mild right-sided hydroureteronephrosis. No evidence of nephrolithiasis. <MEDICATIONS ON ADMISSION> 1. Acyclovir 400mg TID 2. Ferrous sulfate 3. ASA 81mg <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H Do not take more than 4000 mg (8 tablets) per day. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 2. Cephalexin 500 mg PO QHS Start taking when you complete your prescription for Macrobid (nitrofurantoin) RX *cephalexin 500 mg 1 capsule(s) by mouth at bedtime Disp #*90 Capsule Refills: *3 3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth once a day Disp #*20 Capsule Refills: *0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate Do not drive or drink alcohol while taking this medication. RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*5 Tablet Refills: *0 5. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*90 Tablet Refills: *3 6. Docusate Sodium 100 mg PO BID Hold for loose bowel movements. 7. Prenatal Vitamins 1 TAB PO DAILY RX *PNV,calcium 72-iron-folic acid [Prenatal Plus (calcium carb)] 27 mg iron-1 mg 1 tab-cap by mouth once a day Disp #*90 Tablet Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pyelonephritis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with a kidney infection. You were treated with IV antibiotics and then transitioned to oral antibiotics. You remained stable throughout your admission without any fevers. You should continue the twice daily antibiotic through ___, and then take it only once daily for the rest of pregnancy. You will find two separate prescriptions for this. You also had an ultrasound to measure your cervical length. We do recommend that you use vaginal progesterone at home to decrease the risk of preterm delivery. We feel it is now safe for you to be discharged home.
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Ms. ___ is a ___ year old ___ at 22w5d with a history of preterm birth on progesterone who was transferred from ___ ___ to ___ for pyelonephritis. On arrival to triage she endorsed severe R sided flank pain with movement and denied hematuria, vaginal bleeding, regular contractions or loss of fluid. She was continued on IV ceftriaxone which was initially started on ___ at ___ ___ and was transferred to the antepartum floor. In terms of her pyelonephritis,she was hemodynamically stable and afebrile throughout her hospitalization. Her pain was managed with PRN Tylenol and oxycodone. The urine culture from the outside hospital was positive for Klebsiella with sensitivity to Ceftriaxone/Macrobid. She was transitioned to Macrobid ___ PO BID on ___ for a 10 day course to end on ___. She underwent a renal ultrasound on ___ prior to discharge which demonstrated R sided hydroureteronephrosis with no signs of nephrolithiasis. She was discharge home with instructions to complete her 10 day course of Macrobid and a recommendation for prophylactic 100mg Macrobid qD after course completion. In terms of her history of preterm delivery, she reported inconsistent use of home vaginal progesterone due to difficulties with administration. This formulation was not on formulary in the hospital pharmacy and so patient was not able to receive vaginal progesterone during her admission. At time of discharge she was encouraged to fill prescription for home use.
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10813891-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> chronic hypertension, severe range blood pressures <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G3P1 at ___+4 with cHTN and severe range pressures today during ___ visit. Pt has never been on antihypertensive meds. Currently denies HA, visual changes, RUQ/epigastric pain. Denies CTX, VB or LOF. +AFM. <PAST MEDICAL HISTORY> PNC: -___: ___ by LMP -Labs: O+/Ab-/HBsAg-/RPRNR/Rubella Equivocal/HIV-/GBS unk -Screening: declined ERA/NIPT. CF and HgE WNL ___ -FFS: WNL, posterior placenta, BOY! -GLT: 113, passed -EFW: ___ 64%ile -Issues: *cHTN *obesity BMI 49.6 OBHx: -G1 ___ SVD term boy 7#12 Jabarri -G2 TAB 9w -G3 current GynHx: ___ ASCUS/HPV neg, repeat WNL with PCP per pt. H/O ovarian cysts (with associated pain) PMH: cHTN, obesity, anxiety/depression (issues with son, has contact info for ___ PSH: WT, D&C <SOCIAL HISTORY> h/o MJ use, none since +UCG, ___ E/D. Fiance/FOB ___, works at ___ <PHYSICAL EXAM> Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, no edema FHR: present at a normal rate <PERTINENT RESULTS> ___ WBC-9.9 RBC-4.18 Hgb-11.2 Hct-34.0 MCV-81 Plt-323 ___ Creat-0.4 ALT-14 AST-11 UricAcd-4.1 ___ URINE Hours-RANDOM Creat-51 TotProt-18 Pr/Cr-0.4 ___ URINE pH-9 Hrs-24 ___ Cre-68 TotProt-13 Pr/Cr-0.2 ___ URINE 24Creat-1700 24Prot-325 R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> PNV <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic hypertension complicating pregnancy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear. Ms. ___, You were admitted to the hospital with elevated blood pressures. Your blood pressures were monitored overnight and remained normal to moderately elevated. Your urine collection is pending. 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 (make apt for next ___ - Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ is a ___ G3P1 with cHTN admitted at 28w4d with elevated blood pressures. She had normal to mild range blood pressures and normal labs. Her 24 hour urine revealed 325mg of protein, which is difficult to interpret given the fact that she has a diagnosis of chronic HTN and no baseline 24hr urine protein. Fetal testing was reassuring. Her blood pressures during her stay were all within normal to mild range. Her only severe range BPs had been in the clinic. At this time, she likely has chronic hypertension without superimposed preeclampsia, and outpatient close follow-up was recommended.
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10813891-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> Ms. ___ was a ___ yo G3P1 on ___ at 34w2d when she presented to OB triage for pre-term contractions. She had reported cramping pain that began approximately ___ the evening of ___. She states that the cramping had occurred regularly approximately every ___ minutes which felt like period pain. She endorsed feeling fetal movement. Her pregnancy had been complicated by a history of chronic hypertension requiring evaluation in triage for a severe range blood pressure in the office. She had been admitted to ___ from ___ where her blood pressures were normal to mild range. She had normal serum labs. 24-hr urine was 325 mg which was thought to be elevated in the setting of chronic hypertension. (She had not completed her ordered baseline 24hr urine.) She had reassuring fetal testing. Her blood pressures all within normal to mild range. Given this presentation, it was felt that her HTN was ___ to chronic hypertension without superimposed preeclampsia. She was made BMZ complete on ___. She was not started on any anti-hypertensive medications. Ms. ___ was admitted for evaluation for preterm labor. <PAST MEDICAL HISTORY> PNC: -___: ___ by ___ -Labs: O+/Ab-/HBsAg-/RPRNR/Rubella Equivocal/HIV-/GBS unk -Screening: declined ERA/NIPT. CF and HgE WNL ___ -FFS: WNL, posterior placenta, BOY! -GLT: 113, passed -EFW: ___ 64%ile -Issues: *cHTN *obesity BMI 49.6 OBHx: -G1 ___ SVD term boy 7#12 Jabarri -G2 TAB 9w -G3 current GynHx: ___ ASCUS/HPV neg, repeat WNL with PCP per pt. H/O ovarian cysts (with associated pain) PMH: cHTN, obesity, anxiety/depression (issues with son, has contact info for ___ PSH: WT, D&C <SOCIAL HISTORY> h/o MJ use, none since +UCG, ___ E/D. Fiance/FOB ___, works at ___ <PHYSICAL EXAM> Constitutional: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: soft, non-tender EXTREMITIES: non-tender, no edema <PERTINENT RESULTS> ___ 07: 26AM OTHER BODY FLUID FETALFN-POSITIVE ___ 07: 51AM URINE RBC-6* WBC-70* BACTERIA-NONE YEAST-NONE EPI-8 ___ 07: 51AM URINE BLOOD-LG* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 06: 49PM ___ ___ 06: 49PM ___ PTT-31.5 ___ ___ 06: 49PM PLT COUNT-342 ___ 06: 49PM ALT(SGPT)-17 AST(SGOT)-12 ___ 06: 49PM CREAT-0.5 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Mild Pain RX *acetaminophen 500 mg 1 - 2 tablet(s) by mouth q 6 hrs Disp #*30 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*10 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 hrs Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal delivery pre-eclampsia preterm labor <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see nursing sheet
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Ms. ___ was admitted to the antepartum floor due to preterm contractions and for further evaluation for preterm labor. On hospital day 1, a SVE showed she was closed but changed to 3 cm. Her exam remained unchanged over several hours. On Hospital day two, Ms. ___ continued to endorse contractions in the same frequency and intensity since the prior ___ evening. She denied any leakage of fluid, vaginal bleeding and reported good fetal movement. On hospital day 3, she was transferred to L&D after SROM at approximately 0400. She reported to have increase discomfort with contractions. She denied HA, CP, SOB, RUQ pain. She had NSVD with viable baby boy. NICU was present due to prematurity. Her postpartum course was uncomplicated. She did not require any postpartum magnesium or anti-hypertensives. Her pain was treated with oral pain medications. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced without incident. By postpartum day 2, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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10816834-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy (removal of uterus, cervix, both fallopian tubes and ovaries) <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ who had been on hormone replacement therapy since the age of ___ and began experiencing vaginal spotting in the beginning of ___. A TVUS showed a heterogeneous 6mm endometrial stripe. An endometrial biopsy on ___ reported "focus of at least endometrial intraepithelial neoplasia involving an endometrial polyp". This was reviewed at ___ who agreed with a diagnosis of EIN. The patient was referred to GYN oncology for further evaluation and treatment recommendations. After counseling, she agreed with the recommendation for surgical management. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> hypertension, hyperlipidemia, h/o +PPD, h/o hepatitis A, anxiety, osteoarthritis, MVP, plantar fasciitis, dry eyes Past Surgical History: LSC tubal ligation (___), laser conization of the cervix (___), HSC/D&C/PPY (___), breast biopsy (___), Operative laparoscopy with open technique and excision of pelvic peritoneal endometriosis/Endometrial ablation via thermo-choice/Hysteroscopy and Dilatation and curettage (___), cataract surgery (___) Past OB History: G1P1, SVD x 1 Past GYN History: - Menopause at ___ - +h/o condyloma and HSV - abnormal pap 25+ years ago, last ___ NIL - + HRT as above - Denies history of fibroids or cysts <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies family history of GYN cancer, breast cancer, colon cancer <PHYSICAL EXAM> Gen: No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Amitriptyline 25 mg PO QHS 3. ___ 100 mg oral DAILY 4. Calcitrate (calcium citrate) 200 mg (950 mg) oral DAILY 5. Lidocaine 5% Patch 1 PTCH TD DAILY: PRN back pain 6. LORazepam 0.5 mg PO QHS: PRN insomnia 7. alpha lipoic acid 50 mg oral DAILY 8. Tretinoin 0.025% Cream 1 Appl TP DAILY 9. coenzyme Q10 10 mg PO DAILY 10. ginkgo biloba 60 mg oral BID 11. s-adenosylmethionine 200 mg oral DAILY 12. Magnesium Citrate 100 mg PO BID 13. Vitamin D ___ UNIT PO DAILY 14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH BID: PRN shortness of breath or wheezing 15. Testosterone Cypionate 1 application topical DAILY 16. Fish Oil (Omega 3) 1000 mg PO BID <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4000 mg in 24 hours RX *acetaminophen [Tylophen] 500 mg ___ capsule(s) by mouth every six (6) hours Disp #*50 Capsule Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drive while taking, may cause drowsiness RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills: *0 5. alpha lipoic acid 50 mg oral DAILY 6. Amitriptyline 25 mg PO QHS 7. Calcitrate (calcium citrate) 200 mg (950 mg) oral DAILY 8. coenzyme Q10 10 mg PO DAILY 9. Fish Oil (Omega 3) 1000 mg PO BID 10. ginkgo biloba 60 mg oral BID 11. Lidocaine 5% Patch 1 PTCH TD DAILY: PRN back pain 12. Lisinopril 5 mg PO DAILY 13. LORazepam 0.5 mg PO QHS: PRN insomnia 14. Magnesium Citrate 100 mg PO BID 15. s-adenosylmethionine 200 mg oral DAILY 16. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH BID: PRN shortness of breath or wheezing 17. Testosterone Cypionate 1 application topical DAILY 18. Tretinoin 0.025% Cream 1 Appl TP DAILY 19. ___ 100 mg oral DAILY 20. Vitamin D ___ UNIT PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrial intraepithelial neoplasia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 8 weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
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Ms. ___ was admitted to the gynecologic oncology service after undergoing a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and washings. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV pain medications. Her diet was advanced without difficulty and she was transitioned to oral pain medications. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. 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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10817031-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ciprofloxacin / cyclobenzaprine / isoniazid / Keflex / naproxen / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Neoprene / pravastatin / vancomycin / Tylenol <ATTENDING> ___ <CHIEF COMPLAINT> abnormal endometrial cells on pap smear <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ yo female G3P3 presents for surgical consultation for endometrial adenocarcinoma grade 1 found on endometrial biopsy. She went in for routine gyn exam and had a pap smear done which showed endometrial cells. She denies any PMB, no abdominal/pelvic pain. She has not had any recent imaging. Endometrial biopsy at ___ revealed endometrial adenocarcinoma, grade 2, endometrioid type with squamous differentiation. Pathology was reviewed at ___ and showed endometrial adenocarcinoma, endometrioid type, with squamous differentiation, FIGO Grade 1. She denies any change in bowel or bladder habits. She does report baseline on and off constipation due Tramadol use for lower back pain. Additionally, she has Rheumatoid Arthritis and takes Methotrexate. She self dc'd methotrexate due to pending surgery. <PAST MEDICAL HISTORY> PMH: Rheumatoid Arthritis, Obesity, Diabetes, Asthma, HTN, Hyperlipidemia, Hypothyroid, Seizure, Goiter, Depression, ADD, PSH: C-Section x 2, BTL, Left Knee Replacement, Tonsillectomy OB/GYN: G3P3, C-Section x 2, NVD x1, ___, No PMB, no HRT use, no sexually active, no h/o uterine fibroids or ovarian cyst, last pap smear: ___- + endometrial cells, no previous abnl pap smears <SOCIAL HISTORY> ___ <FAMILY HISTORY> Breast Cancer: sister, Mother: ___ Cancer dx age ___ and CAD <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 06: 15AM BLOOD WBC-6.7 RBC-3.89* Hgb-10.7* Hct-32.8* MCV-84 MCH-27.5 MCHC-32.6 RDW-14.1 Plt ___ ___ 06: 10AM BLOOD WBC-5.7 RBC-3.82* Hgb-10.8* Hct-33.1* MCV-87 MCH-28.2 MCHC-32.6 RDW-14.1 Plt ___ ___ 06: 15AM BLOOD Glucose-120* UreaN-15 Creat-0.8 Na-141 K-3.7 Cl-100 HCO3-33* AnGap-12 ___ 06: 10AM BLOOD Glucose-131* UreaN-18 Creat-0.7 Na-137 K-4.7 Cl-100 HCO3-29 AnGap-13 ___ 06: 15AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8 ___ 06: 10AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8 <MEDICATIONS ON ADMISSION> albuterol, clotrimazole cream, fluticasone, levothyroxine 125mcg, lidocaine patch, metformin 500mg daily, promethazine 25mg BID PRN, torsemide 50mg daily, tramadol 50mg Q6H, lisinopril 10mg, <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler ___ PUFF IH Q4H: PRN shortness of breath 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Lorazepam 0.5 mg PO Q4H: PRN anxiety, pain 7. Torsemide 10 mg PO DAILY 8. TraMADOL (Ultram) 50 mg PO Q6H: PRN pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial adenocarcinoma **final pathology pending** <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with dilaudid PCA. Her diet was advanced without difficulty and she was transitioned to tramadol for pain. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 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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10817797-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Heparin Agents / Caffeine <ATTENDING> ___. <CHIEF COMPLAINT> postmenopausal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robot assisted total laparoscopic hysterectomy <HISTORY OF PRESENT ILLNESS> ___ year-old F with history of stroke, chronic kidney disease, and paranoid schizophrenia who presented with postmenopausal bleeding. After consent was obtained from her health care proxy, she underwent an endometrial biopsy on ___ which showed serous endometrial cancer. Transvaginal ultrasound was unable to be completed due to mental status per notes. CT of the chest, abdomen, and pelvis on ___ demonstrated esophageal thickening possibly representing a mass and suspicious pulmonary nodules (largest 18mm). The uterus contains a 6.4 x 6.4 cm partially calcified fibroid stable from prior CT in ___. Mixed density material distends the endometrium. No metastatic disease in the abdomen was seen. CA 125 on ___ was 54. <PAST MEDICAL HISTORY> - Seizure disorder (patient was admitted to ___ in ___ after an episode of status. She was initially treated with Keppra, but was later changed to valproic acid. Oxcarbazepine was added in ___ - Subarachnoid hemorrhage ___ - Paranoid schizophrenia, PTSD and OCD - Depression - Hypertension - Chronic anemia - Chronic kidney disease baseline creatinine 1.4 to 1.6 - HIT diagnosed in ___ on coumadin - Hypothyroidism - Anemia (baseline hematocrit ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of seizure disorders, strokes. Father and mother passed away from coronary disease. Has 1 brother and 2 sisters with no reported major illnesses <PHYSICAL EXAM> On day of discharge: Afebrile with stable vital signs No acute distress, appears comfortable Lungs with minimal crackles at the bases bilaterally Heart regular rate and rhythm abdomen soft, nontender, nondistended with positive bowel sounds genitourinary with minimal bleeding on pad lower extremities nontender, nonedematous <PERTINENT RESULTS> ___ 06: 40AM BLOOD WBC-11.3* RBC-2.95* Hgb-7.7* Hct-26.1* MCV-88 MCH-26.2* MCHC-29.6* RDW-18.2* Plt ___ ___ 12: 30PM BLOOD WBC-16.7*# RBC-2.94* Hgb-7.4* Hct-25.9* MCV-88 MCH-25.1* MCHC-28.4* RDW-18.6* Plt ___ ___ 06: 40AM BLOOD Glucose-96 UreaN-34* Creat-2.2* Na-136 K-4.4 Cl-100 HCO3-26 AnGap-14 ___ 12: 30PM BLOOD Glucose-139* UreaN-35* Creat-2.2* Na-136 K-4.4 Cl-102 HCO3-28 AnGap-10 ___ 06: 40AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.4 ___ 12: 30PM BLOOD Calcium-8.7 Phos-4.4 Mg-2.4 <MEDICATIONS ON ADMISSION> abilify 30' benztropine o.5mg'' divalproex ___ ER'' epoetin alfa 1000U sq q ___, hydrocodone-acetaminophen ___ q4prn, keppra 750mg'' levothyroxine 100' metoprolol 25mg''' omeprazole 20' paroxetine 20' miralax' simvastatin 5' trazodone 25' prn, acetaminopen 325'''' prn, vitamin C, bisacdyl, calcium, vit D, docusate 10' Milk of mag 400' MVI senna 8.6'' <DISCHARGE MEDICATIONS> 1. Aripiprazole 30 mg PO BID 2. Benztropine Mesylate 0.5 mg PO BID 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*50 Capsule Refills: *1 4. LeVETiracetam 750 mg PO BID 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Metoprolol Tartrate 25 mg PO TID 7. Omeprazole 20 mg PO DAILY 8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not take more than 4000mg acetaminophen in 24 hours. RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 9. Paroxetine 20 mg PO DAILY 10. Senna 8.6 mg PO HS: PRN constipation <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> serous endometrial cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 8 weeks. * No heavy lifting of objects >10lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. 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 >10lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecology oncology service after undergoing Robot assisted total laraoscopic hysterectomy and bilateral salpingo-oophorectomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and acetaminophen. Her diet was advanced without difficulty and she was transitioned to oral percocet. Given her pre-operative anemia, a hematocrit was measured in the PACU which was 25. Given concern for her cardiovascular status and liklihood that this hct was not a reflection of her true hemodynamic status given only 1 hour post-op, she was transfused 1u of pRBC. She was also noted to have an elevated creatinine of 2.2 above her baseline of 1.6. IV fluids were continued. On post-operative day #1, her hematocrit had risen only to 26.1 and she was given a 2nd unit of pRBC. Repeat creatinine remained 2.2 on post-op day 1 likely due to the stress of her surgery. Her vitals were stable and her urine output was adequate so her Foley catheter was removed and she voided spontaneously. In the afternoon of POD #1 she was noted to have mild tachycardia in the 100-110s which was likely due to undertreatment of pain as it improved with pain control. An EKG was remarkable only for sinus tachycardia, however there was some limitation to the EKG given motion artifact from the patient's tremor and cardiac enzymes were ordered for reassurance and were negative. On POD#2 she was no longer tachycardic, her creatinine improved to 1.8 and her hct was 30. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, and pain was controlled with oral medications. She was then discharged to her skilled nursing facility in stable condition with outpatient follow-up scheduled.
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10818850-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Heavy vaginal bleeding, anemia <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and evacuation <HISTORY OF PRESENT ILLNESS> ___ G3P1011 w/ LMP ___ now presents with heavy vaginal bleeding x 7 ___, has been passing grapefruit size clots x 3 days. Today presented to ___ with signifiant shortness of breathing, unable to ambulate or do any significant activities, chest pain, and pre-syncopal sx. Has been saturating >5pads/hr, fully. Continues to have clots. At ___, found to be tachycardic, have HCG 1000, Hct 19. INR 1.2. Received 1u PRBC and was sent to the ___ ED. At ___ was found to have chest pain when moving and was placed on a non-rebreather mask. Presently becomes very short of breath with taking the smallest movements. Continues to have vaginal bleeding. <PAST MEDICAL HISTORY> PMHx: None. No h/o easy bruising. OBHx: TAB x 1 (D&C) SVD x 1, ___ years ago current GYNhx: regular but heavy menses, usually lasting 7 days. No h/o fibroids. No abnl pap smears. No STI's. PSHx: D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> AVSS NAD, resting comfortably RRR, no m/r/g CTAB, no wheezes/ crackles Abdomen soft, ND, mild suprapubic tenderness Pad with scant blood ext NT/ NE <PERTINENT RESULTS> ___ 04: 30PM BLOOD WBC-9.7 RBC-2.31* Hgb-6.0* Hct-18.2* MCV-79* MCH-25.9* MCHC-32.9 RDW-17.5* Plt ___ ___ 09: 29PM BLOOD WBC-12.1* RBC-2.64* Hgb-7.1* Hct-20.9* MCV-79* MCH-27.0 MCHC-34.1 RDW-16.9* Plt ___ ___ 07: 40AM BLOOD WBC-13.7* RBC-2.34* Hgb-6.3* Hct-18.9* MCV-81* MCH-26.8* MCHC-33.1 RDW-16.6* Plt ___ ___ 04: 00PM BLOOD WBC-14.1* RBC-2.62* Hgb-7.6* Hct-21.5* MCV-82 MCH-28.8 MCHC-35.1* RDW-16.3* Plt ___ ___ 09: 20PM BLOOD WBC-14.5* RBC-2.66* Hgb-7.4* Hct-21.7* MCV-82 MCH-27.8 MCHC-34.0 RDW-16.3* Plt ___ ___ 06: 05AM BLOOD WBC-9.3 RBC-2.36* Hgb-6.8* Hct-19.7* MCV-84 MCH-28.7 MCHC-34.3 RDW-16.5* Plt ___ ___ 03: 00PM BLOOD WBC-8.8 RBC-3.08*# Hgb-9.0*# Hct-26.1*# MCV-85 MCH-29.1 MCHC-34.3 RDW-16.0* Plt ___ ___ 04: 30PM BLOOD ___ PTT-22.9 ___ ___ 09: 29PM BLOOD ___ PTT-22.4 ___ ___ 09: 20PM BLOOD ___ PTT-25.3 ___ ___ 04: 30PM BLOOD ___ 09: 29PM BLOOD ___ 07: 40AM BLOOD ___ 09: 20PM BLOOD ___ 04: 30PM BLOOD Glucose-84 UreaN-12 Creat-0.6 Na-138 K-3.6 Cl-109* HCO3-21* AnGap-12 ___ 09: 29PM BLOOD Glucose-147* UreaN-11 Creat-0.6 Na-138 K-3.5 Cl-107 HCO3-22 AnGap-13 ___ 09: 20PM BLOOD LD(LDH)-213 CK(CPK)-199 TotBili-0.3 ___ 09: 20PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 09: 29PM BLOOD Calcium-7.9* Phos-2.5* Mg-1.7 ___ 09: 29PM BLOOD Hapto-97 ___ 09: 20PM BLOOD Hapto-99 Pelvic US: Nonviable intrauterine gestation likely representing spontaneous miscarriage with RPOC. Perigestational hematoma. Left corpus luteum. CTA: Study limited by motion and suboptimal timing of contrast bolus. Allowing for this, no definite pulmonary embolus nor pulmonary parenchymal abnormality seen to account for patient's symptoms. ECG: Sinus, nl rate, no ST elevations or depressions, ? subtle T wave inversions in III <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> incomplete spontaneous abortion (miscarriage) <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Nothing in your vagina x 2 weeks Do not drive while taking narcotics Call for: - heavy vaginal bleeding, soaking 1 pad per hour - foul smelling vaginal discharge - pain not improved after medications prescribed - dizziness, lightheadedness - shortness of breath, chest pain
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Ms. ___ initially presented to OSH with heavy vaginal bleeding x 7 days passing large clots at ~5w GA. She had significant SOB, chest pain, and presyncopal symptoms. She was found to be tachycardic with HCT 19 and HCG 1000. She was transfused 1 u PRBC's and then transferred to ___ for further management. At ___ she was tachycardic to the 130's intermittently with significant CP/ SOB with minimal movement. She had a pelvic US which showed and IUP with perigestational hematoma, no evidence of ectopic. In the ED, EBL ~ 400ml. She was further transfused with PRBC's and FFP and taken emergently to the operating room for a D&C which was uncomplicated. Please see the operative report for full details. During the postoperative period, her vitals remained stable and her CP/SOB initially improved however her HCT fell once again <20 (thought likely ___ equilibration) so she was further transfused. Her post transfusion HCT did not rise as much as expected and her symptoms of shortness of breath/ chest pain returned. Her vital signs were stable except for mild tachycardia. The workup for this included hemolysis labs which were normal, multiple ECG's which were normal, and a CT of her chest to r/o PE which was also normal. Her symptoms were attributed to a combination of her anemia and history of chronic bronchitis. She was given albuterol/ flovent and transfused another 2 units PRBC's (total of 7 units PRBC's during hospital stay). Her HCT responded appropriately and her symtpoms improved. She was discharged on HD 3 in stable condition.
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10821892-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> epinephrine <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> CT-guided abscess drainage <HISTORY OF PRESENT ILLNESS> ___ yo G1P1 presented with 3 days of lower abdominal pain and cramping. The night prior to presentation she had two episodes of emesis and continued to have nausea. She denied any sick contacts. She reported one episode of loose bowel movement the day of presentation for which she took pepto bismol. She denied fevers, chills, chest pain, cough, shortness of breath, dysuria, constipation, dizziness. <PAST MEDICAL HISTORY> POB/GYNH: ___ s/p LTCS. Denies hx of STIs, abnormal Pap tests. LMP approx 2 weeks ago. Sexually active with husband only. Endorses dypareunia since c-section ___ years ago. Also reports recent yeast infections after intercourse. PMH: - Ventricular bigeminy PSURGH: LTCS Meds: Denies All: latex -> rash, epinephrine -> palpitations <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies hx of breast, ovary, uterine, colon cancers. <PHYSICAL EXAM> Admission PE: Tm-102.8 Tc-102.4 HR-92 BP-107/52 RR-24 O2-100% RA Gen: NAD CV: RRR, no murmurs Pulm: CTAB, good airmovement, breathing comfortably Abd: +BS, soft, nondistended, diffuse lower abdominal tenderness to palpation, no rebound or guarding. Ext: nontender Pelvic: normal appearing external genitalia, inner labial folds. Bimanual exam reveals no CMT. Likely uterine and b/l adnexal tenderness on palpation with abdominal hand. Rectovaginal exam: normal, nontender posterior culdesac Discharge PE: Gen: NAD, comfortable CV: RRR Pulm: CTAB Abd: soft, non-distended, non-tender GU: voiding spontaneously Ext: calves non-tender <PERTINENT RESULTS> ___ 09: 30PM LACTATE-1.5 ___ 05: 06PM LACTATE-3.3* ___ 04: 57PM GLUCOSE-97 UREA N-7 CREAT-0.8 SODIUM-136 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-22 ANION GAP-18 ___ 04: 57PM estGFR-Using this ___ 04: 57PM HCG-<5 ___ 04: 57PM URINE UCG-NEGATIVE ___ 04: 57PM URINE HOURS-RANDOM ___ 04: 57PM WBC-21.8*# RBC-4.63 HGB-14.0 HCT-44.3 MCV-96 MCH-30.2 MCHC-31.6 RDW-12.4 ___ 04: 57PM NEUTS-90.9* LYMPHS-6.0* MONOS-2.0 EOS-0.6 BASOS-0.5 ___ 04: 57PM PLT COUNT-212 ___ 04: 57PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04: 57PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR ___ 04: 57PM URINE RBC-1 WBC-8* BACTERIA-FEW YEAST-NONE EPI-9 ___ 04: 57PM BLOOD WBC-21.8*# RBC-4.63 Hgb-14.0 Hct-44.3 MCV-96 MCH-30.2 MCHC-31.6 RDW-12.4 Plt ___ ___ 07: 05AM BLOOD WBC-14.1* RBC-3.71* Hgb-11.5* Hct-35.8* MCV-97 MCH-31.0 MCHC-32.1 RDW-12.7 Plt ___ ___ 09: 08AM BLOOD WBC-12.6* RBC-3.41* Hgb-10.2* Hct-31.9* MCV-94 MCH-29.9 MCHC-32.0 RDW-12.7 Plt ___ ___ 07: 05AM BLOOD WBC-11.3* RBC-3.69* Hgb-11.3* Hct-34.8* MCV-94 MCH-30.7 MCHC-32.5 RDW-12.8 Plt ___ ___ 06: 50AM BLOOD WBC-11.0 RBC-3.50* Hgb-10.7* Hct-33.6* MCV-96 MCH-30.5 MCHC-31.8 RDW-13.0 Plt ___ ___ 09: 00AM BLOOD WBC-13.6* RBC-4.07* Hgb-12.5 Hct-38.7 MCV-95 MCH-30.7 MCHC-32.3 RDW-13.0 Plt ___ ___ 07: 50AM BLOOD WBC-14.5* RBC-4.25 Hgb-13.1 Hct-40.3 MCV-95 MCH-30.9 MCHC-32.6 RDW-12.8 Plt ___ ___ 07: 40AM BLOOD WBC-11.8* RBC-4.24 Hgb-12.7 Hct-40.6 MCV-96 MCH-30.0 MCHC-31.3 RDW-13.0 Plt ___ ___ 07: 05AM BLOOD %HbA1c-5.5 eAG-111 ___ 08: 50AM BLOOD HCV Ab-NEGATIVE ___ 08: 50AM BLOOD HIV Ab-NEGATIVE ___ 08: 50AM BLOOD HBsAg-NEGATIVE ___ 2: 00 pm ABSCESS Site: PELVIS PELVIS ABSCESS, SUSPECTED PID. **FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: FUSOBACTERIUM SPECIES. MODERATE GROWTH. BETA LACTAMASE NEGATIVE. ___ 9: 31 am ABSCESS Source: left pyosalpinx SAMPLE #2, 1 SYRINGE RECEIVED. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 9: 31 am ABSCESS Source: Pelvic abscess SAMPLE 1 .2 SYRENGES RECEIVED. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. CT Abd/Pevis ___ IMPRESSION: 1. Borderline diameter appendix measuring 7 mm; however, without hyperemia or immediate surrounding fat stranding is indeterminate for appendicitis. However, given prominent pelvic findings, likelihood is very low. 2. Bilateral adnexal serpiginous complex cystic structures suggestive of ___. Additional pelvic fluid collection measuring 5.9 x 3.6 cm with rim enhancement between the uterus and rectum concerning for abscess. Ultrasound may be helpful for further characterization. 3. Possible hepatic hemangiomas not fully characterized on this examination. Recommend ultrasound for further characterization. The study and the report were reviewed by the staff radiologist. Pelvic US ___: IMPRESSION: 1. Complex bilateral adnexal collections with tubular appearance and internal echoes, suggestive of pyosalpinges. 5.7 x 2.7 cm collection in the cul-de-sac, compatible with the patient's known abscess. The above findings are suggestive of tubo-ovarian abscess/PID. 2. Normal uterus. The study and the report were reviewed by the staff radiologist ___ US ___: FINDINGS: The liver demonstrates a smooth homogeneous echotexture. Solid echogenic lesions within segment 2 of the liver measuring 2.3 cm and 0.9 cm do not demonstrate any internal flow on color Doppler imaging and are in keeping with hemangiomas. Echogenic focus in the right lobe of the liver measuring 5 mm with minimal posterior acoustic shadowing is in keeping with a granuloma. There is no intra or extrahepatic biliary dilatation. The common bile duct measures 1 mm. The portal vein is patent and normal hepatopetal flow is demonstrated. There is dependent sludge within the gallbladder with no stones or wall thickening. The pancreas is unremarkable. The spleen is normal size measuring 8.4 cm. The visualized IVC and aorta are unremarkable. There is no ascites. IMPRESSION: Echogenic lesions in segment 2 of the liver measuring up to 2.3 cm corresponding to the lesion seen on recent CT are in keeping with hepatic hemangiomata. <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. 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> tubo-ovarian 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 at ___ ___ for the tubo-ovarian abscesses and pelvic abscess. You have received antibiotics and a CT-guided drainage procedure. You have recovered well, and met all of your post-operative milestones, including, pain controlled with medications, 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, take your medicine as instructed and follow the instructions below General instructions: * Take your medications as prescribed. * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 4weeks * 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. 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 bilateral pyosalpinges and an abscess in the posterior cul-de-sac. She was started on Unasyn, doxycycline and ceftriaxone in the Emergency Room. In the emergency room, acute care surgery was consulted to rule-out appendicitis or diverticulitis which was deemed less likely. Her ultrasound showed on ___: complex adnexal collections bilaterally, which appear tubular with internal echoes suggestive of pyosalpix as well as a collection in the cul-de-sac measures 5.7 x 2.7 cm, normal uterus. The patient was transferred from the ED to the gynecology service, and started on gentamicin and clindamycin for pelvic inflammatory disease coverage. On ___, the patient had a transgluteal drainage of the cul-de-sac abscess, where a total of 50cc of purulent drainage was drained. The patient continued to have fevers though her WBC continued to decrease, a repeat pelvic ultrasound showed an overall improvement, though with a persistent left pyosalpinx and a 3.5cm left adnexal abscess. On ___, she underwent a transvaginal ultrasound-guided aspiration of a left-sided pyosalpinx (for 5 cc purulent fluid) and left adnexal fluid collection (for 30 cc of purulent fluid). Her GC/chlamydia, HIV, Hepatitis B and C panels were all negative. Her HgbA1C was 5.1%. A complete fever work-up was also performed since the patient also complained of a cough and diarrhea. The ID service was consulted. Her CXR showed a small right pleural effusion, that was consistent with her mild URI/cough. Pleural effusions may occur at times with pulmonary embolisms, though the pt was never tachypnic and her oxygenation status remained normal. Her blood cultures showed no growth. Her urine culture was negative for infection. Her WBC initially increased after drainage to a maxiumum of 14.5, then trended down on ___ to 11.8. Her antibiotics were changed from genatmicin and clindamycin to Zosyn on ___ then to Unasyn on ___. Her last temperature was 100.6 on ___ at 18:00. After she was afebrile for more than 24 hours, she was transitioned to PO Augmentin for a planned 14 day course on the recommendation of the ID service. She overall felt clinically improved, with no lower abdominal pain, no fevers or chills, and with a normal appetite and bowel habits. Of note, the patient had an incidental liver hemangioma that was found on CT, her RUQ U/S confirmed at finding of a 2.3 cm consistent with hepatic hemangiomata. She was counseled to follow-up with her PCP about this result. She was discharged home on hospital day 8 with close outpatient follow-up scheduled.
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10821892-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> epinephrine / Augmentin <ATTENDING> ___. <CHIEF COMPLAINT> Fevers and lower abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound-guided drainage of abscesses <HISTORY OF PRESENT ILLNESS> ___ G1P1 with h/o bilateral TOAs in ___ s/p ___ guided drainage and course of abx who presents to ED with lower abd pain and fever to 102. States recovered well from TOAs in ___ and the day before admission started to have lower abdominal pain, constant, ___. Had nausea and vomiting. Did not have vaginal discharge, changes in bowel/bladder habits, or dysuria. Re: course in ___, was admitted to GYN for PID/bilateral TOAs. Initially started on gent/clinda. Underwent bilateral ___ guided drainage. ID was consulted who changed abx to zosyn then unasyn. Discharged home with course of augmentin, but stopped course early ___ hives. During this course, was ? bowel etiology s/p CT scan and ACS consult to thought etiology more likely gynecologic. The preliminary read on the ___ pelvic ultrasound was: Complex bilateral adnexal collections with tubular appearance and internal echoes suggestive of pyosalpinges are new compared to the prior study of ___. <PAST MEDICAL HISTORY> POB/GYNH: - ___ s/p LTCS. - Denies hx of STIs, abnormal Pap tests. - LMP approx 2 weeks ago. - Sexually active with husband only. - Endorses dypareunia since c-section ___ years ago. - Also reports recent yeast infections after intercourse. PMH: - Ventricular bigeminy PSURGH: LTCS All: latex -> rash, epinephrine -> palpitations <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies hx of breast, ovary, uterine, colon cancers. <PHYSICAL EXAM> Afebrile. General: appears well, not diaphoretic as on admission CV: RRR Resp: bibasilar crackles c/w atelectasis Abd: soft, non-tender, non-distended. minimal tenderness to palpation. Ext: no edema Skin: no rashes <PERTINENT RESULTS> ___ 07: 35AM BLOOD WBC-10.2 RBC-4.08* Hgb-12.7# Hct-39.4 MCV-97 MCH-31.0 MCHC-32.2 RDW-13.3 Plt ___ ___ 07: 30AM BLOOD WBC-7.7 RBC-3.28* Hgb-10.1* Hct-32.6* MCV-100* MCH-30.8 MCHC-31.0 RDW-13.5 Plt ___ ___ 08: 10AM BLOOD WBC-12.1* RBC-3.32* Hgb-10.1* Hct-32.5* MCV-98 MCH-30.6 MCHC-31.2 RDW-13.6 Plt ___ ___ 04: 45AM BLOOD WBC-14.7* RBC-3.63* Hgb-11.3* Hct-35.1* MCV-97 MCH-31.1 MCHC-32.2 RDW-13.2 Plt ___ ___ 07: 15AM BLOOD WBC-15.7* RBC-3.91* Hgb-12.1 Hct-37.6 MCV-96 MCH-30.9 MCHC-32.1 RDW-13.5 Plt ___ ___ 09: 50PM BLOOD WBC-13.1*# RBC-4.18* Hgb-13.1 Hct-40.4 MCV-97 MCH-31.4 MCHC-32.5 RDW-13.4 Plt ___ ___ 07: 35AM BLOOD Neuts-75.9* Lymphs-17.3* Monos-6.0 Eos-0.4 Baso-0.3 ___ 07: 30AM BLOOD Neuts-68.8 ___ Monos-8.7 Eos-0.9 Baso-0.4 ___ 08: 10AM BLOOD Neuts-85.9* Lymphs-9.0* Monos-4.0 Eos-1.0 Baso-0.1 ___ 04: 45AM BLOOD Neuts-90.3* Lymphs-6.4* Monos-2.2 Eos-1.0 Baso-0.1 ___ 07: 15AM BLOOD Neuts-89.6* Lymphs-6.8* Monos-2.9 Eos-0.6 Baso-0.1 ___ 09: 50PM BLOOD Neuts-88* Bands-2 Lymphs-5* Monos-5 Eos-0 Baso-0 ___ Myelos-0 ___ 09: 50PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 07: 35AM BLOOD Plt ___ ___ 07: 35AM BLOOD ___ PTT-34.1 ___ ___ 07: 30AM BLOOD Plt ___ ___ 08: 10AM BLOOD Plt ___ ___ 08: 10AM BLOOD ___ PTT-33.9 ___ ___ 04: 45AM BLOOD Plt ___ ___ 04: 45AM BLOOD ___ PTT-34.6 ___ ___ 07: 15AM BLOOD Plt ___ ___ 07: 15AM BLOOD ___ PTT-34.2 ___ ___ 09: 50PM BLOOD Plt Smr-NORMAL Plt ___ ___ 07: 35AM BLOOD ___ ___ 08: 10AM BLOOD ___ ___ 04: 45AM BLOOD ___ ___ 07: 15AM BLOOD ___ ___ 07: 35AM BLOOD ESR-88* ___ 04: 45AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-135 K-3.3 Cl-106 HCO3-20* AnGap-12 ___ 09: 50PM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-138 K-3.4 Cl-103 HCO3-21* AnGap-17 ___ 07: 35AM BLOOD Calcium-8.7 Phos-3.4# Mg-1.8 ___ 04: 45AM BLOOD Calcium-8.5 Phos-1.7*# Mg-1.7 ___ 10: 40PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10: 40PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM ___ 10: 40PM URINE RBC-<1 WBC-18* Bacteri-FEW Yeast-NONE Epi-6 <MEDICATIONS ON ADMISSION> - Clotrimazole-betamethasone 1 %-0.05 % topical cream. Apply to rash once daily x one week. <DISCHARGE MEDICATIONS> 1. Levofloxacin 500 mg PO Q24H RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills: *0 2. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> tubo-ovarian abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for bilateral tuboovarian abscesses. You were treated with antibiotics. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns at ___. Please follow the instructions below. You should continue to take oral antibiotics - levofloxacin once daily and metronidazole three times daily up until surgery date, will discuss if needed post-op. 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. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service for treatment of suspected bilateral tuboovarian abscesses. She was febrile the day of admission to 103.0. She was empirically started on unasyn and doxycycline, which was then changed to ceftriaxone and flagyl based on culture results from her prior tuboovarian abscesses. Chlamydia and gonorrhea testing performed on admission were negative. A pelvic ultrasound done the day of admission showed bilateral pyelosalpinges. By pelvic ultrasound, there was not sufficient fluid to aspirate, so a CT was performed on hospital day two to better evaluate fluid collections and the presence of pelvic abscesses. The CT revealed bilateral pyosalpinges and 7 cm pelvic abscess. She underwent an ultrasound-guided aspiration of 110ccs from the abscess and placement of a drain on hospital day two, which drained 40cc. The gram stain of the fluid from her abscess showed gram negative rods, but bacteria did not grow for sensitivities. Blood cultures taken during the admission were also negative. On hospital day three the drain fell out, and a follow up ultrasound showed insufficient fluid for aspiration. On hospital day three she had a repeat pelvic ultrasound showing fluid collection and 65cc was aspirated. She had an isolated fever to 101.3, but had shown significant clinical improvement. Her last fever was 101.1 on hospital day four (___). She was transitioned to a PO regimen of metronidazole and levofloxacin. She continued to remain afebrile on hospital day five. Although the plan was to monitor her vitals and symptoms for a 48-hour time period, the patient chose to leave against medical advice on hospital day 5. During her hospitalization she was also noted to have a prolonged INR of 2.0 on hospital day one, which was thought to be due to the imflammatory reaction caused by her pelvic infection. She was given vitamin K and monitored closely for bleeding. Her follow up INRs were 1.2-1.4's.
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10822800-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim / Motrin / latex / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) <ATTENDING> ___ <CHIEF COMPLAINT> Persistent cervical dysplasia with inadequate colposcopy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic-assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ gravida 4 para ___ who presents today in the office for consultation requested by Dr. ___ surgical management of persistent cervical dysplasia with inadequate colposcopy. The patient had a cold knife cone excision procedure performed by Dr. ___ in ___. She was left with a significantly small, stenotic cervix that with time has become so atrophic as to be flushed with the vaginal apex. Her h.o is as follows: Hx of LEEP ___ with negative path. Last Pap ___ negative. ___ - pap showed LGSIL, HPV+ ___ - Colpo showed LGSIL/CIN-1 ___ - pap showed normal cytology, HPV + ___ - pap showed normal cytology, HPV + ___ - pap showed normal cytology, HPV negative ___ Pap - cytology neg/+HR-HPV ___ - Pap: NILM, HPV positive ___ - Colposcopy: Cervical biopsy at 8 o'clock: Benign squamous mucosa; No transformation zone present. ___ - Pap showed ASCUS, HPV positive She understands the significant of having persistently HPV positive Pap smears despite no sexual partner in the last ___ years. She denies any vaginal bleeding or sensation of dryness. There is no change in her urinary or bowel habits. She does admit to occasional constipation which she manages with dietary modification. She believes it to be due to some of the supplementation that she takes. She does offer history of pulmonary embolism after her breast reduction surgery in ___. She is otherwise without any other clinically significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Problems (Last Verified ___ by ___, MD): ABNORMAL PAP SMEAR ALOPECIA AREATA ANEMIA ARTHRITIS COMPRESSION FRACTURES DOMESTIC VIOLENCE HEMMORHOID NECK PAIN PULMONARY EMBOLISM RECURRENT GENITAL HSV OSTEOPOROSIS COLONIC ADENOMA HIP PAIN OSTEOARTHRITIS TROCHANTERIC BURSITIS PAST SURGICAL HISTORY Surgical History (Last Verified ___ by ___, MD): CESAREAN SECTION DILATION AND CURETTAGE x 2 ROTATOR CUFF REPAIR right arm BUNIONECTOMY left foot LEEP Breast reduction (P) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Ovarian or Colon cancer. She has 2 aunts with breast cancer. She is single and works for the ___ for ___ ___'s office. <PHYSICAL EXAM> Physical Exam on Initial Evaluation: BP: 106/66 Weight: 122 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. VAGINAL EXAM - There was moderate vaginal atrophy. Cervical stenosis with atrophy (flushed with the vaginal apex) No apical descent (prior C-section followed by a vaginal delivery of a premature infant weighing 2 pounds) _ _ _ _ _ ________________________________________________________________ Physical Exam on Discharge: Vitals 24 HR Data (last updated ___ @ 324) Temp: 98.4 (Tm 98.6), BP: 100/59 (100-115/59-67), HR: 78 (78-79), RR: 18 (___), O2 sat: 95% (94-95), O2 delivery: Ra Fluid Balance (last updated ___ @ 601) Last 8 hours Total cumulative -75ml IN: Total 575ml, PO Amt 220ml, IV Amt Infused 355ml OUT: Total 650ml, Urine Amt 650ml Last 24 hours Total cumulative 905ml IN: Total 2045ml, PO Amt 340ml, IV Amt Infused 1705ml OUT: Total 1140ml, Urine Amt 1040ml, Emesis 100ml General: NAD, A&Ox3 CV: RRR, no m/r/g RESP: CTAB, no respiratory distress, normal work of breathing Abd: soft, non-tender, no rebound or guarding Incision: 5 LSC port sites c/d/i , gauze and bioocclusive taken down Dressings: steris GU: foley present Extremities: no calf tenderness, wwp, pboots on and active bilaterally, neg homans, no palp cords, vis symetric <PERTINENT RESULTS> Procedural pathology pending <MEDICATIONS ON ADMISSION> FLUOXETINE - fluoxetine 10 mg capsule. 1 (One) capsule(s) by mouth once a day FLUTICASONE PROPIONATE - fluticasone propionate 50 mcg/actuation nasal spray,suspension. 2 sprays(s) in each nostril once per day Use every day, not just as needed. LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth BID PRN as needed for anxiety Medications - OTC CALCIUM CARBONATE - calcium carbonate 500 mg calcium (1,250 mg) chewable tablet. 1 tablet(s) by mouth twice per day CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 10,000 unit capsule. 1 capsule(s) by mouth weekly OXYMETAZOLINE [AFRIN (OXYMETAZOLINE)] - Afrin (oxymetazoline) 0.05 % nasal spray. 3 sprays(s) each nostril twice daily for 3 days then stop! DO NOT USE FOR MORE THAN 3 DAYS EVERY 3 WEEKS. <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet by mouth twice a day Disp #*50 Tablet Refills: *0 3. Enoxaparin Sodium 30 mg SC DAILY RX *enoxaparin 30 mg/0.3 mL 30 mg subcutaneously once a day Disp #*6 Syringe Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet by mouth every four (4) hours Disp #*10 Tablet Refills: *0 FLUOXETINE - fluoxetine 10 mg capsule. 1 (One) capsule(s) by mouth once a day FLUTICASONE PROPIONATE - fluticasone propionate 50 mcg/actuation nasal spray,suspension. 2 sprays(s) in each nostril once per day Use every day, not just as needed. LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth BID PRN as needed for anxiety Medications - OTC CALCIUM CARBONATE - calcium carbonate 500 mg calcium (1,250 mg) chewable tablet. 1 tablet(s) by mouth twice per day CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 10,000 unit capsule. 1 capsule(s) by mouth weekly OXYMETAZOLINE [AFRIN (OXYMETAZOLINE)] - Afrin (oxymetazoline) 0.05 % nasal spray. 3 sprays(s) each nostril twice daily for 3 days then stop! DO NOT USE FOR MORE THAN 3 DAYS EVERY 3 WEEKS. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cervical dysplasia with inadequate colposcopy Urogenital atrophy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking opioids (e.g. oxycodone, hydromorphone) * Take a stool softener such as colace while taking opioids to prevent constipation. * Do not combine opioid and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Leave the steri-strips in place. They will fall off on their own. If they have not fallen off by 7 days post-op, you may remove them. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the Gynecology service after undergoing robotic-assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid and Toradol. 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 acetaminophen with oxycodone. 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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10824215-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Dilaudid / azithromycin / vancomycin / Rocephin / morphine <ATTENDING> ___. <CHIEF COMPLAINT> bilateral leg and knee pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ 17 weeks pregnant female PMHx sickle cell anemia and h/o peripartum UE DVT on ___ who presents for ongoing management of sickle cell crisis after being discharged from ___ on ___ for her sickle cell crisis. She has been having bilateral leg pain (mostly extending from her knees up) consistent with prior pain crises. She has not had any rash, joint swelling, no vaginal bleeding/discharge, dysuria, abdominal pain. She also denies any infectious symptoms of fever/chills. Per ED report, she was initially admitted to ___ where she had a complex admission for pain crisis with difficulty weaning her off morphine PCA and IV Benadryl 50 mg q3h with concern for addictive potential related to the IV Benadryl (she has morphine allergy but tolerates the morphine with Benadryl). During this hospitalization, both Psychiatry and MFM were closely involved. The patient ultimately decided to transfer her OB and Hem/Onc care (previously followed by hematologist Dr. ___ at ___ ___ to ___. In the ED, initial VS 98.3, 98, 103/79, 18, 100% on RA. Exam showed TTP of her knees and quadriceps without any appreciable effusion or deformity. Fetal heart tones were intact with HR 140. Initial labs showed wnl chemistries, LDH 175, WBC 15.7, Hgb 9.1, Plt 483. Retic-Aut 7.2, Abs-Ret 0.28. Lactate 1.0. UA notable for moderate leuks, negative nitrites, 1 WBC, few bacteria, 1 Epi. The patient was given 1L NS and morphine x 2 with Benadryl prior to transfer to the floor. Upon arrival to the floor, the patient reports ongoing pain of her BLE which prohibit her from walking. She states that during her pregnancies, she experiences frequent pain crises because she cannot take her hydroxyurea. She is not sure what precipitated her pain crisis but states that her typical triggers are cold weather, dehydration, and stress. She does not significant social stressors recently (having to move recently, etc.). Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. <PAST MEDICAL HISTORY> Prenatal Care: -___ ___ by U/S on ___ -Prenatal labs: Rh positive; remainder of labs not available -U/S ___: NT 2.3mm, normally shaped gestational sac, CRL 12.3wks 55mm --> pt denies any subsequent ultrasounds -Issues: #sickle cell disease: FOB sickle trait. Multiple hospital admissions in pregnancy for pain crises. #chronic pain, chronic opioid use #hx peripartum UE DVT: on lovenox 40mg QD #transfer of care: Was seeing ___ MD at ___. #NIPT with XXX: s/p ___ genetics c/s ___. per records, was considering amnio, but pt declined further w/u as of today. maternal karyotype 46XX. #Hx 35w PPROM: Was offered IM vs PV by ___ provider. Started on PV progesterone during ___ admission ___. #Admission to ___ ___ with acute pain crisis (back pain, chest pain, but no acute chest syndrome). Hct nadir 24. No e/o significant hemolysis. Per discharge summary, pt was on home regimen of MS ___ ___ and oxycodone 20mg q3h at admission. Treated with morophine PCA + home regimen, IVF. Uptitrated to MS ___ 45mg TID, Oxycodone 30mg q6h. Discharged without narcotic rx. #Admission to ___ ___: for bilateral leg/knee pain, pain crisis. See HPI. Left AMA. ObHx: -___ -G1: ___, SAB -G2: ___, SVD, 35w PPROM, multiple hospital admissions for sickle cell pain crises; neonate hospitalized for ___ weeks due to neonatal abstinence syndrome, pt on high doses of narcotics throughout pregnancy -G3: ___, SAB -G4: current PMH: -Sickle cell disease: Hemoglobin S/beta-thalassemia null (HbS/0) disease. Recurrent admissions for pain crises. Flares are sometimes intense and sudden onset. Other times more indolent. Difficult IV access. Off hydroxyurea since ___ due to pregnancy. -History of acute chest syndrome -History of bilateral avascular necrosis of femoral heads and shoulder -Opioid dependence: Per ___ records, has signed narcotic contract in ___ and "she agreed to not receive pain medicines from any other office aside from the ___ Primary Care Associates." Review of records shows MS-Contin use dating back to ___. Records confirm pt receives IV/PO Benadryl with morphine because of hives vs rash. -Chronic pain -Peripartum BUE DVT, dx ___ ___, 3 months postpartum, on Depo-Provera. Anticoagulated x 6 months. Per records, DVT in UE recurred in ___ ___enies. -Hx retropharyngeal abscess ___ at ___, treated w clindamycin -Dental abscess -Hx retinopathy in R eye ___ -Hx MRSA positivity ___: Rpt swab ___ negative. PSH: - Splenectomy - Cholecystectomy - Port cath placement in right subclavian given difficult peripheral access - R hip repair for avascular necrosis - shoulder exploration for avascular necrosis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Both parents with sickle cell trait. Her daughter is a carrier. <PHYSICAL EXAM> On day of discharge: VS: afebrile, wnl Gen: well-appearing, NAD, ambulating with minimal assistance around room Resp: nl resp effort Abd: soft, non-tender, gravid Ext: mild tenderness to palpation in bilateral knees and anterior thighs, no edema <PERTINENT RESULTS> ___ 07: 00PM BLOOD WBC-15.7* RBC-3.84* Hgb-9.1* Hct-28.4* MCV-74* MCH-23.7* MCHC-32.0 RDW-14.8 RDWSD-37.3 Plt ___ ___ 07: 00PM BLOOD Neuts-71.3* Lymphs-17.0* Monos-4.5* Eos-6.2 Baso-0.4 NRBC-1.7* Im ___ AbsNeut-11.20* AbsLymp-2.68 AbsMono-0.71 AbsEos-0.97* AbsBaso-0.06 ___ 03: 54PM BLOOD WBC-15.6* RBC-3.81* Hgb-9.1* Hct-27.5* MCV-72* MCH-23.9* MCHC-33.1 RDW-14.6 RDWSD-35.7 Plt ___ ___ 07: 15AM BLOOD WBC-13.9* RBC-3.29* Hgb-7.9* Hct-24.0* MCV-73* MCH-24.0* MCHC-32.9 RDW-14.3 RDWSD-35.9 Plt ___ ___ 05: 52AM BLOOD WBC-13.1* RBC-3.40* Hgb-8.1* Hct-24.8* MCV-73* MCH-23.8* MCHC-32.7 RDW-14.1 RDWSD-35.5 Plt ___ ___ 07: 00PM BLOOD ___ PTT-29.1 ___ ___ 07: 00PM BLOOD Ret Aut-7.2* Abs Ret-0.28* ___ 07: 00PM BLOOD Glucose-78 UreaN-5* Creat-0.5 Na-135 K-4.2 Cl-102 HCO3-21* AnGap-16 ___ 03: 54PM BLOOD Glucose-91 UreaN-4* Creat-0.5 Na-132* K-4.1 Cl-99 HCO3-20* AnGap-17 ___ 07: 15AM BLOOD Glucose-89 UreaN-4* Creat-0.5 Na-137 K-3.7 Cl-105 HCO3-20* AnGap-16 ___ 05: 52AM BLOOD Glucose-96 UreaN-3* Creat-0.5 Na-135 K-3.8 Cl-104 HCO3-22 AnGap-13 ___ 07: 00PM BLOOD LD(LDH)-175 ___ 03: 54PM BLOOD ALT-28 AST-27 LD(LDH)-180 AlkPhos-160* TotBili-0.4 ___ 07: 15AM BLOOD LD(LDH)-139 ___ 07: 00PM BLOOD Calcium-10.2 Phos-4.3 Mg-1.7 ___ 03: 54PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.7 ___ 07: 15AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.7 ___ 05: 52AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.8 ___ 07: 00PM BLOOD Hapto-51 ___ 07: 09PM BLOOD Lactate-1.0 ___ 08: 15PM URINE Color-Yellow Appear-Clear Sp ___ ___ 08: 15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD ___ 08: 15PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1 ___ 04: 20PM URINE Color-Straw Appear-Clear Sp ___ ___ 04: 20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 04: 50PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG marijua-NEG ___ 8: 15 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ CXR: IMPRESSION: No previous images. There is a right IJ Port-A-Cath that extends to the level of the cavoatrial junction or upper right atrium. The cardiac silhouette is within normal limits and there is no vascular congestion, pleural effusion, or acute focal pneumonia. There may be mild atelectatic changes above the elevated right hemidiaphragm <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Morphine SR (MS ___ 30 mg PO Q12H 2. OxyCODONE (Immediate Release) 30 mg PO Q6H: PRN Pain - Moderate 3. Morphine SR (MS ___ 15 mg PO NOON 4. FoLIC Acid 1 mg PO DAILY 5. Prenatal Vitamins 1 TAB PO DAILY 6. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time <DISCHARGE MEDICATIONS> 1. proGESTerone micronized 200 mg vaginal QHS prevention of recurrent preterm delivery RX *progesterone micronized [Endometrin] 100 mg Insert two tablets iinto vagina nightly. Disp #*60 Insert Refills: *3 2. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 3. FoLIC Acid 1 mg PO DAILY 4. Morphine SR (MS ___ 30 mg PO Q12H 5. Morphine SR (MS ___ 15 mg PO NOON 6. OxyCODONE (Immediate Release) 30 mg PO Q6H: PRN Pain - Moderate 7. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> sickle cell pain crisis <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 in the setting of leg pain consistent with a sickle cell crisis. We attempted to control your pain in the hospital and had the Hematology Oncology team consulted in your care. We recommended that you remain in the hospital for further titration of your pain medications, however you have decided to leave the hospital against medical advice. Dr. ___ has spoken with you extensively about your options and our recommendation for you to remain in the hospital, however you have clearly expressed your desire to go home. Please call you primary physician ___ to make an appointment this week to discuss your pain medications. Given your history of short cervix, you were given a prescription for vaginal progesterone, which you should continue every night.
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Ms. ___ is a ___+ weeks pregnant female PMHx sickle cell anemia, h/o peripartum UE DVT on Lovenox, chronic pain and chronic opioid use, hx PPROM who presents for ongoing management of sickle cell crisis after being discharged from ___ on ___ for her sickle cell crisis. # Sickle cell crisis: Patient p/w ongoing pain crisis after being discharged from ___ on day of admission for the same presentation. Here, her labs were consistent with likely chronic compensated hemolysis (___ is reassuringly wnl, haptoglobin is normal) given her reticulocytosis. There was not evidence of acute chest syndrome. Unclear what the precipitant of her pain crisis was, though patient has been admitted for same presentation for most of past 6 weeks so suspect significant element of chronic pain, with exacerbation of pains symptoms in pregnancy while off hydroxyurea. No infectious symptoms. Patient was continued on home dose of MSContin, and initially treated with a Morphine PCA (as she has been on at ___. She was seen by Hematology/Oncology who recommended pain control and O2. She was seen by chronic pain service. She reported mild improvement in symptoms on hospital day 3 and was transitioned off of PCA and started on home dose of oxycodone (30mg q6h). She also reported needing IV Benadryl while using morphine PCA due to history of allergy (?hives versus rash). There was concern at ___ per records re addictive behavior regarding benadryl; this was continued only while she was using the PCA. She was recommended to remain inpatient for further monitoring off her symptoms on home regimen, but she declined and left the hospital against medical advice. She had reported significant immobility due to her symptoms upon arrival to the hospital. A ___ consult was requested but they were unable to see the patient prior to her discharge. She was able to ambulate with minimal assistance on the day of discharge. #Chronic pain, chronic opioid use: Patient has a significant narcotic regimen that predates the pregnancy by many years. She has seen her PCP for approximately the last year, Dr. ___ at ___, who prescribes the narcotics and has a narcotics contract with her. He was contacted upon her admission and her history was reviewed. She has seen multiple chronic pain specialists but without regular follow-up care anywhere and has remained on chronic short and long acting opioids for many years. She was not provided with any prescriptions for opioids upon discharge. *) Hx BUE DVT: The patient reports being on prophylactic lovenox 40mg QD for at least last month of pregnancy. This was continued during her admission. It is unclear if she has ever had a thrombophilia work-up in past and this will be re-addressed as an outpatient. *) Hx PPROM: Per report, the patient had PPROM at 35 weeks in her prior pregnancy. She was counseled re progesterone supplementation in this pregnancy to decrease the risk of recurrent PPROM/PTL, and offered IM vs PV progesterone. She was started on PV progesterone during her inpatient stay at ___. She was continued on this regimen while here. The decision to continue PV vs IM progesterone will be re-addressed at her outpatient visit, but she was recommended to continue PV for now at the time of discharge. *) NIPT with XXX: Patient did not report any problems with the fetus at the time of admission but review of records noted NIPT results notable for XXX. Per summative discharge notes, patient was seen by genetic counseling at ___. Per patient's report, she was told that results were "not a big deal" and she did not need any further testing. Patient was briefly counseled re NIPT results, including potential for placental mosaicism, and neonatal implications of XXX aneuploidy, and option for amniocentesis for diagnostic testing. Patient underwent a bedside ultrasound that showed normal appearing fetus with appropriate fluid levels. Patient was recommended to see genetic counselors for further counseling and advised to continue inpatient admission to expedite formal ultrasound and genetic counselor appointment. Patient declined and decided to leave hospital against medical advice. *) Routine prenatal care: Patient has received all of her prenatal care at ___ but reports she would like to trasnfer her care to ___. This was reaffirmed on the day of discharge. A request to ___ schedulers will be sent to set up outpatient appointments. Once established, patient will need: -Medical records release to obtain prenatal labs and outpatient prenatal records from current pregnancy and prior pregnancy -Anesthesia consult -SW consult -NICU consult given hx NAS, opioid use #Dispo: Patient was discharged home on hospital day 3, against medical advice. Precautions were reviewed. Prescriptions were provided for vaginal progesterone alone. An outpatient appointment with ___ will be set up for prenatal care.
| 3,108
| 1,015
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10824564-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> A.E.R. ___ ___. <CHIEF COMPLAINT> vaginal bleeding/ abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p D&C for products of conception <HISTORY OF PRESENT ILLNESS> Ms. ___ was a ___ G4P2 who was ___ s/p SVD when she presented to ___ with increased abdominal pain and increased vaginal bleeding. She reports that she was recovering very well postpartum with decreasing bleeding every day, until day of presentation when she woke up with sharp constant abdominal pain that was worse with movement and increased vaginal bleeding. She changed about ___ pads throughout the day. Each pad has not been soaked upon changing. She denies lightheadedness, dizziness, chest pain or shortness of breath. At ___, she had a pelvic ultrasound demonstrating a heterogenous and thickened endometrium measuring 8.0 x 4.5 x 6.4cm with vascularity seen throughout. She also had a CT scan that was otherwise uremarkable. Given this finding, she was transferred to ___ for further evaluation and management. Of note, her primary OB is ___. She ultimately delivered at ___ because she could not make it to ___ in time for delivery. <PAST MEDICAL HISTORY> OBHx: - SAB x2 - SVD x 2 (___) GYNHx: - denies hx of abnormal pap, STDs, abnormal fibroids or ovarian cysts PMH: none PSH: appendectomy Meds: PNV, ibuprofen, Tylenol <ALLERGIES> NKDA SHx: engaged to ___, former smoker. Patient is breastfeeding for "vinny" <PHYSICAL EXAM> General: NAD, A&Ox3 Breasts: non-tender, no erythema, soft, nipples intact, pumping Lungs: No respiratory distress Abd: soft, nontender, fundus firm below umbilicus, mild fundal tenderness Extremities: no calf tenderness <PERTINENT RESULTS> LABS (OSH) CBC 8.3 > 11.2 | 34.8 < 242 IMAGING PUS ___: FINDINGS: The uterus is anteverted and measures 13.8 x 8.7 x 10.7 cm. The endometrium is heterogenous and thickened, measuring approximately 8.0 x 4.5 x 6.4 cm, with vascularity seen throughout, compatible with vascularized retained products of conception. The ovaries are normal. There is no free fluid. IMPRESSION: Vascularized retained products of conception in the endometrial cavity measure up to 8.0 cm. CT Abd/Pelvis: IMPRESSION: 1. Enlarged uterus demonstrating heterogeneous enhancement is likely secondary to patient's postpartum state. 2. Mild-to-moderate intermediate density fluid in the endometrial ___ is nonspecific but may represent hemorrhage products. Retained products of conception cannot be completely excluded. Please correlate with clinical history and physical exam. <DISCHARGE INSTRUCTIONS> See printed discharge instructions
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Patient was admitted and underwent a D&C for retained products of conception. She also began IV gent/clinda for c/f endometritis. She underwent a D&C with out issues. Please see op report for further details. She was continued on IV gent/clinda for 24 hours post procedure. Her blood cultures showed no growth in 24 hours. She was monitored for 24 hrs post procedure during which time she remained afebrile, was tolerating PO, was voiding and ambulating with out issue. She was then discharged home in stable condition with outpatient follow up. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain 2. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: s/p D&C for products of conception Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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| 239
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10824981-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Right flank pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at approx 7wks with right sided flank persistent flank pain since ___ AM. Pt reports that pain is aggravated by movement and deep inspiration. She reports low grade fevers of 100.2 or 100.1 but denies any temp >100.4. Pt also notes nausea and emesis today and difficulty to tolerate much food PO. She denies any dysuria but feels very full in her abdomen. She notes difficulty starting her stream. She denies any diarrhea or sick contacts at home. No VB/LOF. Pt has known quad gestation. She was discharged on ___ after LSC for left ovarian torsion reduction. Pt is still taking her PO Dilaudid which give her some pain relief. Pt was seen in office by Dr. ___. In the office pt had WBC count of 13, neg UA, and nl flow to both ovaries by ultrasound. <PAST MEDICAL HISTORY> None <SOCIAL HISTORY> Married. No T/E/D <PHYSICAL EXAM> On admission: 98.7 81 108/58 20 99 NAD Abd: soft, Mildly tender at incision sites and suprapubic regions, no rebound, no guarding, abd slightly distended Incision sites: C/D/I Ext: no calf tenderness SSE: nl appearing cervix, closed os Bi-manual exam: no CMT or adnexal tenderness <PERTINENT RESULTS> ___ 06: 00AM BLOOD WBC-10.4 RBC-3.25* Hgb-10.5* Hct-28.7* MCV-89 MCH-32.2* MCHC-36.4* RDW-12.0 Plt ___ ___ 02: 31PM BLOOD WBC-11.7* RBC-3.54* Hgb-11.3* Hct-31.1* MCV-88 MCH-31.9 MCHC-36.3* RDW-12.2 Plt ___ ___ 06: 00AM BLOOD Plt ___ ___ 02: 31PM BLOOD Plt ___ ___ 06: 00AM BLOOD Glucose-79 UreaN-12 Creat-0.6 Na-134 K-4.1 Cl-101 HCO3-25 AnGap-12 ___ 06: 00AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8 ___ 02: 31PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9 <MEDICATIONS ON ADMISSION> pre-natal vitamins <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *20 Tablet(s)* Refills: *0* 3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> R flank pain quadruplet pregnancy ovarian hyperstimulation syndrome recent ovarian torsion` <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor for fevers, chills, severe headache, chest pain, shortness of breath, increasing or changing abdominal pain, heavy vaginal bleeding, leg pain, any concerns/questions.
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This is a ___ G1P0 at approx 7wks with quad pregnancy and hx of left ovarian torsion, s/p laparoscopic reduction ___, admitted to gyn with right sided persistent flank attributed most likely secondary to right hemorrhage cyst. On arrival, in triage pt underwent TVUS which demonstrated no evidence of torsion, gall stones, hydronephrosis, only right hemorrhagic cyst. As pt was requiring IV narcotics she was admitted for serial abdominal exams and IV pain control overnight. Pt's Hct remained stable, and her pain improved. She was able to tolerate PO regular diet and PO narcotic for adequate pain control. She was discharged on HD#2 and will follow up with ___ IVF for pain management and quad pregnancy. Of note, while in house pt was seen by ___ attending, ___, for consultation regarding quad gestation.
| 843
| 177
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10824981-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> - leakage of fluid at 18 wks gestational age <MAJOR SURGICAL OR INVASIVE PROCEDURE> - vaginal delivery x 4 <HISTORY OF PRESENT ILLNESS> On admission: Ms. ___ is ___ yo G1P0 at 18.0 weeks with tetra-tetra quadruplet pregnancy who presents by ambulance with leakage of blood-tinged fluid at 8pm this evening. Patient notes large gush of fluid that "kept coming." No fetal movement yet. No abdominal cramping/CTX. No abdominal pain. No fevers/dysuria. <PAST MEDICAL HISTORY> - none <SOCIAL HISTORY> ___ <FAMILY HISTORY> - non-contributory <PHYSICAL EXAM> On admission: Vitals - T: 98.6 BP: 108/57 HR: 104,93 RR: 18 Gen: well, NAD Abd: soft, gravid, non-tender Ext: soft, non-tender Perineum: small bleeding at perineum, no active bleeding Speculum: +small amount of pooling, umbilical cord visualized, hand seen with movement, 30 cc blood clot in vault <PERTINENT RESULTS> ___ WBC-11.3 Hgb-11.3 Hct-31.5 Plt ___ ___ Neuts-73.2 ___ Monos-5.6 Eos-1.8 Baso-0.3 ___ WBC-11.3 Hgb-11.3 Hct-31.5 Plt ___ ___ Neuts-76.7 ___ Monos-5.3 Eos-1.4 Baso-0.3 . ___ ___ PTT-30.9 ___ ___ ___ PTT-30.8 ___ . ___ ___ . ___ FetlHgb-0 <MEDICATIONS ON ADMISSION> - none <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: 90 Tablet(s) Refills: 1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - quadruplet pregnancy; delivered at 18 weeks of gestation - premature rupture of membranes - intraamniotic infection <DISCHARGE CONDITION> - good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - take temperature twice per day; call with temp > 100.4 - call with increased vaginal bleeding, abdominal pain or malaise - nothing in the vagina and no tub bathing for 2 weeks
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*)PPROM/IUFD On admission, rupture of membranes and imminent delivery of quadruplet A was confirmed by exam and ultrasound. Intra-uterine fetal demise of quadruplet A was also noted at that time. There was no evidence of infection or abruption on presentation. After counseling regarding her options for management, she elected to initially proceed with expectant management. However, given the poor prognosis for carrying the remaining fetuses to viability, and the imminent delivery of quadruplet A, the decision was made to give cytotec to facilitate delivery. She subsequently delivered all four quadruplets via vaginal delivery, with spontaneous delivery of the placenta afterward. Rhogam was administered for Rh negative blood type, and she was seen by both the chaplain and social work during her hospitalization. Prophylactic antibiotics were administered for 24 hours postpartum; she was never febrile. Postpartum course was uneventful, with stable hematocrit and coagulation panel. She was discharged home in stable condition.
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10827553-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Post-partum hemorrhage/DIC <MAJOR SURGICAL OR INVASIVE PROCEDURE> (OB) ___: Repeat low transverse cesarean section. ___: Dilatation and curettage with Bakri balloon placement and exploratory laparotomy with supracervical hysterectomy, extensive lysis of adhesions, small-bowel resection, repair of cystotomy. ___ of small intestine near the ileocecal valve with no anastomosis performed, loops left in discontinuity, and repair of 3 pinhole perforations to the urinary bladder in a double-layer closure with an open abdomen. ___: Small Bowel resection, primary anastomosis, bladder repair, wound vac <HISTORY OF PRESENT ILLNESS> ___, gravida 6, para ___ who presented to Labor and Delivery on the day of delivery at 35 weeks and 4 days' gestation. She had felt leaking of fluid, and examination confirmed that she had had rupture of membranes. She had had a prior C-section for the term intrauterine fetal demise, as well as a prior myomectomy and had been advised not to labor or attempt a trial of labor after these surgeries. After the rupture was confirmed and delivery was recommended, she agreed with the plan to proceed with a repeat low transverse cesarean section which was complicated by delayed postopartum hemorrhage s/p reopening of celiotomy, cervical hysterectomy, with emergent intraoperative consultation by ACS for possible bowel injury. ACS intraoperative findings included approximately 20cm segment of bowel with contusions, hematoma, serosal tears and dense adhesions that did not appear viable as well as extraperitoneal bladder tears. <PAST MEDICAL HISTORY> PMH: Migraines, leiomyomatosis, anxiety, depression, hypothyroidism, insomnia, hyperlipidemia, factor V Leiden PSH: Myomectomy over ___ years ago, right breast lumpectomy (benign), cesarean section (intrauterine death) in ___ OBHx: SAB x 4 with D+Cs, c-section for ___ IUFD <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> NAD, A&Ox3 rrr no m/r/g NO respiratory distress Abd, mild Post op/ post partium ttp, no rebound or guarding. Wound vac over lower ___ incision. No erythema MAE, no edema <PERTINENT RESULTS> ___ 11: 52PM GLUCOSE-128* UREA N-19 CREAT-1.6* SODIUM-149* POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-25 ANION GAP-20 ___ 11: 52PM CALCIUM-13.5* PHOSPHATE-5.4* MAGNESIUM-3.9* ___ 11: 52PM WBC-7.2 RBC-3.23* HGB-9.7* HCT-26.4* MCV-82 MCH-30.2 MCHC-37.0* RDW-15.5 ___ 11: 52PM PLT COUNT-76* ___ 11: 52PM ___ PTT-30.8 ___ ___ 11: 52PM ___ 08: 27PM URINE HOURS-RANDOM CREAT-5 TOT PROT-132 PROT/CREA-26.4* ___ 07: 26PM TYPE-ART PO2-109* PCO2-46* PH-7.36 TOTAL CO2-27 BASE XS-0 ___ 07: 26PM GLUCOSE-115* LACTATE-6.4* ___ 07: 26PM freeCa-1.23 ___ 07: 18PM ___ PTT-37.4* ___ ___ 07: 18PM ___ 07: 16PM GLUCOSE-123* UREA N-18 CREAT-1.4* SODIUM-146* POTASSIUM-5.6* CHLORIDE-107 TOTAL CO2-23 ANION GAP-22* ___ 07: 16PM estGFR-Using this ___ 07: 16PM ALT(SGPT)-29 AST(SGOT)-55* ALK PHOS-56 TOT BILI-1.2 ___ 07: 16PM CALCIUM-15.0* PHOSPHATE-6.9* MAGNESIUM-1.5* ___ 07: 16PM WBC-6.8 RBC-3.49* HGB-10.8* HCT-29.7* MCV-85 MCH-31.0 MCHC-36.5* RDW-14.5 ___ 07: 16PM PLT COUNT-109* ___ 06: 07PM TYPE-ART PO2-121* PCO2-38 PH-7.37 TOTAL CO2-23 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED ___ 06: 07PM GLUCOSE-116* LACTATE-7.8* NA+-144 K+-6.4* CL--107 TCO2-22 ___ 06: 07PM freeCa-1.01* ___ 06: 00PM WBC-6.6 RBC-2.99* HGB-9.4* HCT-25.3* MCV-85 MCH-31.2 MCHC-36.9* RDW-14.4 ___ 06: 00PM PLT COUNT-153# ___ 06: 00PM ___ PTT-40.6* ___ ___ 06: 00PM ___ 05: 11PM TYPE-ART PO2-237* PCO2-39 PH-7.35 TOTAL CO2-22 BASE XS--3 ___ 05: 11PM GLUCOSE-133* LACTATE-8.3* NA+-144 K+-6.0* CL--107 TCO2-21 ___ 05: 11PM freeCa-1.23 ___ 04: 59PM WBC-6.5 RBC-3.92*# HGB-12.0# HCT-33.3* MCV-85 MCH-30.7 MCHC-36.1* RDW-14.4 ___ 04: 59PM PLT SMR-VERY LOW PLT COUNT-33*# ___ 04: 59PM ___ PTT-41.4* ___ ___ 04: 59PM ___ ___ 04: 03PM TYPE-ART PO2-210* PCO2-42 PH-7.30* TOTAL CO2-21 BASE XS--5 INTUBATED-INTUBATED VENT-CONTROLLED ___ 04: 01PM ___ PTT-47.2* ___ ___ 04: 01PM ___ ___ 03: 28PM TYPE-ART TEMP-34.6 RATES-14/ TIDAL VOL-530 PEEP-12 O2-58 PO2-209* PCO2-41 PH-7.22* TOTAL CO2-18* BASE XS--10 INTUBATED-INTUBATED VENT-CONTROLLED ___ 03: 28PM GLUCOSE-192* LACTATE-9.9* NA+-145 K+-5.0 CL--110* TCO2-17* ___ 03: 28PM HGB-10.4* calcHCT-31 O2 SAT-98 ___ 03: 28PM freeCa-1.11* ___ 02: 56PM WBC-12.7* RBC-3.04* HGB-9.5* HCT-26.7*# MCV-88 MCH-31.3 MCHC-35.7* RDW-14.3 ___ 02: 56PM NEUTS-71* BANDS-5 ___ MONOS-4 EOS-0 BASOS-0 ___ METAS-2* MYELOS-0 NUC RBCS-1* ___ 02: 56PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL ___ 02: 56PM PLT SMR-LOW PLT COUNT-128*# ___ 02: 56PM ___ PTT-63.6* ___ ___ 02: 56PM ___ ___ 02: 52PM TYPE-ART TEMP-35 PO2-152* PCO2-35 PH-6.90* TOTAL CO2-8* BASE XS--26 INTUBATED-INTUBATED VENT-CONTROLLED ___ 02: 52PM GLUCOSE-167* LACTATE-9.4* NA+-142 K+-3.3 CL--116* ___ 02: 52PM freeCa-0.63* ___ 02: 37PM TYPE-ART O2-95 PO2-100 PCO2-40 PH-6.83* TOTAL CO2-8* BASE XS--29 AADO2-541 REQ O2-89 INTUBATED-INTUBATED VENT-CONTROLLED ___ 02: 37PM GLUCOSE-191* LACTATE-10.5* NA+-140 K+-5.1 CL--115* ___ 02: 37PM HGB-10.7* calcHCT-32 O2 SAT-94 ___ 02: 37PM freeCa-0.91* ___ 02: 37PM freeCa-0.91* ___ 12: 52PM HGB-11.3* calcHCT-34 ___ 12: 52PM freeCa-1.07* ___ 12: 45PM WBC-20.6*# RBC-3.98* HGB-12.1 HCT-37.0 MCV-93 MCH-30.3 MCHC-32.7 RDW-15.7* ___ 12: 45PM NEUTS-78.3* LYMPHS-17.5* MONOS-3.6 EOS-0.2 BASOS-0.4 ___ 12: 45PM PLT SMR-VERY LOW PLT COUNT-77* ___ 12: 45PM ___ ___ 12: 45PM FIBRINOGE-44* ___ 11: 29AM VoidSpec-CLOTTY SPE ___ 07: 55AM WBC-6.6 RBC-3.97* HGB-11.8* HCT-34.5* MCV-87# MCH-29.7 MCHC-34.2 RDW-17.3* ___ 07: 55AM PLT SMR-LOW PLT COUNT-115* Renal US: ___: 1. No hydronephrosis. 2. Tiny nonobstructing right renal stone. 3. Echogenic cortices, suggestive of a diffuse parenchymal disease. Lower Extremity ___: No evidence of deep venous thrombosis in the bilateral lower extremity veins. CXR: ___: In comparison with the earlier study of this date, the nasogastric tube extends to the lower body of the stomach. Endotracheal tube and right IJ catheter remain in good position. At the left base, there is continued opacification consistent with volume loss in the left lower lobe and effusion. On the right, hemidiaphragm is now sharply seen. Cystogram ___ IMPRESSION: 1. No evidence of bladder leak. 2. Smooth contour deformity along the dome of the bladder likely relates to postsurgical changes or external compression from a hematoma. <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Hydrocortisone (Rectal) 2.5% Cream ___ID 2. Tucks Hemorrhoidal Oint 1% 1 Appl PR Q3H: PRN pain 3. Levothyroxine Sodium 25 mcg PO DAILY RX *levothyroxine 25 mcg 1 tablet(s) by mouth day Disp #*30 Tablet Refills: *4 4. Lorazepam 0.5 mg PO BID: PRN anxiety RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth twice a day Disp #*30 Tablet Refills: *0 5. OxycoDONE (Immediate Release) ___ mg PO Q3H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth four times a day Disp #*50 Tablet Refills: *0 6. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H: PRN headache RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills: *1 7. Enoxaparin Sodium 40 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc q day Disp #*25 Syringe Refills: *0 8. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth four times a day Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> twin pregnancy delivered previous c-section post partum hemmorrage placenta accreta intra abdominal adhesions of bladder and intestine <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 1rest. wound care for wound vac per ___ nurses.
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Mrs. ___ was admitted to the hospital on ___ for pre term rupture of membranes and underwent an initially uncomplicated low transverse cesearean section. In the PACU she began to have but in the PACU she began to have increased vaginal bleeding and become hypotensive and hemodynamicly unstable. She returned to the operating room where a bakri balloon placement was attempted however she continued to have ongoing uterine bleeding so the decision was made to reopen her the incision. At that time it was decided to perform a hysterectomy, however there were multiple adhesions to the small bowel and bladder. The ACS service was emergently called to the OR for evaluation of the small bowel and bladder adhesions. She required primary repair of her bladder and a small bowel resection. Please see operative reports for full details. She required multiple units of blood products and fluids. She was left open and in discontinuity and was transferred, intubated, to the TSICU. She continued to improve, but she did require platelet transfusions to maintain her platelets above 30. She also had an acute kidney injury likely due to ATN which resolved prior to discharge. She returned to the OR on ___ where she had an uncomplicated reanastomosis and closure. She tolerated the procedure well. A wound vac was placed and she returned to the TSICU. She was extubated on ___ and her platelets continued to increase. She was initially hypertensive and there was concern for pre-eclampsia so she received 12 hours of magnesium. She remained normotensive for the remainder of her hospital stay. She was transferred to the floor under the ACS service on ___. She remained NPO until she had return of bowel function, which was on ___. She was started on a regular diet, which she tolerated without difficulty and was transferred to the postpartum floor. On ___ she had a cystogram showing no bladder leak so her foley catheter was removed and she voided spontaneously. Her wound vac was removed and a wet to dry dressing applied to transition her to a different wound vac to be used at home. On hospital day 13, she was ambulating, voiding spontaneously, tolerating a regular diet and taking po pain medicine. She was discharged to home with ___ wound care and outpatient follow-up scheduled.
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10829221-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Gentamicin / Macrodantin / Bacitracin / Neosporin (neo-bac-polym) <ATTENDING> ___. <CHIEF COMPLAINT> complex adnexal cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic bilateral salpingo oopherectomy <HISTORY OF PRESENT ILLNESS> ___ G2P1 with history of right ovarian cyst that has been followed for a number of years. Patient reported that this cyst was first diagnosed pre menopausally. She was followed with surveillance by Dr. ___ at ___ and was discharged from the practice after having stable imaging. In ___, a PUS described this right cyst as being simple. A repeat ultrsaound in ___, described it as a 1.8cm cyst with an echogenic focus. The most recent PUS on ___ showed a 2.2cm right adnexal cyst with a thick wall that has increased from prior imaging. She had a CA-125 checked on ___ that was 8.7. The patient denies any symptoms related to this cyst. She had no abdominal or pelvic pain/early satiety/bloating/change in bowel or urinary habits/nausea/vomiting. 10 point ROS otherwise negative. <PAST MEDICAL HISTORY> OB-GYN History: G2P1010. SAB x 1, C Section x 1 LMP in ___. Patient reports one brief episode of PMB ___ years ago that was not further worked up as it resolved. She reports a longstanding history of uterine fibroids. She is followed by Dr. ___ Lichen ___ and vulvovaginal atrophy for which she takes Premarin and clobetasol. She denies a history of abnormal Pap smears or STDs. PMH: Multiple sclerosis (last flare in ___ Hypertension; Ocular hypertension PSH: Cesarean section, tonsillectomy, wisdom teeth extraction <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father with colon cancer and lung cancer in ___. Paternal grandmother with colon cancer in ___. Paternal cousin with breast cancer at age ___. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm pulm: clear to ausculatation bilaterally abd: soft, nontender, nondistended, incision clean/dry/intact ___: nontender, nonedematous <PERTINENT RESULTS> ___ 09: 55PM BLOOD WBC-9.7# RBC-3.87* Hgb-12.4 Hct-37.7 MCV-97 MCH-31.9 MCHC-32.8 RDW-13.3 Plt ___ ___ 01: 35PM BLOOD WBC-4.3 RBC-4.33 Hgb-13.9 Hct-41.5 MCV-96 MCH-32.2* MCHC-33.6 RDW-13.4 Plt ___ ___ 09: 55PM BLOOD Glucose-120* UreaN-12 Creat-0.8 Na-139 K-4.0 Cl-104 HCO3-30 AnGap-9 ___ 09: 55PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8 <MEDICATIONS ON ADMISSION> metoprolol 25 ER qday, premarin, clobetasol <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN pain RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 3. TraMADOL (Ultram) 50 mg PO Q4H: PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ovarian mass <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted for observation after your surgery. 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 for 2 weeks * No heavy lifting of objects >10lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecology oncology service after undergoing Laparoscopic bilateral salpingo oopherectomy. Please see the operative report for full details. She was admitted post-operatively for hypoxemia. For her hypoxemia she had a persistent oxygen requirement post-operatively in the setting of sedation. She declined a chest xray and the oxygen requirement resolved with IS overnight. Her urinary retention also resolved overnight. 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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10830614-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Lower left quadrant pain with large pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy and bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> This is a ___ yo G2P2 who presents as a transfer from ___ ___ for GYN Oncology consult re: large pelvic mass. Patient states she has had intermittent abdominal pain for the past 2 months but yesterday morning around 630am her pain became more severe ___ in the left lower quadrant associated with nasuea and vomiting, which prompted her to go to urgent care. They identified a large pelvic mass and sent her to ___ ___. At ___, they then decided that given the concern for torsion vs. malignancy, that she be transferred to ___ for Oncology care. She states that her pain has persisted. Without medication it is ___, with the medication it improves to ___. No further nausea, but endorses decreased appetite. No weight changes, no early satiety. ROS otherwise negative. <PAST MEDICAL HISTORY> Past OB History: G2P2, SVD x 1, LTCS x 1 Past Gyn History: Regular menses, denies history of sexually transmitted infections. Denies history of abnormal Papsmears. Last Pap was approximately ___ years ago and negative. Last mammogram also approximately ___ years ago and negative. Past medical history: reports history of provoked lower extremity deep vein thrombosis in setting of knee surgery (did not take anticoagulation) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother had a deep vein thrombosis in the setting of long plane flight. Denies family history of ovarian, endometrial, cervical, breast, or colon cancer. <PHYSICAL EXAM> Afebrile, vitals stable No acute distress, comfortable, and conversing actively CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, vertical midline incision clean/dry/intact with sutures, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 04: 36AM BLOOD WBC-11.8* RBC-2.86* Hgb-8.4* Hct-24.9* MCV-87 MCH-29.4 MCHC-33.7 RDW-13.1 RDWSD-41.5 Plt ___ ___ 07: 05AM BLOOD WBC-12.1* RBC-3.69* Hgb-10.8* Hct-31.4* MCV-85 MCH-29.3 MCHC-34.4 RDW-13.1 RDWSD-40.4 Plt ___ ___ 09: 11PM BLOOD WBC-11.6* RBC-4.11 Hgb-11.9 Hct-34.7 MCV-84 MCH-29.0 MCHC-34.3 RDW-13.0 RDWSD-39.6 Plt ___ ___ 04: 36AM BLOOD Neuts-78.5* Lymphs-13.9* Monos-7.0 Eos-0.1* Baso-0.1 Im ___ AbsNeut-9.26* AbsLymp-1.64 AbsMono-0.82* AbsEos-0.01* AbsBaso-0.01 ___ 09: 11PM BLOOD Neuts-78.1* Lymphs-16.1* Monos-5.0 Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.03* AbsLymp-1.87 AbsMono-0.58 AbsEos-0.02* AbsBaso-0.04 ___ 04: 36AM BLOOD Glucose-130* UreaN-11 Creat-0.6 Na-139 K-3.8 Cl-106 HCO3-23 AnGap-14 ___ 07: 05AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-138 K-3.7 Cl-107 HCO3-22 AnGap-13 ___ 09: 11PM BLOOD Glucose-99 UreaN-13 Creat-0.6 Na-138 K-3.8 Cl-106 HCO3-20* AnGap-16 ___ 04: 36AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.6 ___ 07: 05AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 ___ 09: 11PM BLOOD CEA-<1.0 CA125-20 ___ 12: 12AM URINE Color-Yellow Appear-Clear Sp ___ ___ 12: 12AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 12: 12AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Blood Culture, Routine (Pending): <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ 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: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> left adnexal mass ovarian torsion <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 an exploratory laparotomy with left salpingo-oophorectomy (removal of your left ovary and tube). You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ yo G2P2 who initialy presented from outside hospital for left lower quadrant pain and large pelvic mass who was admitted to the gynecologic oncology service for further evaluation. A pelvic US showed: large, left adnexal solid and cystic mass, worrisome for malignancy. Nonvisualized left ovary, precluding the exclusion of left ovary torsion, particularly in the setting of large volume, complex free pelvic fluid which may represent hemorrhage. Due to the findings on ultrasound, the decision was made to proceed with an exploratory laparotomy. Intraoperatively, a torsed necrotic left ovary was noted, so the patient underwent a left salpingo-oophorectomy. Please see the operative report for full details. Immediately postoperatively, her pain was controlled immediately with an epidural, and advanced post operative day #1 to Acetaminophen and Ibuprofen after epidural was removed. She never required narcotics. Her diet was advanced without difficulty to a regular diet immediately after her procedure. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She was ambulating independently during her hospital stay. She was discharged home on post-operative day #2 in stable condition with outpatient follow-up scheduled.
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10832136-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> CC: chest pain, emesis HPI: ___ yo G2P1 at 9 ___ transferred from OSH ED for chest pain. Recently admitted to ___ on ___ for hyperemesis and chest pain, discharged ___. Patient sent home with PO unisom and B6, reports that she has since been unable to tolerate PO however. Reports recurrence of chest pain, which had previously entirely resolved per patient during prior admission, and subsequently presented to OSH. Labs there included a negative troponin, ___ 225, EKG showed sinus rhythm with T wave fluttering in 3 and aVF. Prior to transfer she received IVF, Zofran, Tylenol, morphine, Pepcid, Benadryl, and reglan with minimal improvement in symptoms. Transfer records report that she has been seen in the ED multiple times for LUQ pain, nausea, vomiting, diarrhea. Prior to being transferred, patient became agitated, began vomiting and passed a "vaginal clot," however, declined pelvic exam. BPs at outside hospital were 126s-170/70-109. Upon being transferred, patient was initially very aggressive both verbally and physically. Repeatedly asking for pain medications per RN. Per RN she has been entirely quiet while alone, but becomes disruptive, agitated and symptomatic upon being engaged. She denies CP, SOB, vaginal bleeding. She has not been able to keep anything down today, including fluids. During interview patient intermittently became agitated demanding pain medication. She would occasionally spit up in a kidney bin. ___ interpreter offered, however, patient declined and again became aggressive and began to yell "you are killing me." OB: G2P1 - G1: SVD in ___, full term, no complications per patient - G2: Current GYN: Not discussed given patient agitated during interview PMH: - T2DM, poorly controlled, on lantus - HTN, labetalol 300 mg BID, not compliant per patient - PTSD - Diabetic nephropathy, per OSH records, recently had a renal biopsy - Migraines - Myopia of both eyes - Sciatica left side - Depression PSH: - Total laminectomy L4-5 Meds: - Labetalol 300 mg BID - Lantus 15 units QHS ALL: NKDA SH: Originally from ___. Lives home alone. Her other child is back in ___. Does not work. Denies T/E/D. FH: She is not sure if she has any family history of breast, ovarian, or colon cancer. <MAJOR SURGICAL OR INVASIVE PROCEDURE> EGD, barium swallow <PHYSICAL EXAM> ADMISSION EXAM: Vitals: 96.8 95 173/105 17 100% RA General: Sleeping, awoken after raising voice and explaining reason for interview, intermittently upset, asking for pain medication, yelling, "you are killing me," "what is wrong with you," occasionally spitting up in waste bin CV: tachycardic, no murmurs Resp: CTAB Abd: soft, non-tender, no rebound or guarding, +BS, non-acute Ext: non-tender, no edema, discoloration of hands and feet bilaterally Pelvic: deferred given patient aggressiveness Msk: no CVA tenderness bilaterally, mild tenderness to palpation of left costal/sternal margin DISCHARGE EXAM: VS: temp 99, 142 / 88, HR 98, 18, 98% on RA 24 hr BP Range: 110s-1480s/60s-80s Gen NADs CV regular rate, tenderness over left lower ribs Pulm nl respiratory effort Abd mild epigastric and diffuse abdominal TTP. abdomen nondistended. no r/g. Ext no calf tenderness/edema <PERTINENT RESULTS> LABS -=== ___ 09: 00AM BLOOD WBC-4.7 RBC-2.52* Hgb-8.1* Hct-23.5* MCV-93 MCH-32.1* MCHC-34.5 RDW-13.7 RDWSD-46.2 Plt ___ ___ 06: 30AM BLOOD WBC-4.7 RBC-2.22* Hgb-6.9* Hct-20.4* MCV-92 MCH-31.1 MCHC-33.8 RDW-13.7 RDWSD-45.2 Plt ___ ___ 05: 53AM BLOOD WBC-5.1 RBC-2.21* Hgb-6.9* Hct-20.2* MCV-91 MCH-31.2 MCHC-34.2 RDW-13.6 RDWSD-44.3 Plt ___ ___ 10: 39PM BLOOD WBC-8.2 RBC-2.81* Hgb-8.8* Hct-25.5* MCV-91 MCH-31.3 MCHC-34.5 RDW-13.2 RDWSD-43.0 Plt ___ ___ 10: 39PM BLOOD Neuts-85.6* Lymphs-10.0* Monos-2.4* Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.03* AbsLymp-0.82* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.02 ___ 05: 53AM BLOOD Ret Aut-8.7* Abs Ret-0.19* ___ 09: 00AM BLOOD Glucose-185* UreaN-7 Creat-0.5 Na-131* K-4.0 Cl-95* HCO3-23 AnGap-13 ___ 06: 30AM BLOOD Glucose-107* UreaN-7 Creat-0.5 Na-134* K-3.7 Cl-100 HCO3-23 AnGap-11 ___ 05: 53AM BLOOD Glucose-82 UreaN-7 Creat-0.5 Na-137 K-3.3 Cl-103 HCO3-22 AnGap-12 ___ 06: 19AM BLOOD Glucose-137* UreaN-8 Creat-0.5 Na-132* K-3.4 Cl-100 HCO3-23 AnGap-9* ___ 09: 30AM BLOOD Glucose-184* UreaN-8 Creat-0.5 Na-130* K-3.8 Cl-97 HCO3-23 AnGap-10 ___ 10: 39PM BLOOD Glucose-229* UreaN-7 Creat-0.5 Na-131* K-4.0 Cl-95* HCO3-21* AnGap-15 ___ 09: 00AM BLOOD ALT-21 AST-18 TotBili-0.3 ___ 06: 30AM BLOOD ALT-21 AST-19 TotBili-0.3 ___ 05: 53AM BLOOD ALT-24 AST-25 LD(LDH)-241 ___ 10: 39PM BLOOD ALT-23 AST-29 AlkPhos-103 TotBili-0.5 ___ 10: 39PM BLOOD cTropnT-<0.01 ___ 10: 39PM BLOOD proBNP-215* ___ 10: 39PM BLOOD Lipase-40 ___ 09: 00AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.5* ___ 06: 30AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.6 ___ 05: 53AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.9 ___ 10: 39PM BLOOD Albumin-3.3* ___ 05: 53AM BLOOD Hapto-81 ___ 12: 51AM BLOOD D-Dimer-3407* ___ 06: 19AM BLOOD %HbA1c-6.4* eAG-137* ___ 10: 59PM BLOOD %HbA1c-6.2* eAG-131* ___ 10: 53PM BLOOD ___ pO2-35* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 ___ 10: 53PM BLOOD Lactate-1.7 ___ 10: 53PM BLOOD O2 Sat-62 ___ 04: 21AM URINE Color-Straw Appear-Clear Sp ___ ___ 04: 21AM URINE Blood-SM* Nitrite-NEG Protein-300* Glucose-1000* Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 04: 21AM URINE RBC-29* WBC-2 Bacteri-FEW* Yeast-NONE Epi-4 ___ 04: 21AM URINE CastHy-4* ___ 02: 30PM URINE Hours-RANDOM Creat-160 Albumin-854.5 Alb/Cre-5340.6* ___ 04: 21AM URINE CT-NEG NG-NEG ___ 04: 21AM URINE UCG-POSITIVE* MICROBIOLOGY -=== ___ 4: 21 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING -=== Pelvic US ___: Single live intrauterine pregnancy with size measuring 9 weeks 6 days. ___. CTA Chest ___: No evidence of pulmonary embolism or aortic abnormality. Abdominal US ___: 1. Small amount of retroperitoneal perinephric fluid is seen surrounding the right kidney, which may be sequela of forniceal rupture from prior hydronephrosis. However, no definite hydronephrosis seen on today's study. 2. Small amount of nonspecific perisplenic fluid is also noted. <DISCHARGE INSTRUCTIONS> Dear. Ms. ___, You were admitted to the hospital with epigastric pain with nausea and vomiting. You had an EGD done by the GI doctors that showed normal mucosa, possible mild gastroparesis. You had normal liver labs. You did a barium swallow test that was negative, and had a CT of your lungs that did not show a blood clot. You were noted to have a low blood cell count, though it was stable throughout your stay. Your labs looking for the cause of your low blood cell count were normal. We reviewed these findings with hematology, who did not recommend further evaluation at this time, but arranged for you to see them as an outpatient. You were also seen by the ___ Diabetes team and your insulin was adjusted. You reported feeling depressed, and were followed by the psychiatry team during your stay here. Your symptoms improved and we feel you are able to be discharged home. You reported that you do not have concerns about safety or thoughts about hurting yourself. If you start to feel more depressed or have thoughts of hurting yourself, you should call ___. You can also use the following resources: --___ Community Services ___. 24 hour a day crisis line and emergency psychiatric services --MCPAP for Moms ___ We are arranging for the PT1 transport system for you to get to and from your appointments. ___ and ___, our social workers, will continue to be in touch with you about transportation and helping to arrange a safe place for you to go when you leave your apartment on ___. Don't hesitate to reach out to us with any questions or concerns. We are always here for you.
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Ms. ___ is a ___ yo G2P1 admitted to the Antepartum Service on ___ at 9 weeks gestational age. She has a history of poorly controlled hypertension and type 2 diabetes and presented to the ED (transferred from OSH) with chest pain. *) Left thoracic, left upper quadrant, epigastric pain, nausea/vomiting: Pt reported a ___ year history of recurrent symptoms. She had negative troponins and a normal EKG at the OSH and at ___ ED. Her labs on ___ were notable for normal liver function tets, lipase, Tbili, BNP, and anti-TTA> She also had a CTA on ___ that was negative for PE. During her hospital stay, her pain and nausea improved with IV Pepcid and a GI cocktail. She also received several other reflux/gastritis, and antiemetic medications (including regland, famotidine, zofran). She was able to tolerate a regular diet. GI was consulted and the decision was made to proceed with an EGD to exclude ___, pelvic ulcer disease, and esophagitis. The EGD (___) was unremarkable and her discomfort was thought to be due to reflux and gastroparesis. *) T2DM: Her HbA1c was noted to be 8.7% on ___ (per OSH records). Of note, her repeat HbA1c was 6.4% on ___ (unclear why there was such a drastic change from 2 weeks prior. per discussion w/ ___ Diabetes service Ddx includes recent blood loss vs. hemolytic episode). During this admission, her medication regimen was titrated by the ___ endocrinology service. She was initially on Lantus 15U QHS and a Humalog sliding scale (___). On ___ she was switched from Lantus 15U QHS to Levemir 15U QHS but remained on the Humalog sliding scale with meals. She was ultimately placed on Levemir 13U QHS and Humalog 2U with meals (breakfast/lunch/dinner) in addition to a sliding scale (this regimen was started on ___. Her FSBG were in the 100s-140s range in the 2 days leading up to discharge. *) Anemia: Ms. ___ trend was as follows: Hct 34.9 (___) -> 25.5 (___) -> 20.2 (___) -> 20.4 (___) -> 23.5 (___). Per review of OSH records her iron studies and Hb electrophoresis were within normal limits. Her stool guiac was negative. The etiology of her anemia was unclear (per Heme Onc curbside ?hemolytic/bleeding episode in the past which has since resolved). Given that she remained asymptomatic and that her anemia stabilized then improved, she was scheduled for outpatient follow-up. *) Chronic HTN: She was continued on labetalol 300mg BID during this admission and her blood pressures remained within goal range. *) Depression/poor coping: Ms. ___ was seen by the Psychiatry service for depression and poor coping while in the hospital. They recommended starting Haldol prn anxiety and agitation. She was also seen by social work during this admission. On ___, Ms. ___ pain was minimal, she was tolerating a regular diet, her blood sugar levels were less poorly-controlled, and her blood pressures remained within goal range. She was discharged home with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen [Children's Acetaminophen] 325 mg/10.15 mL 20.3 mL by mouth every 6 hours Disp #*1 Vial Refills:*2 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*2 3. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills:*2 4. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN dyspepsia RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400 mg-400 mg-40 mg/5 mL 5 mL by mouth daily Refills:*0 5. Ondansetron ___ mg PO Q8H:PRN nausea 6. Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Levemir 13 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin lispro [Humalog] 100 unit/mL 6 units SC with meals Disp #*1 Cartridge Refills:*2 RX *insulin detemir [Levemir] 100 unit/mL 13 units SC 13 Units before BED Disp #*1 Vial Refills:*2 7. Labetalol 300 mg PO BID RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: epigastric pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10834821-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> monostat <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo G0 woman s/p egg retrieval ___ who is transferred from ___ for ___. She is an egg donor and s/p egg retrieval ___ with Lupron trigger + 1,000 HCG, peak E2 >7400, 51 eggs retrieved. Since the retrieval she has noted nausea vomiting and inability to tolerate p.o.'s. She has not able to keep anything down since her procedure. She also noted increasing abdominal distention and diffuse tenderness. Yesterday she had episode of syncope and overall weakness and presented to ___ for evaluation. She denies hitting her head or trauma. Findings at ___ was significant for ___ count 21, Hct 45, normal kidney and liver function tests, moderate ascites on exam. She was also noted to have some pleural effusion and ascites on imaging. She was transferred to twice daily MC for further management. In the ED here, she reports that her nausea vomiting has resolved. She continues to note abdominal distention. She had diffuse tenderness that worsened on her ambulance ride here that is now controlled after IV morphine. She denies any chest pain. She has no shortness of breath but does feel that her abdominal pressure is making it harder to take deep breaths. Denies any cough, fevers, vaginal bleeding, abnl vaginal discharge, dysuria, hematuria. <PAST MEDICAL HISTORY> OBHx: -TAB x 1 , D&C GynHx: - denies h/o abnl Pap, fibroids, STIs PMH: -Asthma PSH: -Open umbilical hernia repair <SOCIAL HISTORY> ___ <FAMILY HISTORY> denies bleeding/clotting disorders <PHYSICAL EXAM> Physical exam Upon prsentationL VS: 98.4 92 115/75 16 97% RA 98.3 89 110/71 18 98% RA Gen: A&Ox3, NAD CV: RRR Pulm: no respiratory distress, decreased breath sounds in the lower bases Abd: soft, moderately distended, no rebound/guarding. Diffusely mildly tender. No peritoneal signs Ext: no TTP, no edema Pelvic: Deferred Physical Exam on Discharge: <PERTINENT RESULTS> ___ 06: 20AM BLOOD WBC-11.1* RBC-3.80* Hgb-10.7* Hct-31.3* MCV-82 MCH-28.2 MCHC-34.2 RDW-13.2 RDWSD-39.3 Plt ___ ___ 03: 10AM BLOOD WBC-17.9* RBC-4.50 Hgb-12.5 Hct-37.5 MCV-83 MCH-27.8 MCHC-33.3 RDW-13.2 RDWSD-40.1 Plt ___ ___ 03: 10AM BLOOD Neuts-74.0* Lymphs-16.1* Monos-8.6 Eos-0.0* Baso-0.3 Im ___ AbsNeut-13.27* AbsLymp-2.88 AbsMono-1.55* AbsEos-0.00* AbsBaso-0.05 ___ 06: 20AM BLOOD Glucose-81 UreaN-7 Creat-0.6 Na-143 K-4.3 Cl-107 HCO3-21* AnGap-15 ___ 03: 10AM BLOOD Glucose-70 UreaN-13 Creat-0.8 Na-137 K-4.1 Cl-102 HCO3-20* AnGap-15 ___ 03: 10AM BLOOD ALT-12 AST-16 AlkPhos-45 TotBili-1.1 ___ 03: 10AM BLOOD Lipase-10 ___ 03: 10AM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.0 Mg-1.8 Chest PA/Lateral: Small right and trace left pleural effusions. Subsegmental atelectasis at the lung bases, versus very small infiltrates. Pelvic Ultrasound: FINDINGS: The uterus is anteverted and measures 7.7 x 3.5 x 4.7 cm. The endometrium is homogenous and measures 5 mm. The ovaries are markedly enlarged, and contain multiple cysts with a open "spoke-wheel appearance." Right ovary measures 10.6 x 8.1 x 8.4 cm. The left ovary measures 10.9 x 7.2 x 11.7 cm. Small to moderate ascites is noted. IMPRESSION: Markedly enlarged ovaries with multiple cysts, associated with mild to moderate ascites, suspicious for ovarian hyperstimulation syndrome. <MEDICATIONS ON ADMISSION> Cabergoline <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4000 mg in a day RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6HR Disp #*50 Tablet Refills: *1 2. cabergoline 0.5 mg oral DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ovarian hyperstimulation syndrome <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. 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 for care of ovarian hyperstimulation syndrome. The team feels you have recovered well. Please follow the instructions below: * Please call Dr. ___ for a follow up appointment in the 1 week * Please call your doctor if you notice the below: - rapid weight gain - abdominal pain - vomiting - shortness of breath
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Ms. ___ was admitted to the GYN service due to concern for ovarian hyperstimulation syndrome. *)Moderate ovarian hyperstimulation syndrome She was status post egg retrieval on ___ and was transferred from ___ for ___. She is an egg donor and status post egg retrieval on ___ with Lupron trigger + 1,000 HCG, peak E2 >7400, 51 eggs retrieved. She presented with abdominal pain and inability to tolerate PO and syncopal episode. She was hemodynamically stable but hemoconcentrated. She also had abdominal ascites on ultrasound and a small pleural effusion however so she was admitted to the GYN service for further management. She had her weight monitored daily and was started on lovenox prophylaxis. Her pain was controlled with PO pain meds. She was made NPO for a possible parcentesis for symptomatic relief and given IV fluids. She had an interventional radiology consult for possible drainage of fluid however, there was no large enough pocket to drain via paracentesis. Her symptoms improved the next morning as well, so paracentesis was deferred. On hospital day 2, her pain had significantly improved and she was able to tolerate PO. Her hemoconcentration resolved with judicious IV and PO fluids. Given her improved clinical picture and normalized labs, she was discharged home with instructions to follow up closely with Dr. ___.
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10843678-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Bentyl / Compazine / Ciprofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> This is a ___ yo ___ s/p LSC excision of endometriosis on ___ who presents with fever. Last night she states she felt tired and had a low grade temp of 99 to 101. She woke up at 0300 with rigors and found her temperature to be 105. At this time she felt nauseous and short of breath. These complaints spontaneously resolved. She states that she took 3 percocet, 2 fentanyl, and zofran at home. She then presented to ___ where she had a temp of 100.0 and was treated with vanc before transfer to ___ ED. She has a long history of chronic abdominal pain and opiod dependence. She has had a colectomy for diverticulitis and now an excision of endometriosis. ROS notes 25 pound weight loss in last month, recent diarrhea, constipation, nausea, chest pain and shortness of breath which all preceed her surgery. <PAST MEDICAL HISTORY> POB: - SVD x 2 term 7#5 and 6#13 ___ and ___ PGYN: - menarche age ___, menses q25-30 days - LMP "recent", states irregular bleeding on Lupron -sexually active with mutually monogamous male partner - contraception-> partner s/p vasectomy - no history of abnl paps or STIs, last pap ___ - On Lupron, last dose ___ PMH: - anxiety - liver hemangioma - diverticulitis - IBS - IC - atrophic right kidney with duplicate left renal collecting system PSH: - lap cholecystectomy ___ - lap right colectomy for diverticulitis ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother and sister with diverticulitis Dad with MI Mother with Stage IV metastatic breast ca, age ___ maternal cousin with breast cancer in ___ <PHYSICAL EXAM> (On admission) VS: 99.5 110 100/68 18 100%RA Gen: NAD Card: Mildly tachycardiac, regular Resp: Reduced in right base Abd: Soft, diffuse mild tenderness, port sites well healed without drainage Pelvic: +Diffuse pain on bimanual exam, unable to assess for CMT. No masses. (+stool in rectal vault) Ext: NT, NE (On discharge) VS: 99.0 ___ 16 100%RA Gen: NAD Card: Mildly tachycardiac, regular Resp: Reduced in right base with faint crackles on R side Abd: Soft, diffuse mild tenderness, port sites well healed without drainage Ext: NT, NE <PERTINENT RESULTS> ___ 09: 20AM BLOOD WBC-9.1 RBC-3.39 Hgb-10.5 Hct-32.7 MCV-97 MCH-31.0 MCHC-32.2 RDW-13.4 Plt ___ ___ 09: 20AM BLOOD Neuts-85.9 ___ Monos-4.6 Eos-1.2 Baso-0.2 ___ 09: 20AM BLOOD ___ PTT-26.7 ___ ___ 09: 20AM BLOOD Glucose-90 UreaN-7 Creat-0.7 Na-142 K-3.7 Cl-113 HCO3-22 AnGap-11 ___ 09: 20AM BLOOD ALT-12 AST-18 AlkPhos-49 TotBili-0.2 ___ 09: 20AM BLOOD Lipase-20 ___ 09: 20AM BLOOD Albumin-3.4 Calcium-7.6 Phos-2.5 Mg-1.6 ___ 06: 54AM BLOOD HIV Ab-NEGATIVE ___ 09: 20AM URINE Color-Straw Appear-Clear Sp ___ ___ 09: 20AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 09: 20AM URINE UCG-NEGATIVE ___ CXR HISTORY: Fevers in a patient status post laparoscopic excision of endometriosis. Evaluate for pneumonia. COMPARISON: The radiographs from ___. FINDINGS: There is a focus of heterogeneous opacity in the right upper lobe, which may represent acute infectious process. The lungs are otherwise clear. There is no pneumothorax or pleural effusion. The hilar and cardiomediastinal contours are normal. The pulmonary vascularity is normal. Postoperative pneumoperitoneum seen on the prior radiograph has resolved. IMPRESSION: New focus of heterogeneous opacity in the right upper lobe is concerning for pneumonia. The study and the report were reviewed by the staff radiologist. ___ CTAP HISTORY: ___ female postop day 8 status post lysis of adhesions and excision of endometriomas, now with diffuse abdominal pain and fever. TECHNIQUE: Axial CT images through the abdomen and pelvis were acquired after administration of intravenous contrast. Coronal and sagittal reformatted images were reviewed. COMPARISON: ___. FINDINGS: The lung bases demonstrates subtle ground-glass opacities bilaterally without pleural effusion. This is new compared to prior. No pericardial effusion is seen. Abdomen: The spleen, pancreas, adrenal glands, left kidney, stomach, small bowel, and postoperative colon appear unremarkable; the colonic anastomosis appears patent. The patient is status post cholecystectomy and surgical clips are seen in the gallbladder fossa. hypodensity and calcification is seen. The right kidney is absent. In the right renal fossa there is a 2.6 x 1.1 cm hyperdense or enhancing mass with areas of hypodensity and calcification, which likely represents the right renal remnant. An 11 x 9 mm round hypodensity is seen in segment VI of the liver with a central hyperdense or enhancing focus. No free intraperitoneal air or ascites is detected. Major central intra-abdominal vasculature appears patent and normal in caliber. Pelvis: The bladder, uterus, and rectum are unremarkable. No free fluid is seen in the pelvis. No concerning lytic or sclerotic osseous lesions are detected. Postsurgical changes are seen in the anterior abdominal wall, most notable around the umbilicus. IMPRESSION: 1. Subtle mild ground-glass opacities in the lung bases bilaterally are new compared to prior. Differential diagnosis includes infection and aspiration. 2. No acute intra-abdominal or pelvic findings. 3. 11 mm round hypodensity in segment VI of the liver with a central hyperdense or enhancing focus, which likely represents a hemangioma. The study and the report were reviewed by the staff radiologist. <MEDICATIONS ON ADMISSION> Medications - Prescription AMITRIPTYLINE - amitriptyline 10 mg tablet. 1 tablet(s) by mouth at bedtime GABAPENTIN - gabapentin 100 mg capsule. 1 capsule(s) by mouth three times a day - (2 capsules daily) HYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 325 mg tablet. 1 tablet(s) by mouth q 6 hours as needed for severe pain - (Prescribed by Other Provider) HYDROMORPHONE [DILAUDID] - Dilaudid 2 mg tablet. ___ tablet(s) by mouth Q4hrs as needed for pain IBUPROFEN - ibuprofen 600 mg tablet. 1 Tablet(s) by mouth q6hrs as needed for pain LEUPROLIDE (3 MONTH) [LUPRON DEPOT (3 MONTH)] - Lupron Depot (3 Month) 11.25 mg IM Syringe Kit. 1 injection IM once LIDOCAINE [LIDODERM] - Lidoderm 5 % (700 mg/patch) Adhesive Patch. 1 patch every 12 hours wear for 12 hours on and 12 hours off every 24 hours LORAZEPAM - Dosage uncertain - (Prescribed by Other Provider; 1 mg qid) NORETHINDRONE ACETATE - norethindrone acetate 5 mg tablet. 1 tablet(s) by mouth daily for treatment of vasomotor symptoms ONDANSETRON - ondansetron 8 mg disintegrating tablet. 1 tablet(s) by mouth three times a day TRAZODONE - Dosage uncertain - (Prescribed by Other Provider: 50 mg daily) VENLAFAXINE - Dosage uncertain - (Prescribed by Other Provider; 37.5 mg daily) Medications - OTC ACETAMINOPHEN [TYLENOL] - Dosage uncertain - (Prescribed by Other Provider; up to 4/d) PROBIOTICS - Dosage uncertain - (___) <DISCHARGE MEDICATIONS> 1. Azithromycin 250 mg PO Q24H Duration: 4 Days please take 1 per day for additional 4 days RX *azithromycin 250 mg 1 tablet(s) by mouth every 24 hours Disp #*4 Tablet Refills: *0 2. Amitriptyline 10 mg PO HS 3. Gabapentin 100 mg PO TID 4. Ibuprofen 600 mg PO Q6H: PRN pain 5. Lidocaine 5% Patch 1 PTCH TD DAILY: PRN pain 6. traZODONE 50 mg PO HS 7. Venlafaxine 37.5 mg PO DAILY 8. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO PER DISCUSSION WITH MD 9. HYDROmorphone (Dilaudid) 2 mg PO PER DISCUSSION WITH MD 10. Azithromycin 250 mg PO Q24H Duration: 4 Doses 11. norethindrone acetate *NF* 5 mg Oral daily <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pneumonia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted into Gynecology service for observation and treatment for pneumonia. You have been stable and it is now safe to discharge you home with follow up. *) Please take your antibiotics as prescribed *) Please keep your appointment as scheduled with Dr. ___ *) Please keep your appointment as scheduled with Dr. ___ ___ Instructions: ___
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Ms ___ was admitted to the gynecology service for observation given a presumptive diagnosis of community-acquired pneumonia. She was treated with azithromycin. She remained afebrile while inpatient, with a Tmax of 100.1. Blood cultures were pending on discharge. Notably, patient stated she took Percocet and fentanyl at home, while her medications at ___ reveal narcotic perscriptions for Vicodin and Dilaudid. She carries a diagnosis of opiod dependence. Her home medications were continued while in-patient and she was discharged home without any new narcotic prescriptions. She states she has follow up with her primary care physician, Dr ___, on ___. She was encouraged to keep this appointment and Dr ___ was given a copy of the discharge summary.
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10843678-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Bentyl / Compazine / Ciprofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> abdominal ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G2P2 woman who underwent diagnostic laparoscopy, excision of endometriosis in the left pelvis, lysis of adhesions, and cystoscopy for chronic pelvic ___ on ___. Her post-operative course was notable for urinary retention, which resolved, and hospitalization for community-acquired pneumonia for which she completed a course of azithromycin. She presents at this time complaining of worsening abdominal ___ as well as blurry vision, shortness of breath, vaginal discharge, unsteadiness on feet, weakness, and "feeling like heartbeat not there." She was recently seen for a post-operative visit on ___. At that time, she was found to be doing well, but suffering from symptoms from Lupron. Since being discharged from the hospital, premarin had been added to her norethindrone as she was having vasomotor symptoms from Lupron. At that visit, she stated that the Lupron was controlling her pelvic ___ relatively well until two weeks ago when it started to become worse, mostly in the lower mid and left abdomen. She now takes ___ percocet/day, which is prescribed by her PCP. She does not feel that she received any relief from the last nerve block that was performed at the ___ center, and is not sure she wants to continue with them. At that visit, she had been having urinary frequency and some mild dysuria, but denies any fever/chills or back ___. Urine culture from ___ was consistent with genital contamination. Patient is currently reporting that for the last two weeks her pelvic and abdominal ___ is worsening. Reports it is a dull, aching, deep, constant ___ at ___. She reports that it is as bad as it was prior to initiating Lupron therapy at the beginning of this year. She also notes a new vaginal discharge starting yesterday, which she reports is thick and white. She is also reporting shortness of breath, but states that this is a sensation of difficulty taking a deep breath because she feels limited by her abdominal ___. She is also complaining of new onset blurry vision since today where she complains alternately of blurry vision, double vision, and triple vision. She also reports a sensation that she is unsteady on her feet and feels weak. She reports that she has been bumping into things because of this unsteadiness. She also reports a subjective sensation where she feels that her heart is not beating and she feels that she has to check her pulse to make sure that it is still beating. She reports that she has been able to tolerate a regular diet, although states that she is dehydrated and has trouble drinking liquids. She is able to take PO, but says she takes an anti-nausea medication to do so. Denies emesis. Denies fevers and chills. Reports generalized sensation of being unwell. Also endorses dysuria as well as recent leaking of pencil thin stools at night. She has seen gastroenterology for this complaint and their recommendation was agents to bulk stools. She has been taking ___ percocet per day along with ibuprofen for ___. She has been seen at chronic ___ clinic, but states that injections do not help at all. She reports that she is dehydrated and would like an IV for hydration and ___ medication. <PAST MEDICAL HISTORY> POB: - SVD x 2 term 7#5 and 6#13 ___ and ___ PGYN: - menarche age ___, menses q25-30 days - sexually active with mutually monogamous male partner - contraception-> partner s/p vasectomy - no history of abnl paps or STIs, last pap ___ PMH: - anxiety - liver hemangioma - diverticulitis - IBS - IC - atrophic right kidney with duplicate left renal collecting system PSH: - diagnostic laparoscopy, excision of endometriosis in the left pelvis, lysis of adhesions, and cystoscopy as above ___ - lsc cholecystectomy ___ - lsc right colectomy for diverticulitis ___ <ALLERGIES> penicillin, bentyl, cipro, Compazine <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with breast cancer in her ___. Maternal cousin with breast cancer in ___. Knows about <PHYSICAL EXAM> On admission: VS: T 98.2 HR 70 BP 126/78 RR 18 SpO2 99% General: NAD, somewhat uncomfortable CV: RRR, no m/r/g Lungs: CTAB Abdomen: soft, diffusely tender to palpation throughout, no rebound or guarding Pelvic: normal external genitalia, small amount of white discharge in vault, cervix with large ectropion, no visible lesions Ext: no edema, no tenderness Neuro: grossly intact On discharge: VSS Gen: NAD CV: RRR Lungs: CTAB Abdomen: soft, minimally tender, no rebound/guarding <PERTINENT RESULTS> On hospital day 0 to 1 (___): WBC-6.8 RBC-3.76* Hgb-11.3* Hct-34.6* MCV-92 MCH-30.1 MCHC-32.7 RDW-12.9 Plt ___ Neuts-58.3 ___ Monos-8.9 Eos-1.1 Baso-0.8 Glucose-103* UreaN-13 Creat-0.7 Na-139 K-3.6 Cl-106 HCO3-28 AnGap-9 ALT-11 AST-13 AlkPhos-45 TotBili-0.3 Calcium-8.7 Phos-2.8 Mg-2.0 URINE ___ Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG RBC-8* WBC-0 Bacteri-NONE Yeast-NONE Epi-1 AmorphX-RARE CaOxalX-MOD F/u LABS ___ at 10AM Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.0 Leuks-NEG RBC-10* WBC-7* Bacteri-FEW Yeast-NONE Epi-0 MICROBIOLOGY: ___ 11: 46 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 11: 46 pm SWAB Source: Cervical. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria Gonorrhoeae by PCR. <MEDICATIONS ON ADMISSION> AMITRIPTYLINE - amitriptyline 10 mg tablet. 1 tablet(s) by mouth at bedtime CLONAZEPAM - clonazepam 1 mg tablet. 1 tablet(s) by mouth three times a day - (Prescribed by Other Provider) CONJUGATED ESTROGENS [PREMARIN] - Premarin 0.625 mg tablet. 1 tablet(s) by mouth daily GABAPENTIN - gabapentin 300 mg capsule. 1 capsule(s) by mouth four times a day HYOSCYAMINE SULFATE - hyoscyamine sulfate 0.125 mg tablet. 1 tablet(s) by mouth three times a day 1 po tid for diarrhea LEUPROLIDE (3 MONTH) [LUPRON DEPOT (3 MONTH)] - Lupron Depot (3 Month) 11.25 mg IM Syringe Kit. 1 injection IM once LIDOCAINE [LIDODERM] - Lidoderm 5 % (700 mg/patch) Adhesive Patch. 1 patch every 12 hours wear for 12 hours on and 12 hours off every 24 hours NORETHINDRONE ACETATE - norethindrone acetate 5 mg tablet. 1 tablet(s) by mouth daily for treatment of vasomotor symptoms ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth three times a day as needed for nausea please give po tablets, NOT ODT OXYCODONE-ACETAMINOPHEN - oxycodone-acetaminophen 5 mg-325 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for ___ - (Prescribed by Other Provider: Dr. ___ TRAZODONE - Dosage uncertain - (Prescribed by Other Provider: 50 mg daily) VENLAFAXINE - venlafaxine ER 75 mg capsule,extended release 24 hr. 1 capsule,extended release 24hr(s) by mouth daily - (Prescribed by Other Provider) Medications - OTC ACETAMINOPHEN [TYLENOL] - Dosage uncertain - (Prescribed by Other Provider; up to 4/d) PROBIOTICS - Dosage uncertain - (___) <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H 2. Amitriptyline 10 mg PO HS 3. ClonazePAM 1 mg PO TID anxiety 4. Gabapentin 600 mg PO TID RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day Disp #*60 Capsule Refills: *2 5. Ibuprofen 600 mg PO Q6H 6. Lidocaine 5% Patch 1 PTCH TD DAILY 7. TraZODone 50 mg PO HS: PRN insomnia 8. Venlafaxine XR 75 mg PO DAILY 9. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN ___ RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Chronic pelvic ___ <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the gynecology service given acutely worsened ___. The chronic ___ service was consulted who made some adjustments to your ___ regimen. We also discussed pushing up your surgery for a hysterectomy and removal of fallopian tubes and ovaries. You should follow-up with Dr. ___ at ___ to facilitate this surgery. In the meantime, follow these instructions: *Take all medications as prescribed *Do not drive while taking narcotic ___ medication *Do not take more than 4000mg acetaminophen in 24 hours
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On ___, Ms. ___ was admitted to the gynecology service with abdominal ___ and several other vague complaints. Her abdominal ___ appeared most consistent with prior episodes of chronic ___, but given acute onset, she was admitted for observation and for consultation with chronic ___ service, who follow patient as an outpatient. With respect to her abdominal ___, she was continued on her oral regimen of tylenol/motrin/gabapentin/amitriptyline/lidocaine patch and she was given oxycodone ___ every 4 hours. She was not started on any IV medication. Her ___ was satisfactorily controlled with addition of oxycodone. The chronic ___ service was consulted, who recommened an increase in gabapentin to 600mg three times daily and to continue oxycodone, with plan to wean off narcotic as soon as possible. They also recommended consulting with psychiatry, as patient likely has opioid dependence and significant anxiety. Psychiatry in house was consulted, who recommended patient follow-up as outpatient with her own psychiatrist. The only lab abnormality was in the urinalysis, which showed a small amount of RBCs and oxalate crystals. This was repeated, and there was still a small amount of blood. Urine culture was negative for infection, and history and exam not consistent with nephrolithiasis. Patient should have a repeat urinalysis to see if there is still blood in the next few weeks. Patient also was empirically treated for yeast with diflucan x 1. In addition, discussion was had with patient regarding moving up her surgery, originally planned for ___, to sooner, as this may potentially help alleviate her ___. Patient was counseled that the ___ may still be present after surgery, but patient would like to pursue surgery sooner if possible. Social work was consulted to assist patient with hardship associated with surgery and impact on job prospects. Patient will follow-up with Dr. ___ will be transitioning care to ___ OB/GYN and who will arrange surgery. For outpatient follow-up, Ms. ___ PCP, ___ office was contacted to investigate whether patient had a ___ contract, but there was no contract in place. Follow-up appointment was made with PCP. By the end of hospital day 1, patient's ___ was moderately well controlled and outpatient follow-up was made with her PCP, OB/GYN (Dr. ___ Dr. ___, and the chronic ___ service. She was discharged with a small supply of oral dilaudid (2mg x 20 pills).
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10843678-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Bentyl / Compazine / Ciprofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> chronic abdominal and pelvic pain, endometriosis, failed conservative management <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, lysis of adhesions, uretolysis, L ureteral stent placement and removal, cystoscopy x 2 <HISTORY OF PRESENT ILLNESS> HPI: ___ yo G2P2 has a diagnosis of surgically evident endometriosis for which she has been on treatement with Lupron and add-back. She receives some relief with Lupron, particularly in the weeks following the injection, but she still has pain flares requiring hospitalization. She is requiring chronic narcotic medications (5 mg Oxycodone q2 hrs) which are prescribed by her PCP under narcotics contract. ___ has a complicated history of chronic abdominal and pelvic pain. She is under treatment with GI, chronic pain and her PCP in addition to being treated by GYN. In ___ she underwent a diagnostic laparoscopy, excision of endometriosis, lysis of adhesions, and cystoscopy. Operative findings were suggestive of endometriosis and possible adenmyosis and pelvic congestion syndrome. Her post-operative course was notable for urinary retention, which resolved, and hospitalization for community-acquired pneumonia for which she was completed a course of azithromycin. After extensive counseling she has elected to proceed with definitive surgical management. ROS: stable pelvic pain, most recent flare ___ requiring hospitalization in ___. Also notes several episodes of fecal incontinence. Happens only at night while she is sleeping and never during the day. denies fecal urgency or frequency. Also reports increased vaginal discharge since ___ with vulvar irritation but neg GC/CT screening. Has recently been treated for several UTIs and then urine cultured returned negative. <PAST MEDICAL HISTORY> POB: - SVD x 2 term 7#5 and 6#13 ___ and ___ PGYN: - menarche age ___, menses q25-30 days - sexually active with mutually monogamous male partner - contraception-> partner s/p vasectomy - no history of abnl paps or STIs, last pap ___ PMH: - anxiety - liver hemangioma - diverticulitis - IBS - IC - atrophic right kidney with duplicate left renal collecting system PSH: - diagnostic laparoscopy, excision of endometriosis in the left pelvis, lysis of adhesions, and cystoscopy as above ___ - lsc cholecystectomy ___ - lsc right colectomy for diverticulitis ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with breast cancer in her ___. Maternal cousin with breast cancer in ___. <PHYSICAL EXAM> General: NAD Respiratory: CTAB CV: s1s2 clearly heard, RRR, no m/r/g Abdomen: +BS, soft, non-distended, mild diffuse tenderness with voluntary guarding, appropriately tender to palpation Incisions: steri strips C/D/I GU: Foley in place with clear urine Extremities: no edema, swelling or tenderness <PERTINENT RESULTS> ___ 09: 22AM URINE Color-Straw Appear-Clear Sp ___ ___ 09: 22AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM ___ 09: 22AM URINE RBC-16* WBC-12* Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 ___ 09: 22AM URINE Mucous-RARE ___ 10: 55PM BLOOD UreaN-10 Creat-0.7 Pathology Examination ___: SPECIMEN SUBMITTED: uterus, cervix, bilateral fallopian tubes and ovaries. DIAGNOSIS: Uterus, cervix, bilateral fallopian tubes and ovaries (A-P): Leiomyomata (up to 0.6 cm). The endometrium grossly shows a polypoid configuration of growth. Microscopic exam reveals benign endometrium with inactive appearing glands and pseudodecidualized stroma consistent with exogenous hormone effect. Unremarkable fallopian tubes, ovaries, and cervix. <MEDICATIONS ON ADMISSION> AMITRIPTYLINE - amitriptyline 10 mg tablet. 1 tablet(s) by mouth at bedtime CLONAZEPAM - clonazepam 1 mg tablet. 1 tablet(s) by mouth three times a day - (Prescribed by Other Provider) CONJUGATED ESTROGENS [PREMARIN] - Premarin 0.625 mg tablet. 1 tablet(s) by mouth daily GABAPENTIN - gabapentin 300 mg capsule. 1 capsule(s) by mouth four times a day HYOSCYAMINE SULFATE - hyoscyamine sulfate 0.125 mg tablet. 1 tablet(s) by mouth three times a day 1 po tid for diarrhea LEUPROLIDE (3 MONTH) [LUPRON DEPOT (3 MONTH)] - Lupron Depot (3 Month) 11.25 mg IM Syringe Kit. 1 injection IM once LIDOCAINE [LIDODERM] - Lidoderm 5 % (700 mg/patch) Adhesive Patch. 1 patch every 12 hours wear for 12 hours on and 12 hours off every 24 hours NORETHINDRONE ACETATE - norethindrone acetate 5 mg tablet. 1 tablet(s) by mouth daily for treatment of vasomotor symptoms ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth three times a day as needed for nausea please give po tablets, NOT ODT OXYCODONE-ACETAMINOPHEN - oxycodone-acetaminophen 5 mg-325 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for pain - (Prescribed by Other Provider: Dr. ___ TRAZODONE - Dosage uncertain - (Prescribed by Other Provider: 50 mg daily) VENLAFAXINE - venlafaxine ER 75 mg capsule,extended release 24 hr. 1 capsule,extended release 24hr(s) by mouth daily - (Prescribed by Other Provider) Medications - OTC ACETAMINOPHEN [TYLENOL] - Dosage uncertain - (Prescribed by Other Provider; up to 4/d) PROBIOTICS - Dosage uncertain - (___) <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth q6 hrs Disp #*112 Tablet Refills: *0 2. Amitriptyline 10 mg PO HS 3. ClonazePAM 1 mg PO Q6H: PRN anxiety 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*24 Capsule Refills: *0 5. Gabapentin 600 mg PO TID 6. Ibuprofen 600 mg PO Q6H RX *ibuprofen 600 mg 1 tablet(s) by mouth q6-8hrs Disp #*60 Tablet Refills: *0 7. Omeprazole 20 mg PO DAILY 8. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain 9. Venlafaxine XR 75 mg PO DAILY 10. Morphine SR (MS ___ 30 mg PO Q8H Duration: 2 Weeks RX *morphine 30 mg 1 tablet extended release(s) by mouth every 8 hours Disp #*42 Tablet Refills: *0 11. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic pelvic pain, endometriosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after undergoing the procedures listed below. You have done well post-operatively and the team feels that you are now ready to be discharged home. General instructions: * Take your medications as prescribed. You should NOT take any addition narcotics other than the following: MScontin 20 mg three times daily, and Oxycodone ___ mg every 4 hours. Taking additional narcotics not prescribed to you will result in a breech of your narcotics contract and could result in serious complications including death. You should bring your narcotics bottle with you to your visit with Dr ___ in 2 weeks. * 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. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ G2P2 who underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, extensive lysis of adhesions, left ureterolysis, left ureteral stent placement and removal, and cystoscopy x2 on ___. Please see the operative report for full details. The surgery was uncomplicated and the patient was admitted for post-op pain management and standard post-op care. Ms. ___ hospital course was complicated by urinary retention. On post-operative day 1, she failed a first trial of void but passed her second trial, with PVR <100 cc. On post-operative day 2, she experienced urinary urgency but was unable to void urine for 7.5hrs. Her foley catheter was replaced and 340cc was drained from the bladder. Given that she has a history of post-operative urinary retention and only has one ureter/kidney congenitally, the decision was made to keep the foley catheter in place for several days post-operatively. She received teaching in how to care for the catheter at home and was discharged to home with a Foley catheter in place with scheduled follow-up with Dr. ___ foley removal. Ms. ___ hospital course was also notable for difficulty with pain management. Given her history of chronic pain and narcotic use, Ms. ___ had signed a narcotics contract pre-operatively that indicated a plan to use either 20 mg Oxycodone q2h total or if needed Dilaudid 6 mg PO q 3 hours instead of (not in addition to) Oxycodone; a low threshold to get inpatient chronic pain consult; planned follow-up with Dr ___ in 2 weeks; and no further narcotics from GYN after 2 weeks post-operatively unless there are outstanding surgical complications which require additional narcotics. Immediately post-operatively, her pain was controlled with IV pain medications. On post-operative day 1, she was complaining of persistent abdominal pain with minimal relief from PO oxycodone so she was switched to PO Dilaudid. She continued to have significant pain. The Acute Pain Service was consulted and recommended a new medication regimen of Oxycontin 20mg PO TID and Oxycodone ___ PO q4h PRN, in addition to ATC Tylenol, ATC Motrin, Gabapentin, Amitryptiline (which she was already receiving). They continued to follow her throughout her hospitalization. She was started on this regimen and experienced an improvement but not resolution of her pain. On the evening of post-operative day 1, the nurses identified that her purse containing all of her home medications (including narcotics) was in the patient's room. The patient denied use of these medications and her belongings were locked up safely in a different location. On post-operative day 2, she was more sedated than prior and there was concern that she had taken unauthorized home medications. Her Oxycontin dosing was decreased to BID and her sedation resolved. For discharge planning, the necessary forms were submitted to obtain authorization for home prescription ofOxycontin 20mg PO TID, however, per BI review, she did not meet the prerequisite criteria (to have tried and failed pain management with MSContin ER prior to Oxycontin trial) so was not approved for the home medication. APS recommended instead she be discharged home with MSContin 30mg PO TID. Ms. ___ continued to improved clinically during her hospital course. By post-operative day 3, her pain was moderately controlled with PO meds, she was tolerating a normal diet, she was ambulating well, and had return of bowel function. She was discharged home in stable condition with plan for close follow-up.
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10844378-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> preterm contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G8P5 at 32w2d presents for r/o ROM. States she woke up and noticed some mucous on her leg but wasn't sure if there was watery fluid mixed with it. continued to feel a little more wet, but denies a gush of fluid or obvious leaking. denies any bleeding. reports irregular contactions which she feels are mildly increased in intensity over the past couple days. Feels active FM. Pregnancy c/b siezure d/o and is followed by neurology here. Reports no recent significant seizure activity over the past week. <PAST MEDICAL HISTORY> PMH: epilepsy, anemia, obesity, migraines PSH: gastric bypass Meds: Phenytoid ER 400 daily, Banzel 800 BID, Topamax 150 BID, Onfi 10mg/20mg <PHYSICAL EXAM> Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, no edema FHR: present at a normal rate <PERTINENT RESULTS> Labs on Admission: ___ 04: 01PM BLOOD Neuts-81.1* Lymphs-11.1* Monos-4.6* Eos-2.1 Baso-0.5 Im ___ AbsNeut-7.09* AbsLymp-0.97* AbsMono-0.40 AbsEos-0.18 AbsBaso-0.04 ___ 04: 01PM BLOOD WBC-8.7 RBC-4.20 Hgb-11.5 Hct-37.0 MCV-88 MCH-27.4 MCHC-31.1* RDW-20.3* RDWSD-63.7* Plt ___ ___ 04: 01PM BLOOD Plt ___ ___ 01: 29PM URINE Color-Straw Appear-Clear Sp ___ ___ 01: 29PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR* ___ 01: 29PM URINE RBC-<1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-3 <MEDICATIONS ON ADMISSION> 1. Clobazam 10 mg PO QAM 2. Clobazam 20 mg PO QPM 3. Phenytoin Sodium Extended 200 mg PO QHS 4. Phenytoin Sodium Extended 100 mg PO NOON 5. Prenatal Vitamins 1 TAB PO DAILY 6. Rufinamide 800 mg PO BID 7. Topiramate (Topamax) 150 mg PO BID <DISCHARGE MEDICATIONS> 1. Clobazam 10 mg PO QAM 2. Clobazam 20 mg PO QPM 3. Phenytoin Sodium Extended 200 mg PO QHS 4. Phenytoin Sodium Extended 100 mg PO NOON 5. Prenatal Vitamins 1 TAB PO DAILY 6. Rufinamide 800 mg PO BID 7. Topiramate (Topamax) 150 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm contractions, epilepsy <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 hospital with contractions concerning for preterm labor. You were monitored for 4 days without any evidence of preterm labor. You received betamethasone for fetal lung maturity and you were counseled by the NICU team. All of your fetal testing have been reassuring. We think it is now safe for you to go home. Please attend all appointments with your obstetrician and all fetal scans. Please monitor for the following danger signs: - headache that is not responsive to tylenol - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ was admitted to the hospital for observation after an episode of preterm contractions concerning for preterm labor. A workup including vaginal cultures, urine culture, and urine toxicology screen were all negative. She received a course of betamethasone for lung maturity and was seen by the NICU and Maternal Fetal Medicine. She was started on tocoloysis with Nifedipine until beta complete. She was observed and her cervix was not dilating. She did not have any signs of vaginal bleeding or rupture of membranes. After a period of observation, she was deemed stable for discharge home with precautions.
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10844378-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> increased seizure frequency <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ ___ with epilepsy, h/o Roux-en-Y gastric bypass, di-di twins and polyhydramnios who presented to triage due to increased seizure frequency in the setting of medically refractory epilepsy. She has a history of epilepsy and complex partial seizures along with drop seizures. She is followed by ___ neurology. She reports being compliant with her medications. She is s/p and admission ___ for 2 drop seizures/24hrs and medication titration. She notes that she was doing pretty well with little to no seizures until increased frequency in the past week. Reports two partial seizures last ___ along with ___ seizures yesterday. This morning, as she was waking up, she felt like she was having a seizure in her dream which she states means " I am definitely having a seizure." She is unsure how long it lasted and no one was there to witness this one. She then notes, also witnessed by her husband, that around 1100 she was standing at the sink washing dishes when her head tilted forward toward the sink (no trauma) and her face went blank. She did not fall and was able to get to a chair in time. They think this lasted a minute. She denies any new infections, illnesses, changes in medications. She took Ativan last week one dose but is afraid to take more given she is further along in pregnancy. Regarding her preterm contractions, she notes q ___ ctx as her baseline for the past couple of weeks as her pregnancy has progressed and polyhydramnios has progressed. Reports worse contractions yesterday, still feels them today but they are not bothering her. Denies VB, LOF, Reports active fetal movement x 2. <PAST MEDICAL HISTORY> PMH: epilepsy, anemia, obesity, migraines PSH: roux en y gastric bypass Meds: clobazam 10 mg qAM, 20 mg qPM phenytoin 300 total mg a day rufinamide 800 mg twice a day topiramate 150 mg twice a day <PHYSICAL EXAM> Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, no edema FHR: present at a normal rate <PERTINENT RESULTS> Labs on Admission: ___ 02: 47PM BLOOD WBC-8.8 RBC-4.07 Hgb-11.1* Hct-35.0 MCV-86 MCH-27.3 MCHC-31.7* RDW-18.6* RDWSD-58.0* Plt ___ ___ 02: 47PM BLOOD Neuts-82.1* Lymphs-11.0* Monos-4.9* Eos-1.0 Baso-0.3 Im ___ AbsNeut-7.18* AbsLymp-0.96* AbsMono-0.43 AbsEos-0.09 AbsBaso-0.03 ___ 06: 38PM URINE Color-STRAW Appear-Clear Sp ___ ___ 06: 38PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 03: 16PM OTHER BODY FLUID CT-NEG NG-NEG Relevant Labs: ___ 08: 12AM BLOOD ALT-9 AST-14 ___ 08: 12AM BLOOD Albumin-3.6 ___ 08: 12AM BLOOD Phenyto-9.7* ___ 04: 09PM BLOOD Phenyto-11.1 ___ 09: 55PM BLOOD Phenyto-14.5 ___ 07: 49AM BLOOD Phenyto-14.6 ___ 07: 42AM BLOOD Phenyto-15.7 <MEDICATIONS ON ADMISSION> clobazam 10 mg qAM, 20 mg qPM phenytoin 300 total mg a day rufinamide 800 mg twice a day topiramate 150 mg twice a day <DISCHARGE MEDICATIONS> 1. LORazepam 1 mg PO Q6H: PRN seizure aura RX *lorazepam 1 mg 1 ml by mouth every six (6) hours Disp #*20 Tablet Refills: *0 2. Clobazam 10 mg PO QAM 3. Clobazam 20 mg PO QPM 4. Phenytoin Sodium Extended 100 mg PO BID 5. Phenytoin Sodium Extended 200 mg PO QHS 6. Prenatal Vitamins 1 TAB PO DAILY 7. Rufinamide 800 mg PO BID 8. Topiramate (Topamax) 150 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> increased seizure frequency <DISCHARGE CONDITION> Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the hospital for increased seizure frequency. You were seen by the Neurology Team and your anti-epileptic drug levels were monitored. You had an EEG while you were here. You were also given a loading dose of IV fosphenytoin. You will continue your previous home regimen: clobazam 10 mg qAM, 20 mg qPM phenytoin 400 total mg a day rufinamide 800 mg twice a day topiramate 150 mg twice a day Please follow up with your Neurologist outpatient as scheduled. While you were here, you had preterm contractions concerning for preterm labor. Your cervix remained unchanged during your admission. Your fetal testing was reassuring. You will follow up with a repeat US and Maternal Fetal Medicine appointment with Dr. ___ on ___. At this appointment, please get a lab draw to check you anti-epileptic drug levels. We think it is now safe for you to go home. Please attend all appointments with your obstetrician and all fetal scans. Please monitor for the following danger signs: - headache that is not responsive to tylenol - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ was admitted to the ___ service for increased seizure frequency in the setting of medically refractory epilepsy. On admission, she was also noted to have preterm contractions concerning for PTL. In regards to her epilepsy, Neurology was consulted and recommendations were appreciated. She had an EEG for 24 hours with no evidence of subclinical seizures. Her phenytoin troughs were trended and she was given a loading dose of IV fosphenytoin. Her AED levels were trended. She remained stable with no further seizure activity. Neurology recommended outpatient management on her same admission regimen. Outpatient follow up was scheduled. In regards to her preterm contractions concerning for preterm labor, vaginal swabs and urine studies were negative. Fetal testing was reassuring with no contractions on the monitor. Cervical exam remained unchanged. After 5 days of inpatient monitoring, patient was discharged home in stable condition with outpatient follow up scheduled.
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10846287-DS-5
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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> Laparoscopic total hysterectomy, bilateral salpingo-oophorectomy, partial posterior vaginectomy with excision of pelvic tumor, omental biopsy, and cystoscopy. <HISTORY OF PRESENT ILLNESS> ___ G2P2 presents for surgical consultation for regarding a new diagnosis of serous adenocarcinoma on endometrial biopsy. She presented with vaginal bleeding beginning on ___. Denies any associated symptoms such as pelvic pain, bowel or bladder symptoms, early satiety, or bloating. She underwent an EMB and PUS on ___. US reported an anteverted measuring 5.9 x 3.1 x 4.1 cm. The endometrial cavity appears distended. An isoechoic lesion measuring 2.8 x 2.1 cm is identified with associated vascularity. The ovaries are not visualized. There are no adnexal masses identified. There is no free fluid. Biopsy showed: Serous carcinoma. Note: The finding may represent an endometrial primary, but a drop metastasis from ovary or fallopian tube cannot be excluded. A p53 immunostain is mutant pattern, consistent with the above diagnosis. <PAST MEDICAL HISTORY> PMH: osteoporosis, HTN, hyperlipidemia PSH: breast biopsy (benign); ___'s procedure OB/GYN: G2P2, LMP: unsure, No HRT Use, Last Pap Smear: ___, NIL, denies any other GYN infections/problems <SOCIAL HISTORY> ___ <FAMILY HISTORY> maternal aunt and mother with PMP breast ca, sister died of ovarian cancer at age ___, mother, sister, paternal aunts and uncles as well as maternal uncles with colon ca <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: 15PM BLOOD WBC-12.1* RBC-3.48* Hgb-11.0* Hct-33.0* MCV-95 MCH-31.6 MCHC-33.3 RDW-13.3 Plt ___ ___ 04: 00AM BLOOD WBC-9.2 RBC-3.25* Hgb-10.7* Hct-30.0* MCV-92 MCH-33.0* MCHC-35.7* RDW-13.4 Plt ___ ___ 06: 35AM BLOOD WBC-8.3 RBC-3.14* Hgb-10.2* Hct-29.1* MCV-93 MCH-32.4* MCHC-34.9 RDW-13.2 Plt ___ ___ 07: 03AM BLOOD WBC-7.8 RBC-3.46* Hgb-11.2* Hct-31.9* MCV-92 MCH-32.5* MCHC-35.2* RDW-13.4 Plt ___ ___ 03: 15PM BLOOD Glucose-84 UreaN-18 Creat-0.7 Na-139 K-4.2 Cl-104 HCO3-25 AnGap-14 ___ 04: 00AM BLOOD Glucose-100 UreaN-14 Creat-0.6 Na-131* K-4.2 Cl-98 HCO3-26 AnGap-11 ___ 04: 50PM BLOOD Glucose-87 UreaN-15 Creat-0.7 Na-130* K-4.2 Cl-95* HCO3-27 AnGap-12 ___ 06: 35AM BLOOD Glucose-92 UreaN-13 Creat-0.5 Na-131* K-3.5 Cl-98 HCO3-27 AnGap-10 ___ 07: 03AM BLOOD Glucose-88 UreaN-10 Creat-0.5 Na-139 K-3.5 Cl-103 HCO3-30 AnGap-10 ___ 12: 42PM BLOOD CK(CPK)-55 ___ 12: 42PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 03: 15PM BLOOD Calcium-8.6 Phos-4.3 Mg-1.8 ___ 04: 00AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.2 ___ 06: 35AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.3 ___ 07: 03AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.3 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP QHS 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Simvastatin 20 mg PO QPM 4. Losartan Potassium 25 mg PO DAILY 5. Citracal + D Maximum (calcium citrate-vitamin D3) 315-250 mg-unit oral DAILY 6. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg oral DAILY 7. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral DAILY <DISCHARGE MEDICATIONS> 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Simvastatin 20 mg PO QPM 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills: *2 5. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg oral DAILY 6. Citracal + D Maximum (calcium citrate-vitamin D3) 315-250 mg-unit oral DAILY 7. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral DAILY 8. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP QHS 9. cane miscellaneous Q24H walking RX *cane use cane daily Disp #*1 Each Refills: *0 10. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain do not drink alcohol or drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Endometrial cancer **Final pathology pending** <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . 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. * If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, partial posterior vaginectomy with excision of pelvic tumor, omental biopsy, and cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with morphine and tylenol. Her diet was advanced without difficulty and she was transitioned to oxycodone and tylenol for pain. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She was evaluated by physical therapy who felt recommended home ___. She was restarted on her home hypertension medications on post-operative day 1. She was noted to have atrial bigeminy pre-op and this continued post-operatively. She had a troponin drawn which was negative and she was seen by cardiology who did not recommend any additional testing or intervention. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10846287-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> history of stage IVB serous endometrial cancer with isolated recurrence <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p laparoscopic resection of abdominal and pelvic tumor <HISTORY OF PRESENT ILLNESS> Ms ___ is an ___ yo who presented with post menopausal bleeding. Endometrial biopsy was performed which revealed serous adenocarcinoma. Pelvic ultrasound was done which revealed a distended endometrial cavity with an isoechoic lesion measuring 2.8 x 2.1cm with vascularity. A CT scan was then done which revealed scattered pulmonary nodules largest measuring 8mm in the left upper lobe, enlarged pulmonary arteries suggesting pulmonary hypertension, a hypodense lesion in the uterine fundus, a hepatic cyst within the left lobe of the liver and a smaller hypodense segment. MRI was done to further evaluate hepatic lesions, with benign hepatic lesions, no evidence of malignancy. On ___ patient was taken to the operating room and a laparoscopic total hysterectomy, bilateral salpingo-oophorectomy, partial posterior vaginectomy with excision of pelvic tumor, omental biopsy and cystoscopy. Intraoperatively there was peritoneal gross disease in the posterior cul-de-sac with 1.5cm nodule just inferior to the cervix and on the serosa of the posterior vagina. There were small implants along the pelvic sidewalls. There was a 1cm deposit on the omentum. The peritoneal surfaces of the gutters in the upper abdomen were smooth. Cystoscopic evaluation revealed normal bladder mucosa with no evidence of lesion. Final pathology was notable for serous adenocarcinoma of the endometrium, grade 3, with 1% myometrial invasion. No lymphovascular invasion. Omental biopsy and serosa contained metastatic serous adenocarcinoma. Pelvic washings were positive. She started chemotherapy under the care of Dr. ___ at ___, ___. She has tolerated the chemotherapy except for bilateral foot neuropathy ( each dose it has gotten worse). She is due for her 6th dose of chemotherapy enxt week. She had a recent CT Scan Torso done at ___ and has brought the disc today for our review. She does report a known lung mass for which she is being seen by pulmonary at BWN in the next 1 week. <PAST MEDICAL HISTORY> PMH: osteoporosis, HTN, hyperlipidemia PSH: breast biopsy (benign); Moh's procedure OB/GYN: G2P2, LMP: unsure, No HRT Use, Last Pap Smear: ___, NIL, denies any other GYN infections/problems <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal aunt and mother with PMP breast ca, sister died of ovarian cancer at age ___, mother, sister, paternal aunts and uncles as well as maternal uncles with colon ca <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incisions clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 01: 30AM BLOOD WBC-12.3*# RBC-3.29* Hgb-10.6* Hct-31.6* MCV-96 MCH-32.2* MCHC-33.5 RDW-13.0 RDWSD-45.6 Plt ___ ___ 01: 30AM BLOOD Glucose-123* UreaN-22* Creat-0.7 Na-135 K-3.8 Cl-102 HCO3-25 AnGap-12 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. Simvastatin 20 mg PO QPM 4. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP QHS 5. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral 2 tablets PO daily 6. Vitamin D 1000 UNIT PO DAILY 7. magnesium 250 mg oral DAILY 8. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg oral DAILY 9. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral BID <DISCHARGE MEDICATIONS> 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. Simvastatin 20 mg PO QPM 4. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral 2 tablets PO daily 5. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg oral DAILY 6. magnesium 250 mg oral DAILY 7. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral BID 8. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP QHS 9. Vitamin D 1000 UNIT PO DAILY 10. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 11. Ibuprofen 400 mg PO Q8H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills: *0 12. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills: *0 13. Acetaminophen 650 mg PO TID RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine serous adenocarcinoma <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 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 ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing a laparoscopic resection of abdominal and pelvic tumor in the setting of a history of stage IVB 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 IV dilaudid and IV toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, Tylenol and ibuprofen for pain control. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. The patient was evaluated by physical therapy and was deemed safe and appropriate for discharge home. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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| 197
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10846750-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Systane ointment / eye ointments <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic organ prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ colpocleisis, perineorrhaphy, D&C, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ is an ___ retired ___ who ___ last saw in ___. At that time, she had uterovaginal prolapse which she elected to manage expectantly. She also had urogenital atrophy which she ultimately decided not to treat. I had faxed in a prescription for Premarin cream at our last visit, but she says she never filled it. She also has a history of urge incontinence and was doing well on the Oxytrol patch, but states today that she is no longer using it. It was giving her symptoms of dry mouth. She continues to have all of the same symptoms she had ___ years ago; however, everything is just "worse." She goes to the bathroom frequently, about every two to three hours in the daytime and gets up three to four times at night to urinate. She does have urgency and urge incontinence. She wears a panty liner. She has just mild stress incontinence. She has about three bladder infections a year and denies kidney stones or gross hematuria. She has intermittent urine flow. She sometimes has to strain to urinate. She has a worsening bulge and tissue protrusion in the vagina. She does suffer from chronic constipation and is on Colace and MiraLax daily. Her stools are soft. She does note that she has some fecal smearing after bowel movements, however. She is not sexually active. Her husband suffers from mild dementia. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> She has constipation, GERD, hypercholesterolemia, low back pain and osteopenia. Past Surgical History: Foot surgery last ___, appendectomy in ___, cholecystectomy in ___, ovarian cystectomy in ___, Mohs surgery four times between ___ and ___. Past GYN History: LMP is ___. Past OB History: Gravida 1, para 1. Birth weight of baby delivered vaginally 8 pounds ___ ounces. ? forceps. No vacuum assistance <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother and father heart attack. Mother and sister hypertension. Sister blood clots. <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, nondistended, incision c/d/i GU: minimal vaginal bleeding Ext: no TTP <PERTINENT RESULTS> ___ 09: 10AM BLOOD WBC-6.9 RBC-3.24* Hgb-10.5* Hct-30.5* MCV-94 MCH-32.4* MCHC-34.4 RDW-12.6 RDWSD-44.0 Plt ___ ___ 09: 10AM BLOOD Glucose-160* UreaN-12 Creat-0.5 Na-128* K-3.3 Cl-92* HCO3-29 AnGap-10 ___ 09: 10AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.5* **Pathology Pending <MEDICATIONS ON ADMISSION> HCTZ 25 mg daily lanosprazole 30 mg daily sulfacetamide-prednisolone [Blephamide] Blephamide 10 %-0.2 % eye drops 1 drop either eye prn dry eyes ASA 81 mg daily <DISCHARGE MEDICATIONS> 1. Hydrochlorothiazide 25 mg PO DAILY 2. Sulfacetamide-Prednisolone Ophth. Susp. ___ DROP BOTH EYES DAILY: PRN dry eyes 3. TraMADOL (Ultram) ___ mg PO Q6H: PRN pain ___ cause drowsiness. RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 4. Acetaminophen 650 mg PO TID Do not take more than 4000 mg acetaminophen in 24 hours. RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day Disp #*50 Tablet Refills: *1 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 6. Ibuprofen 400 mg PO Q6H: PRN pain Take with food to prevent GI upset. RX *ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 7. Senna 17.2 mg PO HS Take if Colace/Docusate sodium not managing constipation. RX *sennosides [senna] 8.6 mg 1 tablet by mouth once a day Disp #*30 Capsule Refills: *1 8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H: PRN pain ___ cause drowsiness. Use if pain not controlled by tramadol or other meds. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 9. Phenazopyridine 100 mg PO TID RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a day Disp #*9 Tablet Refills: *0 10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY Continue taking daily until bladder catheter is removed RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth daily Disp #*10 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted 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 or until instructed by Dr. ___. * 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 or until cleared by Dr. ___. You can use a handheld shower head or squeeze bottle to rinse the perineum. Cardiovascular health: *)You were noted to have occasional irregular heart beats during surgery (called premature atrial contractions). This was also seen on an EKG done prior to surgery. You should follow-up with your primary care doctor to ensure you do not need any further testing (such as an echocardiogram or Holter monitor). Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. *) You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ in ___ on ___ for catheter removal. Please see appointment details below.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a Lefort colpocleisis, perineorrhaphy, dilation & curettage, and cystoscopy for pelvic organ prolapse. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV morphine and toradol. Her diet was advanced without difficulty and she was transitioned to PO tramadol, ibuprofen, and acetaminophen. On post-operative day 1, her urine output was adequate, so her foley was removed. Patient was unable to void, and she had a PVR of 587cc on bladder scan. She waited one hour and was able to void ___ with 488cc on bladder scan. Her foley was then replaced for 800cc of urine, and she was instructed on its care. 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 a foley catheter with outpatient follow-up scheduled.
| 1,858
| 234
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10848315-DS-24
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / codeine / loratadine / sulfur medications / shellfish derived <ATTENDING> ___ <CHIEF COMPLAINT> stage IV endometrioid cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p total laparoscopic hysterectomy, bilateral salpingoophorectomy and omentectomy, with cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ gravida 0 woman with h/o stage IV endometrioid carcinoma, unclear primary source. She is now s/p 6 cycles of chemotherapy, overall a difficult course, but with relatively good response. Currently she presents regarding the question of would an attempt at an interval debulking procedure be of benefit for her. Lately she has been feeling somewhat improved and overall well. Normal urinary and bowel habits. Good appetite. No nausea, vomiting, chest pain, SOB. Improving exercise tolerance, now walking up to 1.5 miles per day. No DOE. No abnormal vaginal discharge, no vaginal bleeding. <PAST MEDICAL HISTORY> TREATMENT SUMMARY: ___: C1W1 ___ Taxol ___: C1W2 Taxol ___: C1W3 Taxol ___: C2W1 - ___ Taxol; while inpatient ___: C2W2 - Taxol, while inpatient ___: C2W3 - Taxol ___: C3W1 - HELD for possible urinary retention; Foley placed with no PVR, thus US PVR was felt to be c/w ascites. ___: C3W1 - ___, Taxol ___: C3W2 - Taxol ___: C3 W3, HELD - hospitalized for urosepsis and pyelonephritis. ___: C4 W1, ___ Taxol ___: C4 W2 taxol ___: C4 W3 <---- HELD, neutropenia, ANC 320 ___: Cystoscopy; Bilateral double-J ureteral stent exchange, ___ by 30 cm; Dr ___ ___: Restaging PET CT: 7.7 x 6.7 cm peripherally hyperdense, centrally hypodense pelvic mass extends from uterus with low level FDG avidity with a single focus with SUV max 4.4. Lobulated soft tissue densities within the right hemoiabdomen interiorly likely omental disease, do not demonstrate increased FDG avidity. ill defined hypodensity in the right hepatic lobe with no increased FDG avidity. Hyperdense lesion within the interpolar region of the right kidney is incompletely characterized; ? hemorragic cyst - close follow up recommended. ___: C5 W1 ___ Taxol ___: C5 W2 Taxol ___: C5 W3 Taxol ___: MRI of the pelvis; decrease in size of R adnexal mass since PET CT ___. A clear fat plane is seen between the right adnexal mass and the bladder. Ureters appear clear of the mass; Mild bilateral hydronephrosis is unchanged on the right and slightly worse on the left. Bilateral ureteral stents are in place. ___: C6 W1 ___ Taxol ___: Stents removed. ___: C6 W2; Taxol ___: C6 W3 ___: Saw Dr ___ ---> plan for surgery. PMHx: ENDOMETRIAL CANCER HYDRONEPHROSIS PULMONARY EMBOLISM HYPERTENSION HYPOTHYROIDISM OBESITY SEASONAL ALLERGIES <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father had prostate cancer. Mother is well. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incisions clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 05: 17AM BLOOD WBC-5.1 RBC-2.81* Hgb-9.0* Hct-27.1* MCV-96 MCH-32.0 MCHC-33.2 RDW-12.6 RDWSD-44.5 Plt ___ ___ 02: 02AM BLOOD WBC-9.1# RBC-3.10* Hgb-10.0* Hct-29.1* MCV-94 MCH-32.3* MCHC-34.4 RDW-12.5 RDWSD-43.2 Plt ___ ___ 05: 17AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-140 K-3.8 Cl-107 HCO3-27 AnGap-10 ___ 05: 19AM BLOOD Glucose-98 UreaN-10 Creat-0.6 Na-142 K-3.1* Cl-112* HCO3-24 AnGap-9 ___ 05: 17AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 ___ 05: 19AM BLOOD Calcium-7.3* Phos-3.4 Mg-1.4* <MEDICATIONS ON ADMISSION> 1. Lorazepam 1 mg PO Q6H: PRN nausea, insomnia, anxiety 2. Docusate Sodium 200 mg PO BID 3. Enoxaparin Sodium 80 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 4. Omeprazole 20 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Potassium Chloride 10 mEq PO DAILY <DISCHARGE MEDICATIONS> 1. Docusate Sodium 200 mg PO BID 2. Enoxaparin Sodium 80 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 80 mg/0.8 mL 80mg/0.8mL SC every twelve (12) hours Disp #*60 Syringe Refills: *0 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Lorazepam 1 mg PO Q6H: PRN nausea, insomnia, anxiety 5. Omeprazole 20 mg PO DAILY 6. Potassium Chloride 10 mEq PO DAILY 7. Acetaminophen ___ mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 8. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 9. OxycoDONE (Immediate Release) ___ mg PO Q3H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp #*60 Tablet Refills: *0 10. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H 11. Senna 17.2 mg PO BID: PRN constipation RX *sennosides [senna] 8.6 mg 8.6 mg by mouth twice a day Disp #*30 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> stage IV endometrioid cancer, pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 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 salpingoophorectomy, omentectomy and cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and PO oxycontin, oxycodone, ibuprofen and tylenol. Her diet was advanced without difficulty and she was transitioned to PO pain medication only. 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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10850750-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> pelvic organ prolapse, stress urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total vaginal hysterectomy with bilateral salpingo- oophorectomy, bilateral uterosacral ligament vault suspension, tension-free transvaginal tape Exact sling procedure, cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 1 Para 1001 who initially presented for evaluation of vaginal prolapse. She complained of vaginal pressure and bulging sensation that affected her urination. She reported urinary frequency and an interrupted flow. Her symptoms had been present for approximately ___ year and had worsened. She reported rare urge incontinence events. She reported voiding ___ times per day and ___ times per night with some urinary urgency. She denied any dysuria, hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ also repored vaginal pressure and palpable prolapse. She also admited to constipation. She was sexually active and experienced dyspareunia. She denied any vaginal dryness. <PAST MEDICAL HISTORY> OB/Gyn: G1P1, SVDx1, postmenopausal PMH: depression, hemorrhoids PSH: hemorrhoid I&D, drainage of ___ abscess <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Breast, Ovarian cancer. Her brother is with ___ cancer. <PHYSICAL EXAM> Gen: Well-appearing woman in no acute distress Lungs: CTAB Cardiac: RRR Abd: Soft, ND, BS+. Mild TTP in bilat lower quadrants Incision: dressing is clean, dry, intact GU: voiding spontaneously Ext: non-tender, non-edematous <PERTINENT RESULTS> ___ 08: 00AM BLOOD WBC-8.5 RBC-3.61* Hgb-11.0* Hct-31.9* MCV-88 MCH-30.4 MCHC-34.5 RDW-12.9 Plt ___ ___ 09: 45AM BLOOD WBC-11.6* RBC-3.66* Hgb-10.9* Hct-32.5* MCV-89 MCH-29.8 MCHC-33.6 RDW-12.9 Plt ___ ___ 04: 30PM BLOOD WBC-15.4*# RBC-3.97* Hgb-12.0 Hct-35.4* MCV-89 MCH-30.2 MCHC-33.9 RDW-12.8 Plt ___ ___ 08: 00AM BLOOD Glucose-105* UreaN-15 Creat-1.1 Na-141 K-3.8 Cl-106 HCO3-28 AnGap-11 ___ 09: 45AM BLOOD Glucose-101* UreaN-12 Creat-0.6 Na-136 K-3.8 Cl-99 HCO3-29 AnGap-12 ___ 08: 00AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.3 ___ 09: 45AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.7 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Fluoxetine 20 mg PO DAILY <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: *1 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. Fluoxetine 20 mg PO DAILY 4. Simethicone 40-80 mg PO QID RX *simethicone 80 mg 1 tablet by mouth four times a day Disp #*30 Tablet Refills: *2 5. 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 #*35 Tablet Refills: *0 6. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4000 mg acetaminophen in 24 hrs. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY Duration: 7 Days Take every day while catheter in place. RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth once a day Disp #*7 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine prolapse, stress urinary incontinence with urethral hypermobility, cystocele. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure taking care of you on the gynecology service. You have recovered well after your operation and the team feels you are ready to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months or until advised at post-operative 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. Urinary Catheter: *) You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ on ___ for catheter removal. . 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 with bilateral salpingo- oophorectomy, bilateral uterosacral ligament vault suspension, and tension-free transvaginal tape Exact sling procedure; please see operative report for details. Her recovery was complicated by post-operative nausea and an episode of emesis on post-operative day #1. This resolved with IVF, minimizing narcotic use, and a dose of zofran. Her labs were followed and on post-operative day#2 her Cr was noted to be increased form 0.6 on post-operative day #1 to 1.1. Her last baseline Cr from ___ was 1.3. Her urine output was adequate, her vital signs were stable, and her pain was minimal. Her UA showed no evidence of infection. Her toradol and motrin were held, she received a bolus of 500 cc IVF, and PO hydration was encouraged. On post-operative day #1, she failed to void x2 after her bladder was backfilled with sterile saline for a voiding trial. She was given a leg bag and instruction on its use and a prescription for prophylactic antibiotics. She was discharged home on postoperative day #2 in good condition: ambulating, tolerating a regular diet, with adequate pain control using PO medication, and with an outpatient appointment arranged to repeat a trial of void in the office.
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10852762-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Augmentin / Valium / Latex <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic mass, Splenic cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic splenic cystectomy with omental graft and left salphingo-oopherectomy <HISTORY OF PRESENT ILLNESS> Dr. ___ is a ___ yo G3P3 who presented to gyn oncology in ___ with complex adnexal mass and a large 12 cm upper abdominal mass. The patient reported abdominal pain, extending in a belt-like fashion beneath her rib cage circumferentially. This pain had basically been going on for two to three weeks prior to presentation and was particularly exacerbated with eating. She reported a focus of left upper quadrant discomfort as well. She reported normal bowel function and denies any abdominal bloating or distention. A CA-125 level was notably elevated at 100. The imaging study was performed at the ___ and this was basically just an abdominal ultrasound. No other abnormalities were seen. No additional imaging has been obtained to this point. Dr. ___ is again, otherwise doing fairly well. She has no focal complaints beyond the discomfort in the upper quadrants. She had a follow-up imaging study in ___ which showed persistent masses. She prefered surgical management. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Dr. ___ is otherwise in very good health. She denies any history of asthma, hypertension, mitral valve prolapse, or thromboembolic disorder. She reports having a normal mammogram 14 months ago and she has never had a colonoscopy. Past Surgical History: She had a C-section for her first delivery and then went on to have two normal vaginal deliveries, VBAC. She denies any other surgical history. OB/GYN History: She reports normal menstrual cycles beginning at the age of ___. They occur plus or minus every 21 days and last for 3 days. She denies any history of pelvic infections or abnormal Pap smears. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports her mother had breast cancer at the age of ___. Evidently, she was tested for BRCA mutation and noted to be negative. <PHYSICAL EXAM> At pre-op physical: General: She appears her stated age, in no apparent distress. HEENT: Normocephalic, atraumatic. Oral mucosa without evidence of thrush. Eyes, sclerae are anicteric. Neck: Supple. There are no masses. Lymphatics: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. Chest: Lungs clear. Heart: Regular rate and rhythm. Back: No spinal or CVA tenderness. Abdomen: Soft, nontender, nondistended. There is no fluid wave or palpable mass. There is no hernia or irregularity. Extremities: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. Pelvic: Normal external genitalia. Inner labia minora are normal. Urethral meatus normal. Walls of the vagina are smooth. Cervix is normal. Bimanual exam reveals no mass or lesion. Rectal: Reveals no mass or lesion. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *50 Capsule(s)* Refills: *0* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Likely endometriosis Splenic cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or return to the hospital if you have: -Increased pain -Redness or unusual discharge from your incision -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -No heavy lifting or vigorous activity for 6 weeks -You can shower and clean your wound, but do not use perfumed soaps or lotions. Be sure to pat completely dry after washing. -You may resume your regular diet and home medications.
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Dr. ___ was admitted to the gyn oncology service after her surgery for post-operative care. Please see operative note for full details. Her post-operative course was uncomplicated. She was discharged home on POD 1 in good condition.
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10853896-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> Postmenopausal bleeding, endometrial adenocarcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G5P1 who presented to ___ clinic for evaluation of endometrial adenocarcinoma. She initially presented to her primary gynecologist with 1 month of light postmenopausal bleeding associated w/ lower pelvic cramps. Office endometrial biopsy revealed well-differentiated endometrioid adenocarcinoma, FIGO grade 1. At initial gyn onc consultation, pt reported improvement in her vaginal bleeding since endometrial biopsy. She endorsed 17 lbs intentional weight loss over 2 preceding months. Denied CP, SOB, dysuria, hematuria, constipation, blood in the stool, changes in bowel habits, N/V, fevers, chills. She endorsed chronic urinary hesitancy which was unchanged from her baseline as well as occasional loose stools. <PAST MEDICAL HISTORY> - coronary artery disease, MI (___) - CHF s/p hospital visit ___ for CHF exacerbation - obesity (BMI 39.8) - asthma - diabetes - arthritis - hypercholesterolemia - HTN <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Denies history of gyn or colon cancer, bleeding or clotting disorder - Significant for diabetes, HTN, cardiovascular disease <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 04: 00AM BLOOD WBC-9.8 RBC-3.38* Hgb-9.4* Hct-30.5* MCV-90 MCH-27.8 MCHC-30.8* RDW-14.6 RDWSD-48.4* Plt ___ ___ 04: 00AM BLOOD Glucose-111* UreaN-16 Creat-1.1 Na-140 K-3.4 Cl-97 HCO3-26 AnGap-20 ___ 04: 00AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.8 ___ 03: 48AM URINE Hours-RANDOM Creat-226 Na-<20 ___ 03: 48AM URINE Osmolal-624 <MEDICATIONS ON ADMISSION> - metoprolol 25mg daily - gabapentin 300mg BID - metformin ER 500mg BID - furosemide 80mg daily - potassium 30mg daily - pravastatin - lantus - tylenol - alleve - multivitamin, calcium , ___, osteo biflex <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*50 Capsule Refills: *1 3. Ibuprofen 400 mg PO Q6H: PRN Pain - Moderate take with food RX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. TraMADol 25 mg PO Q4H: PRN Pain - Severe do not drink alcohol or drive while taking tramadol RX *tramadol 50 mg ___ tablet(s) by mouth every 4 hours Disp #*25 Tablet Refills: *0 5. Furosemide 80 mg PO DAILY 6. Gabapentin 300 mg PO BID 7. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Pravastatin 80 mg PO QPM <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: . 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 Tramadol as needed. As you start to feel better and need less medication, you should decrease/stop the Tramadol first. * Do not drive while taking Tramadol. * Do not combine Tramadol and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. * Keep the urinary catheter in place until your follow-up appointment on ___ . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy with urethral dilatation and Foley placement. Please see the operative report for full details. Her post-operative course is detailed as follows: *) Routine post-op: Immediately postoperatively, her pain was controlled with IV Dilaudid and Toradol PRN. Her diet was advanced without difficulty and she was transitioned to PO Oxycodone, Acetaminophen, and Ibuprofen PRN. *)Urethral stricture: Intraoperatively, pt was noted to have dense urethral stricture, requiring intraoperative urology consult. Foley catheter was placed by first passing a Sensor wire, then passing the foley over it. The Foley was kept in place throughout pt's post-operative admission. She was discharged with the foley catheter in place with plan for outpatient voiding trial and possible urethral biopsy. *)Decreased UOP: Pt had decreased UOP ___ on post-operative day #1. Her vital signs were stable, and her exam was not concerning for intra-abdominal hemorrhage or cardiac etiology of decreased urine output (ex. CHF exacerbation). FeNa was consistent with pre-renal etiology. Pt was encouraged to PO hydrate, and her urine output subsequently improved. On post-operative day #2 her urine output was adequate (>100cc/hr) prior to discharge. *) Congestive heart failure: Pt was continued on her home dose of Metoprolol, Lasix, Potassium, and Pravastatin. *) T2DM: Pt was continued on metformin 1000mg BID and was placed on an insulin sliding scale. Her blood glucose levels ranged from 100s-206 during this admission. 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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10854654-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> endometritis, mastitis <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm, incision c/d/i Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 08: 53PM WBC-19.6*# RBC-3.20* HGB-9.6* HCT-30.2* MCV-94 MCH-30.0 MCHC-31.8* RDW-14.1 RDWSD-48.4* ___ 08: 53PM NEUTS-72* BANDS-12* LYMPHS-11* MONOS-5 EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-16.46* AbsLymp-2.16 AbsMono-0.98* AbsEos-0.00* AbsBaso-0.00* ___ 08: 53PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL ___ 08: 53PM PLT SMR-NORMAL PLT COUNT-426*# ___ 08: 53PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08: 53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG ___ 08: 53PM URINE RBC-8* WBC-55* BACTERIA-FEW YEAST-NONE EPI-1 ___ 08: 53PM URINE MUCOUS-OCC <MEDICATIONS ON ADMISSION> ProAir, Advair, metoclopramide <DISCHARGE MEDICATIONS> 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 4. MetroNIDAZOLE 500 mg PO BID RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Moderate to Severe Pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> postpartum mastitis endometritis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest until 6 week postpartum visit keep breast pumping and nursing to keep breasts drained
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On ___ Ms. ___ was admitted to post-partum for left breast mastitis and endometritis. Pelvic ultrasound showed heterogeneous hypoechoic material ~7mm, avascular, with question for retained products. She was started on IV gentamicin and clindamycin for 48 hours for her endometritis, and given dicloxacillin for her mastitis. There was no evidence of abscess on breast exam. By hospital day 2, her leukocytosis and bandemia had resolved, and her symptoms were improving, so she was transitioned to oral augmentin and flagyl. By hospital day 4, she was afebrile, tolerating regular diet, on oral pain medications, ambulating on her own, and symptomatically improving. She was discharged home in stable condition with outpatient follow-up scheduled.
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10855190-DS-29
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Lipitor / Transderm-Nitro <ATTENDING> ___ <CHIEF COMPLAINT> cystocele, rectocele <MAJOR SURGICAL OR INVASIVE PROCEDURE> anterior and posterior colporrhaphy, cystoscopy <HISTORY OF PRESENT ILLNESS> The patient is a ___, gravida 3, para 3, who was referred to me by Dr. ___ urinary incontinence. The patient complained also of nocturia, frequency, and mixed incontinence. She was examined and found to have a second-degree cystocele, second- degree rectocele, and first-degree vault prolapse. Given her significant past medical history for hypertension, diabetes, PE, and the fact that also she was on Coumadin, we elected to proceed with a conservative approach. She was fitted for a pessary which she wore comfortably at first but eventually, in ___ of this year, she experienced too much discomfort and elected to proceed with surgical management. The risks, benefits, and alternatives to surgery were explained to the patient and she elected to proceed with anterior-posterior repair. <PAST MEDICAL HISTORY> - CAD, s/p MI (remote, prior to ___, has a tight ___ RCA which was medically managed) - Type II DM on insulin - Hypertension - Hyperlipidemia - Hypothyroidism - Hx of PE in ___, IVC filter in place - hyponatremia - osteoporosis - allergies - spinal stenosis - s/p laminectomy ___ - s/p appendectomy and cholecystectomy - s/p TAH and oophorectomy - s/p multiple hernia operations - s/p B/L total knee replacements - s/p tonsillectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of abnormal clotting. One brother died of an MI in his early ___. Father died of MI at ___, mother of leukemia at ___. Her family history is unremarkable for Breast/Ovarian or Colon cancer. <PHYSICAL EXAM> Upon discharge: AF VSS NAD RRR, III/VI systolic murmur best heard at ___, split S2 CTAB, no crackles Abd soft, NT, ND, no r/g GU minimal vaginal bleeding, foley catheter in place draining clear yellow urine Ext no TTP, no edema <PERTINENT RESULTS> ___ 03: 10PM BLOOD CK-MB-4 cTropnT-<0.01 ___ 12: 00AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 07: 00AM BLOOD CK-MB-5 cTropnT-0.01 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Diltiazem 120 mg PO BID 2. Escitalopram Oxalate 20 mg PO DAILY 3. ezetimibe-simvastatin *NF* ___ mg Oral qd 4. Gabapentin 300 mg PO BID 5. Levothyroxine Sodium 137 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO BID 8. Omeprazole 20 mg PO BID 9. Warfarin 10 mg PO DAILY16 10. Aspirin 81 mg PO DAILY 11. Loratadine *NF* 10 mg Oral qd 12. ALPRAZolam 0.25 mg PO DAILY 13. Milk of Magnesia 30 mL PO DAILY <DISCHARGE MEDICATIONS> 1. ALPRAZolam 0.25 mg PO DAILY 2. Levothyroxine Sodium 137 mcg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Escitalopram Oxalate 20 mg PO DAILY 5. Gabapentin 300 mg PO BID 6. Lisinopril 10 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO BID 8. Milk of Magnesia 30 mL PO DAILY 9. Omeprazole 20 mg PO BID 10. Warfarin 10 mg PO DAILY16 11. Claritin *NF* 10 mg Oral daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 12. Diltiazem Extended-Release 120 mg PO BID 13. NPH 4 Units Breakfast NPH 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 15. ezetimibe-simvastatin *NF* ___ mg Oral qd 16. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 17. Enoxaparin Sodium 60 mg SC DAILY 18. Hemorrhoidal Suppository 1 SUPP PR PRN hemorrhoids RX *bismuth subg-balsam-ZnOx-resor 1 suppository rectally four times a day Disp #*30 Suppository Refills: *3 19. Nitrofurantoin (Macrodantin) 100 mg PO HS Please take while your foley catheter is still in place RX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth at bedtime Disp #*14 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cystocele, rectocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You are being discharged home after undergoing the procedures listed below. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * 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 ___. *) You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ ___ location, ___, ___ floor) on ___ for catheter removal. Dr. ___ will call you today to confirm this before you leave the hospital. *) Continue to take your warfarin (coumadin) 10mg daily in addition to your lovenox 60mg daily injections. You will see Dr. ___ on ___ for your foley catheter appointment, and he will draw an INR at that time.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing anterior and posterior colporrhaphy and cystoscopy for cystocele and rectocele. Please see the operative report for full details. Her ___ course was complicated by ST depression in the setting of tachycardia upon extubation. # Post-op: Immediately post-op, her pain was controlled with IV dilaudid and tylenol. On post-operative day 1, her vaginal packing was removed and her urine output was adequate so her foley was removed and a formal voiding trial was performed. She failed her voiding trial as she was unable to void x2; she was bladder scanned for 480cc, and a foley catheter was replaced. Her diet was advanced without difficulty and she was transitioned to percocet. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. A foley catheter was left in place for urinary retention, and she was given a prescription for UTI prophlyaxis with macrodantin. # Demand ischemia ___ LV strain without evidence of ACS: Within the ___ period, the patient was noted to have ST depression in the setting of tachycardia upon extubation. She was taken to the PACU and denied any symptoms of chest pain, shortness of breath, etc. An initial ECG was performed which demostrated new 1-2 mm STD in I, aVL, and V3-V6. A cardiology consult was obtained in the PACU. Repeat ECG demonstrated resolution of ST depression, and the first set of cardiac enzymes were negative. She was given ASA 325mg in the PACU. She was recommended to continue with her home medications including aspirin, statin, beta blocker and ACE inhibitor. Upon arrival to the floor, she was continued on telemetry. She had no additional episodes of tachycardia or ST depression for the duration of her hospitalization. She remained asymptomatic and she had negative cardiac enzymes x3. # h/o PE s/p IVC filter: Prior to surgery, the patient was taken off of her Coumadin and started on lovenox. All anti-coagulation was held the day prior to surgery. Immediately after surgery on POD1, she was restarted on her Coumadin and lovenox, with a plan to bridge with lovenox until her INR was in therapeutic range. She was discharged home on Coumadin 10mg qD and lovenox 60mg SC qD. She had plans to follow-up with Dr. ___ on ___ for foley catheter removal and INR check. # T2DM: Immediately post-op, the patient was tolerating po in the PACU and so her diet was advanced without difficulty. She was restarted on her home regimen of humalog sliding scale and NPH BID. Her fingersticks ranged from 110s-170s, with a one time measurement of 334, for which she received 12u humalog and a post-correction FSBG of 114. She was discharged home tolerating a regular diet. The remainder of her chronic co-morbidities did not play a role in her hospitalization and she was otherwise continued on all of her home medications once she was tolerating po. On POD1, the patient was discharged home in good condition with outpatient follow-up scheduled.
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10856421-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Lisinopril / Hydrochlorothiazide <ATTENDING> ___. <CHIEF COMPLAINT> heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G8P4 who reports heavy menstrual bleeding x 3 days. She reports heavy menses since her Mirena was removed ___ months ago; denies prior h/o heavy menstrual bleeding. During her last three menstrual cycles, she has been soaking 20 pads in a 24H period. Today she then soaked 8 pads prior to presentation to ED, estimates she was soaking through 2 pads per hour. Pad has been changed ___ times while in the ED over the past 4 hours, but they were not completely soaked. She is not using any method of contraception since IUD removed, and does not desire future fertility. LMP ___, currently bleeding feels like menses. No other sx of pregnancy. Reports lightheadedness and dizziness today, though this has improved in the ED as she has been seated. No CP, SOB. <PAST MEDICAL HISTORY> PObHx: G8P4 - SAB x 2 - TAB x 2 - SVD x 4 PGynHx: - Denies dysmenorrhea, menorrhagia until IUD recently removed - Distant h/o abnormal Pap, most recent was normal (last at ___ ___ - 4.8cm simple right adnexal cyst and fibroid uterus noted on ___ PUS - Denies history of STIs, gynecological diagnoses such a endometriosis - Has used the following contraceptive methods: ___ IUD, OCPs PMHx: nephrolithiasis, HTN, anemia PSHx: lithotripsy <SOCIAL HISTORY> Currently sexually active with ___ male partner. Feels safe in this relationship, denies h/o DV/abuse. Lives with husband and 2 children. Occupation: ___ at ___. Denies tobacco, alcohol, and drug use. <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> ___ 06: 40PM URINE HOURS-RANDOM ___ 06: 40PM URINE HOURS-RANDOM ___ 06: 40PM URINE UCG-NEGATIVE ___ 06: 40PM URINE UHOLD-HOLD ___ 06: 25PM WBC-8.2 RBC-3.01* HGB-8.0* HCT-25.7* MCV-85 MCH-26.6 MCHC-31.1* RDW-13.2 RDWSD-40.9 ___ 06: 25PM NEUTS-73.4* ___ MONOS-5.1 EOS-0.5* BASOS-0.2 IM ___ AbsNeut-6.04 AbsLymp-1.70 AbsMono-0.42 AbsEos-0.04 AbsBaso-0.02 ___ 06: 25PM PLT COUNT-298 ___ 01: 25PM GLUCOSE-105* UREA N-17 CREAT-0.9 SODIUM-136 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-19* ANION GAP-21* ___ 01: 25PM estGFR-Using this ___ 01: 25PM WBC-7.7 RBC-3.23* HGB-8.7* HCT-26.9* MCV-83 MCH-26.9 MCHC-32.3 RDW-13.3 RDWSD-40.4 ___ 01: 25PM NEUTS-74.3* ___ MONOS-4.9* EOS-0.4* BASOS-0.3 IM ___ AbsNeut-5.73# AbsLymp-1.52 AbsMono-0.38 AbsEos-0.03* AbsBaso-0.02 ___ 01: 25PM PLT COUNT-366 ___ 01: 25PM ___ PTT-30.7 ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atenolol 25 mg PO DAILY 2. Omeprazole 40 mg PO DAILY 3. Loratadine 10 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30 mg-mcg oral TID RX *norethindrone ac-eth estradiol [Microgestin ___ (21)] 1.5 mg-30 mcg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills: *1 2. Atenolol 25 mg PO DAILY 3. Loratadine 10 mg PO DAILY 4. Omeprazole 40 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> heavy menstrual bleeding fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for heavy menstrual bleeding and anemia. You received 2 units of blood. 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. * Please take Loestrin as instructed - three times a day until the bleeding stops, then twice a day for one week, then daily * Please follow up with Dr. ___ at the appointment time listed below * Please review the danger signs below. If you start exhibiting any of them, please either call our office or go to the nearest emergency room. * Please do not hesitate to call our office at ___ should you have any questions. 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 acute on chronic anemia due to menses after Mirena IUD discontinuation. Upon admission she was noted to be anemic to hct of 26. She received 2 units of pRBCs and her hct remained stable at 26. She remained hemodynamically stable throughout her stay. For her history of hypertension, she was continued on atenolol. Her bleeding had improved from admission, saturating 75% of a pad every 3 hours. On HD2, she denied any symptoms of anemia and was stable for discharge, with plan for OCP taper with Loestrin TID until bleeding cessation, then BID for one week, then daily. She was also scheduled for outpatient follow up.
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10856421-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Lisinopril / Hydrochlorothiazide <ATTENDING> ___ <CHIEF COMPLAINT> Vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ ___ with history of fibroid uterus and abnormal uterine bleeding presents with vaginal bleeding x10 days. Patient has been followed by primary OB/GYN at ___ and ___ recently Dr. ___ in MIGS. Briefly, she has had heavy menstrual bleeding for years. She has a nexplanon in place since ___ with minimal improvement in her vaginal bleeding. She was counseled on her options in ___ and given rx for aygestin. On followup ___, she elected to proceed with UAE for treatment. Since her prior visit, she states that her period began ___. She has had bleeding daily using a minimum of 6 super sized tampons. She has passed tennis ball sized clots that are dark red. On day of admission, she noticed heavier bleeding and used 6 tampons over a 5 hour period. She also had some lightheadedness and therefore presented to the emergency room for further evaluation. There, she was found to be tachycardic to 135 and received 1L IVF. Her labs were notable for a hematocrit of 27, downtrend from 33 in ___. On examination, she had clot removed and active bleeding with difficulty visualizing the cervical os. She was given 1000mg tranexamic acid at ___. Patient denies continued dizziness or lightheadedness. No CP, SOB. She has abdominal cramps that are ___, at her baseline. She stated she has continued to have vaginal bleeding and has used 5 pads over a 4 hour period in the emergency room. She states she did not use the prescribed aygestin as it gave her nausea and discomfort. Patient also states she wishes to have a hysterectomy at this time. In the past she had considered UAE but is worried about continued symptoms after the procedure. She has an appointment scheduled with Dr. ___ on ___ and Dr. ___ on ___ to review her options. <PAST MEDICAL HISTORY> PObHx: G8P4 - SAB x 2 - TAB x 2 - SVD x 4 PGynHx: - Denies dysmenorrhea, menorrhagia until IUD recently removed - Distant h/o abnormal Pap, most recent was normal (last at ___ ___ - 4.8cm simple right adnexal cyst and fibroid uterus noted on ___ PUS - Denies history of STIs, gynecological diagnoses such a endometriosis - Has used the following contraceptive methods: Mirena IUD, OCPs PMHx: nephrolithiasis, HTN, anemia PSHx: lithotripsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> General: NAD, resting comfortably in bed CV: RRR Lungs: LCTAB, no respiratory distress Abd: soft, nontender, nondistended, +BS GU: pad saturated with moderate blood, about to be changed Extremities: Nexplanon palpable in L arm; no calf tenderness/erythema <PERTINENT RESULTS> ___ 12: 45PM BLOOD WBC-6.2 RBC-3.12* Hgb-9.3* Hct-27.6* MCV-89 MCH-29.8 MCHC-33.7 RDW-14.5 RDWSD-44.8 Plt ___ ___ 11: 55AM BLOOD Neuts-65.4 ___ Monos-5.5 Eos-1.9 Baso-0.5 Im ___ AbsNeut-4.17 AbsLymp-1.67 AbsMono-0.35 AbsEos-0.12 AbsBaso-0.03 ___ 12: 45PM BLOOD Plt ___ ___ 11: 55AM BLOOD Glucose-110* UreaN-17 Creat-0.8 Na-143 K-5.3* Cl-107 HCO3-21* AnGap-15 <MEDICATIONS ON ADMISSION> amlodipine 5, atenolol 50, epinephrine, nexplanon <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID constipation take if constipated on iron RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *1 3. tranexamic acid ___ mg oral Q8H RX *tranexamic acid ___ mg 2 tablet(s) by mouth three times a day Disp #*20 Tablet Refills: *0 4. amLODIPine 5 mg PO DAILY 5. Atenolol 50 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID anemia <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Heavy vaginal bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for management of heavy vaginal bleeding. Your bleeding has improved and you received 2 units of red blood cells. The team believes you are ready to be discharged home. Please go to your ___ appointment tomorrow. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * You may eat a regular diet. * You may walk up and down stairs. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted on ___ for management of her abnormal uterine bleeding. A pelvic U/S ___ showed a fibroid uterus, largest fibroid in uterine body 11.8 x 8.8 x 10.0 cm, EMS 13.5mm. She received one dose of Tranexamic acid in the ED. Her hematocrit and coags were stable. On ___, she was clinically stable and was discharged with Interventional Radiology follow-up as well as follow-up with Dr. ___. She was also discharged with a prescription for PO tranexemic acid and PO iron.
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10856868-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___ <CHIEF COMPLAINT> Unexplained abdominal pelvic pain, Newly diagnosed right ovarian cyst, Uterine fibroids. <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Exam under anesthesia. 2. Laparoscopic right salpingo-oophorectomy. 3. Laparoscopic excision of endometriosis (left bladder). 4. Extensive lysis of adhesions (extensive bowel, bladder). 5. Right ureterolysis. 6. Cystoscopy with right ureteral catheterization and removal. 7. Biopsy of uterine serosa lesions. <HISTORY OF PRESENT ILLNESS> ___ G0, P0 premenopausal Caucasian female with a history of thrombocytopenia, psoriasis, and seasonal allergies. She reports regular menses at baseline at ___ day intervals with three days of moderate flow. She does experience occasional dyspareunia and reports only modest cramps on day one of her cycle. More recently, she had an episode of unexplained severe diffuse abdominal pelvic pain that was on day 12 of her prior cycle. LMP was ___. Pain began on ___. The severe pain, which is ___ pain lasted roughly 2 days. The patient describes the pain as debilitating and she was in the fetal position for roughly 2 days. She did self-medicate with Advil and Tylenol with no improvement of her pain. The severe pain was then followed by mild-to-moderate pain that lasted a total of three weeks until the onset of her next menses, which began on ___. The patient is currently on day three of her current menstrual cycle, with improvement of her pelvic pain. 3 days after the onset of pain, the patient's PCP ordered an abdominal ultrasound as part of the pain evaluation. A right ovarian cyst measuring 5.7 x 5.2 x 4.6 cm was noted on the abdominal US. A pelvic ultrasound was subsequently ordered for further evaluation of the cyst finding. PUS ___ an anteverted uterus measuring 8.4 x 6.6 x 6.4 cm with a 3.1 cm fundal fibroid and a 1.5 cm lower uterine segment fibroid. The endometrial stripe measured 5 mm. There was a 6.9 x 4.5 x 4.1 cm simple right ovarian cyst. There is no comment regarding the left ovary. Given the pelvic ultrasound findings, the patient was advised to seek consultation with myself. She has no other specific gynecologic complaints. <PAST MEDICAL HISTORY> OB HX: G0P0. -- Patient has never actively tried to conceive, but she has not used contraception for the last ___ years since age ___ and has not conceived spontaneously. GYN HX: -- Menarche age ___. LMP, ___. -- Regular menses at ___ day intervals with three days of moderate flow, moderate cramps on day#1 of cycle, occasional dyspareunia. Denies any notable endometriosis like symptoms. Severe debilitating pain on ___. See HPI. -- Last ___ negative SIL candidiasis noted. -- The patient is sexually active. Reports three sexual partners throughout life, monogamous and heterosexual. -- Contraception: None per patient report has never conceived for the past ___ years. -- STD History: Denies. MED PROBS: 1. Thrombocytopenia, platelet nadir 65 several years ago. More recently ranging between 90-110. Father with ITP. 2. Psoriasis. 3. Seasonal allergies. 4. Right ovarian cyst 6.9 cm on PUS. 5. Small fibroid uterus. 6. Recent episode of abd- pelvic pain, undergoing current eval. 7. Primary Infertility? (no REI testing, no BC x ___ yrs) SURG HX: 1. ___, cataract surgery. 2. Tooth extraction. Neither procedure resulted menorrhagia in the setting of thrombocytopenia. <SOCIAL HISTORY> ___ <FAMILY HISTORY> -- Denies any gynecologic cancers in the family. -- Patient's maternal grandmother with lymphoma. -- Patient's father with hypertension, heart disease, hypercholesterolemia and ITP. <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> ___ 07: 25AM PLT COUNT-83* ___ 07: 25AM WBC-4.7 RBC-5.10 HGB-12.9 HCT-41.4 MCV-81* MCH-25.3* MCHC-31.2* RDW-15.7* RDWSD-45.8 ___ 06: 04AM BLOOD WBC-7.1# RBC-4.06 Hgb-10.3* Hct-33.4* MCV-82 MCH-25.4* MCHC-30.8* RDW-15.9* RDWSD-47.6* Plt Ct-71* ___ 06: 04AM BLOOD Glucose-116* UreaN-9 Creat-0.6 Na-137 K-3.8 Cl-104 HCO3-26 AnGap-11 ___ 06: 04AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.3 <MEDICATIONS ON ADMISSION> cacopotriene 0.005% qd prn psoriasis, clobetasol bid prn, fluticasone 50 QD, halobetasol prn, triazolam QD, Ca, Vit D, ibuprofen, MVI <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4000 mg acetaminophen 2. Docusate Sodium 100 mg PO BID 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. OxycoDONE (Immediate Release) ___ mg PO Q6H: PRN pain ___ cause drowsiness, do not drive while taking. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right ovarian cyst, endometriosis, urinary retention now resolved <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 due to urinary retention. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks. * 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. * You 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. ___ underwent an exam under anesthesia, laparoscopic right salpingo-oophorectomy, laparoscopic excision of endometriosis (left bladder), extensive lysis of adhesions (extensive bowel, bladder), right ureterolysis, cystoscopy with right ureteral catheterization and removal, and biopsy of uterine serosa lesions. Please see the operative report for full details. She was admitted to the gynecology service for observation postoperatively due to urinary retention, which resolved on POD#1. Immediately post-op, her pain was controlled with PO oxycodone and Tylenol. Her post-operative course was complicated for urinary retention in the PACU, her foley was therefore replaced and she was admitted overnight. On post-operative day 1, her urine output was adequate so her foley was removed with a voiding trial and she voided spontaneously. Her diet was advanced without difficulty and pain remained controlled on PO oxycodone and tylenol. By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10859137-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Squamous cell carcinoma of the cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> Placement and removal of interstitial implant <HISTORY OF PRESENT ILLNESS> ___ female who had a routine Pap smear on ___, showing atypical squamous cells of undetermined significance (ASCUS). A urinalysis that day also showed a ___ bright red blood cells and 2+ blood. Repeat urinalysis on ___, showed ___ red blood cells, but no blood. Pap smear with Dr. ___ at ___ OB/GYN on ___ showed high-grade squamous intraepithelial lesion (HGSIL). Urinalysis showed no blood and ___ red blood cells. The patient did not want any further workup for the microscopic hematuria at that point, and preferred close observation. On ___, colposcopy by Dr. ___ an erythematous lesion from 9 to 12 o'clock and 4 to 6 o'clock of the cervix, the entire portio showed grade 3 mosaic, and the vulva had acetowhite patches. Biopsies at 2, 5 and 11 o'clock on the cervix showed HGSIL. On ___, repeat colposcopy and LEEP of the cervix showed tiny gray acetowhite patches at the base of the hair follicles and the vulva. The vulvar abnormalities were not concerning, and it was decided to continue to closely observe the vulva. LEEP of the cervix showed poorly differentiated invasive squamous cell carcinoma extending to the cauterized margin, positive for LVI, extending at least 0.7 cm into the cervical stroma, with positive margins. The patient was diagnosed with a FIGO-1B1 squamous cell carcinoma of the cervix and on ___, Dr. ___ performed a radical hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and examination under anesthesia during which he noted no involvement of the parametria, vagina or cul-de-sac. Pathology showed a 0.7 cm grade 1 squamous cell carcinoma invading to a depth of 3 mm with negative margins and no lymphovascular invasion. One left obturator, two Left iliac, one right iliac and four right obturator lymph nodes were all negative. . Pap smear by Dr. ___ on ___, showed ASCUS. The patient tried Premarin vaginal cream, and vaginal biopsy on ___ was negative for malignancy. Pap smears on ___, on ___ and on ___ showed ASCUS. Colposcopy and Pap smear by Dr. ___ on ___ showed low-grade squamous intraepithelial lesion. Colposcopy by Dr. ___ on ___, showed moderate acetowhite epithelium with possible punctations at the vaginal apex, especially on the left. A biopsy and pap smear showed at least HGSIL/VaIN3. Examination under anesthesia and colposcopy on ___, which was limited by bleeding from the vaginal cuff, showed no changes from the, office exam. Biopsies at 1 o'clock and 11 o'clock of the vaginal cuff showed a HGSIL, and biopsies at 5 o'clock and 12 o'clock were negative. On ___, the patient had carbon dioxide laser ablation of the upper 2-3 cm of the vagina to a depth of 1-2 mm. On ___, gynecologic examination and colposcopy revealed a white plaque at the vaginal apex that peeled-off easily upon insertion of the speculum. Pap smear and pathology of the plaque showed HGSIL. The patient tried weekly Efudex for 6 weeks and on ___, physical exam showed no abnormalities and Pap smear was negative. Pap smears on ___ ___ and ___ were all negative for disease. Of note, on ___ and ___, Pap smears provided insufficient material for evaluation. During this period of time, the patient was diagnosed with DCIS and LCIS of the left breast, status post breast-conserving surgery and adjuvant radiation ending ___ ___ at ___ ___. During the CT scan for her left breast radiation, a right upper lobe mass suspicious for malignancy was visualized and a CT-guided lung biopsy in ___ showed adenosquamous lung cancer. The patient had resection of the right upper lobe and superior segment of the right lower lobe, showing a pT2b, N0, M0, stage IIA lung cancer, with adjuvant cisplatin and Navelbine for four cycles until ___. She started tamoxifen in ___. . In ___, the patient again had an episode of hematuria and CT urogram and chest CT on ___ showed a 5-mm soft tissue mass at the dome of the bladder, and a 3.4 cm cystic lesion in the uncinate process of the pancreas. Cystoscopy on ___, showed no masses or mucosal lesions. There was minimal submucosal impression at the dome without mucosal change, thought to be possibly a hemorrhagic cystic submucosal structure or urachal cystic mass. On ___, endoscopic ultrasound and FNA of the pancreatic cyst was nondiagnostic. As her CEA was not elevated, it was thought that this was likely nonmalignant, but an MRI was recommended to further evaluate the lesion. . She saw Dr. ___ in followup on ___, who visualized a fungating mass at the vaginal apex and a firm shelf-like mass at the apex of the vaginal canal. Rectal examination confirmed the paravaginal extension, but no tumor at the urethral meatus or distal vagina. Biopsy that day demonstrated superficial fragments of squamous mucosa with at least high-grade squamous intraepithelial lesion concerning for invasion. Pelvic MRI on ___, at ___ showed a 3.0 x 4.6 x 4.2 cm heterogeneously enhancing soft tissue mass at the superior aspect of the vaginal cuff extending anteriorly to invade the bladder wall and extending posteriorly to infiltrate the rectovaginal plane, without macroscopic invasion of the rectal wall itself. The inferior margin of the mass was approximately 4 cm above the introitus with additional enhancing nodularity along the posterior wall of the vagina extending inferiorly for another 1.5 cm, potentially representing additional superficial disease. There was also bilateral enlarged pelvic lymphadenopathy. PET-CT on ___ showed an avid soft tissue density at the vaginal cuff extending inferiorly into the vaginal. There was no clear vesicovaginal fat plane, which was concerning for bladder involvement, and haziness of the rectovaginal fat with some uptake concerning for local spread. There was bilateral FDG-avid pelvic sidewall and right common iliac lymphadenopathy, but no evidence of distant metastatic disease. . Currently, is undergoing external beam radiation to the pelvic lymph nodes with concurrent chemotherapy. She has the expected side effects, including moderate fatigue, diarrhea controlled with a low-residue diet, metamucil, and imodium, and severe erythema of the vulva, ___ and perineal tissue within the radiation portal, for which she is using aquaphor and A&D ointments. She has lost 8 lbs over the last 2 weeks and has severely decreased appetite. <PAST MEDICAL HISTORY> 1. Recurrent cervical cancer, as above. 2. Grade 1 DCIS and LCIS of the left breast, status post excision on ___, followed by reexcision ___, and adjuvant radiation ending ___ ___ at ___. She is currently on Tamoxifen. 3. PT2b, N0, M0, stage IIA, adenosquamous carcinoma of the right lung status post resection of the right upper lobe and superior segment of the right lower lobe, and adjuvant chemotherapy with cisplatin and Navelbine until ___. 4. Dysthymic disorder. 5. Osteopenia. 6. Benign colon polyps. 7. CKD 2 stage II. . OB-GYN HISTORY: G1 P0 with one spontaneous abortion. Menarche at age ___, menopause at 45. Hormone replacement therapy for ___ years from age ___. Oral contraceptives for ___ years in the distant past. She is currently sexually active with a partner. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father who is a smoker, had 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, nontender, nondistended ___: nontender, nonedematous <PERTINENT RESULTS> ADMISSION LABS: ___ 07: 30AM BLOOD WBC-3.4*# RBC-2.74* Hgb-8.4* Hct-25.2* MCV-92 MCH-30.5 MCHC-33.2 RDW-16.8* Plt ___ ___ 07: 30AM BLOOD Neuts-76.8* Lymphs-9.8* Monos-12.1* Eos-0.8 Baso-0.5 ___ 07: 30AM BLOOD Glucose-76 UreaN-15 Creat-1.0 Na-137 K-4.4 Cl-103 HCO3-24 AnGap-14 ___ 07: 30AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.4* DISCHARGE LABS: ___ 08: 12AM BLOOD WBC-3.7* RBC-3.05* Hgb-9.2* Hct-27.2* MCV-89 MCH-30.2 MCHC-34.0 RDW-16.8* Plt ___ ___ 08: 12AM BLOOD Neuts-78.9* Lymphs-8.7* Monos-11.1* Eos-1.2 Baso-0.1 ___ 08: 12AM BLOOD Glucose-108* UreaN-7 Creat-0.8 Na-140 K-3.4 Cl-103 HCO3-25 AnGap-15 ___ 08: 12AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.4* <MEDICATIONS ON ADMISSION> 1. Citalopram 10 mg daily. 2. Tamoxifen. 3. Vitamin B. 4. Calcium D plus vitamin K plus vitamin D. 5. Vitamin D3. 6. Multivitamin. <DISCHARGE MEDICATIONS> No changes to home medications above. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cervical cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service for brachytherapy. You have recovered well after your treatment, and the team feels that you are safe to be discharged home. . * You may notice some vaginal discharge, which is normal. You will be instructed to douche with warm water twice a day until your follow-up visit. * After your implant has been removed, it is normal to experience mild pelvic discomfort, and some irritation of your vagina. You may also experience some discomfort when you urinate or move your bowels. Please be sure to discuss any changes in your urinary or bowel patterns with your doctor. * Your activities depend on how you feel. It is important to balance your activities at ___ with frequent rest periods, particularly during the first week. * Eating a balanced diet and drinking an adequate amount of fluids will help you to heal and regain your strength. Please follow these instructions: . * Tap water douches ___ times per day (morning and evening). * You may eat a regular diet. * Clean your skin after you urinate or move your bowels (use ___ bottle). * Refrain from sexual intercourse until your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service for vaginal brachytherapy. She underwent placement of an interstitial implant on ___. Please see operative report for full details. . She received treatments from ___ until ___ for a total of 7 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 5, her diet was advanced without difficulty. Her Foley catheter was removed and she voided spontaneously. She was transitioned to oral acetaminophen for her pain. . By hospital day 6, 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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10860878-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ACE Inhibitors <ATTENDING> ___ <CHIEF COMPLAINT> Tubo-ovarian abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> CT-guided drainage of intra-abdominal abscess <HISTORY OF PRESENT ILLNESS> ___ G0 with several months of abdominal discomfort and fullness which has worsened over the past ___. She was seen by her primary care doctor twice in the past week and also by gyn and underwent a CT scan at ___ that revealed a large cystic mass in the pelvis that appears to be related to the uterus as well as lymphadenopathy. She reports night sweats and chills at home as well as a temperature as high as 100.2, but never a true fever. She has experienced decreased appetite but no nausea or vomiting. Has been having constipation intermittently and loose stool over the past week with last BM today. No bloody stool. Denies vaginal sxs, bleeding, discharge. Abdominal pain exacerbated with urination, but no dysuria. No hematuria. No SOB, dizziness or chest pain. Controlling pain at home with acetaminophen. She was transferred to ___ for further work-up. <PAST MEDICAL HISTORY> Reports being told in the past that she had a cyst/fibroids that potentially required surgery (?at ___. She had a Pap test yesterday but has not had regular gyn care. No intercourse in ___ years. Menses are monthly. Denies hx STIs. Ob/Gyn Hx: G0, last intercourse ___ ago. Underwent initial Pap ___ (result pending). Previous pelvic exam attempted ___ ago. No Hx STIs. Menarche ___. Monthly menses. No intermenstrual bleeding. PMedHx: Pulm HTN (since ___. Hx of rheumatic heart disease s/p mitral valve replacement x 3 (most recently ___. PSurgHx: Cardiac valve replacement x3 - mechanical valve on coumadin. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FamHx: No hx of colon, breast or gyn cancer. <PHYSICAL EXAM> Initial <PHYSICAL EXAM> O: T 99.5 HR 100 BP 110/70 RR 16 O2 96%RA NAD, well-appearing RRR Abd distented/tympanic, diffusely tender to palpation, no rebound or guarding Ext without edema, no calf tenderness SSE: white discharge in vault, narrow vaginal introitus, cervix not well visualized Bimanual exam: limited by pt discomfort, anterior compression of vagina, no discrete mass appreciated but abdomen tensely distended, no CMT, no cervical masses palpated on 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, drain incisions clean/dry/intact ___: nontender, nonedematous <PERTINENT RESULTS> ___ 09: 00AM GLUCOSE-173* UREA N-6 CREAT-0.6 SODIUM-133 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-21* ANION GAP-13 ___ 09: 00AM estGFR-Using this ___ 09: 00AM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.6 ___ 09: 00AM ___ PTT-80.5* ___ ___ 05: 00AM WBC-17.6* RBC-3.37* HGB-7.3* HCT-24.7* MCV-73* MCH-21.6* MCHC-29.6* RDW-17.9* ___ 05: 00AM NEUTS-88.3* LYMPHS-6.4* MONOS-4.5 EOS-0.5 BASOS-0.2 ___ 05: 00AM PLT COUNT-404 ___ 12: 25AM LACTATE-1.5 ___ 12: 00AM URINE HOURS-RANDOM ___ 12: 00AM URINE UCG-NEGATIVE ___ 12: 00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12: 00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 12: 00AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-5 ___ 11: 50PM WBC-16.5* RBC-3.68* HGB-8.1* HCT-26.9* MCV-73* MCH-22.2* MCHC-30.3* RDW-17.9* ___ 11: 50PM NEUTS-87.8* LYMPHS-6.8* MONOS-4.4 EOS-0.7 BASOS-0.3 ___ 11: 50PM PLT COUNT-399 ___ 11: 50PM ___ Final Report EXAMINATION: MR PELVIS WANDW/O CONTRAST INDICATION: ___ year old woman with e-coli tubo-ovarian abscesses s/p CT-guided drainage with interval increased distention; drain with less than 10cc output for the past 24 hs. Evaluate for resolution of TOAs TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the pelvis were obtained prior to, during, and after the administration of 7 mL Gadavist gadolinium based contrast. COMPARISON: MRI pelvis from ___. Pelvis ultrasound from ___ FINDINGS: The uterus is normal in size. Again seen are multiple fibroids, the largest measuring 4.2 x 6.2 cm. The uterus measures 5.9 x 8.1 x 10.7 cm. The junctional zone is not well visualized. The endometrial stripe is not well visualized as well, which may be due to mass effect from the multiple fibroids. The cervix and vaginal canal are also normal in appearance with several subcentimeter nabothian cysts. Several T1 bright masses are noted within the pelvis, largest measuring 3.9 cm, compatible with known endometriomas. Again seen are bilateral multiloculated T2 bright fluid collections with enhancing peripheries. The drained collections are markedly smaller than prior examination. A left lower quadrant drain is seen in place with no significant surrounding fluid collection. The right lower quadrant drain sits in a small collection measuring 2.9 cm, previously measuring 5 cm and now contains some blood product. There are several residual large pockets of fluid, the largest measuring 3.7 x 4.1 cm (series 7, image 8) and in the lower midline of the pelvis measuring 3.6 x 4.5 cm (series 7, image 18), larger than on prior exam. There is a moderate amount of free fluid in the pelvis. There is edema throughout the pelvic soft tissues and to a lesser extent the subcutaneous soft tissues of the pelvis. Left hemorrhagic cyst, although normal ovarian parenchyma is not well seen. Right ovary likely essentially replaced by endometrioma. The urinary bladder is relatively decompressed. The visualized bowel loops are within normal limits. There are prior bilateral inguinal lymph nodes, likely reactive. The osseous structures are unremarkable. The sigmoid colon remains thickened and collapsed. No evidence of vascular thrombosis. Incompletely visualized kidneys, but both ureters appear dilated to the pelvic brim, unchanged. IMPRESSION: 1. Marked interval improvement of bilateral drained tubo-ovarian abscesses. Drainage catheters are in appropriate position with no significant residual fluid collection seen surrounding the left catheter and small collection about the right. 2. Multiloculated fluid collections in the left pelvis, mostly anteriorly, measuring up to 4.5 cm in greatest dimension, have enlarged from prior MRI. This is compatible with residual tubo-ovarian abscess, the largest of which are likely ammenable to drainage if clinically indicated. 3. Decreased size of right drained collection with residual collection remaining with tube in appropriate place. Recommend more aggressive flushing of this tube to ensure continued appropriate drainage. 4. Moderate free fluid in the pelvis with marked edema throughout the pelvis. The colon remains decompressed running through this region, but not hyperenhancing. Not definite evidence of active primary infectious colonic disease at this time. Findings discussed with Dr. ___ at 9am and again at 9: 40am on ___. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___ ___ 12: 54 AM Final Report EXAMINATION: MRI OF THE PELVIS. INDICATION: ___ year old woman with hx significant for CHF, aflutter, mechanical heart valve with complex pelvic mass of unclear etiology on ultrasound // pls further characterize complex pelvic mass TECHNIQUE: T1 and T2 weighted multiplanar images of the pelvis were acquired within a 1.5 Tesla magnet, including 3D dynamic sequences performed prior to,during, and following the administration of 7.5 cc of Gadavist intravenous contrast. COMPARISON: Reference CT from ___. FINDINGS: MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST: The uterus measures 12.1 x 9.1 x 7.2 cm, within normal limits (series 6, image16, series 3, image 12). Multiple intramural fibroids are present, denoted by low signal intensity on T2 weighted sequences, with moderate post-contrast enhancement, the largest arising from the left uterine fundus measuring 5.3 x 4.0 cm (series 6, image 17). A right anterior fibroid measuring 1.9 by 1.7 cm demonstrates a central area of high signal intensity on T2 weighted sequences, possibly representing mild degeneration (series 6, image 18). Arising from the uterine fundus is a well-circumscribed 11 mm submucosal fibroid (series 6, image 16). The endometrium appears normal, distorted rightward by the dominant fibroid. A tiny nabothian cyst is present (series 6, image 28). The cervix and vagina are otherwise normal. A moderate amount of intraperitoneal free fluid is present (series 4, image 21). Arising within the cul-de-sac is a 4.1 x 2.3 cm lesion demonstrating high signal intensity on T1 weighted precontrast images (series 8, image 60), no appreciable internal contrast enhancement, with areas of low signal intensity on T2 weighted sequences, with a markedly T2-hypointense rim (series 4, image 18), most compatible with endometriosis. Adjacent posteriorly is a 3.5 x 3.2 cm cystic lesion with predominantly high internal signal intensity on T2 weighted sequences, with varying low signal intensity likely reflecting debris or small amount of hemorrhage (series 4, image 17). Along the right posterior uterus is an area of spiculated low signal intensity on T2 weighted sequences, with mild tethering against the rectum (series 4, image 22), likely reflecting chronic endometriosis. Arising from the right adnexa is a well-circumscribed 2.5 x 1.5 cm lesion demonstrating a rim of high signal intensity on T1 weighted precontrast images (series 8, image 62, series 4, image 19), likely a hemorrhagic cyst. The remainder of the right ovary is difficult to visualize. The left ovary appears displaced anteriorly and leftwards (series 4, image 16), demonstrating multiple enlarged follicles. Abutting the uterus superiorly is a 11.7 x 7.0 cm tubular structure with mucosal folds, likely a dilated fallopian tube arising from the right (series 6, image 9, series 4, image 15), demonstrating irregular wall thickening and avid contrast enhancement (series 1101, image 52, 40). Adjacent cystic lesions demonstrating predominantly high signal intensity on T2 weighted sequences also demonstrate irregular thickened walls with avid hyperenhancement, the largest collection measuring 5.9 x 3.6 cm, arising from the right lower quadrant (series 1101, image 34), difficult to distinguish from the ovaries. There is extensive adjacent fat stranding which extends superiorly (series 1101, image 20). Multiple enlarged para-aortic and paracaval lymph nodes measure up to 1.6 x 1.4 cm (series 1101, image 16). The bladder appears normal. There are no bony lesions concerning for malignancy or infection. Moderate subcutaneous edema is denoted by increased signal intensity on T2 weighted sequences. IMPRESSION: 1. Multicystic pelvic lesion with a dilated right fallopian tube, demonstrating MR signal characteristics and enhancement pattern most compatible with a tubo-ovarian abscess. Extensive adjacent fat stranding and enlarged para-aortic and paracaval lymph nodes, likely reactive. Given the relatively benign clinical course of this patient per OMR, atypical infections should also be considered. The largest collection within the right lower quadrant may be amenable to percutaneous aspiration. 2. Cul-de-sac endometriosis with a moderate amount of intraperitoneal fluid. Likely right adnexal hemorrhagic cyst. 3. Fibroid uterus, including an 11 mm fundal submucosal leiomyoma. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___: WED ___ 5: 41 ___ Imaging Lab Final Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman with tubo-ovarian abscesses s/p CT-guided drainage with new abdominal distention // ___ persisting? new collection? previous collections after drain placement? TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained utilizing a transabdominal approach . COMPARISON: CT ___ and MR ___. FINDINGS: Bilateral adnexal drains are noted. The left catheter is positioned within a phlegmonous mass in the midline/left adnexal region. This measures approximately 6.4 x 4.0 cm, with a minor thinly septated fluid component seen anteriorly measuring 2.7 x 4.8 cm. There is internal flow on color Doppler imaging. The right adnexal drain is also seen within a region of phlegmon. The major fluid components seen on prior imaging have been drained. Fibroid uterus is demonstrated with dystrophic calcification. IMPRESSION: 1. Bilateral pelvic drains surrounded by solid-appearing phlegmonous material. The major fluid components have been drained bilaterally. 2. Fibroid uterus as seen on the prior imaging. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___: FRI ___ 9: 40 ___ <MEDICATIONS ON ADMISSION> Warfarin (3mg on T/Th/F, 5mg on ___ Metoprolol XL 25mg daily Vitamin C/B FeSO4 Lasix 80mg daily spironolactone 25mg daily Potassium/chloride. <DISCHARGE MEDICATIONS> 1. Furosemide 80 mg PO DAILY 2. Spironolactone 25 mg PO DAILY 3. Metoprolol Succinate XL 75 mg PO BID 4. CeftriaXONE 2 gm IV Q24H RX *ceftriaxone 2 gram 1 unit IV daily Disp #*13 Vial Refills: *0 5. Ferrous GLUCONATE 324 mg PO BID RX *ferrous gluconate 236 mg (27 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 6. MetRONIDAZOLE (FLagyl) 500 mg PO TID do not take with alcohol RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8 hrs Disp #*42 Tablet Refills: *0 7. Warfarin 1.5 mg PO DAILY16 please take daily and work with ___ to manage your coumadin level RX *warfarin 1 mg ___ tablet(s) by mouth every day Disp #*45 Tablet Refills: *0 8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain don't combine with alcohol or driving. no more than 4g in 24 hrs RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every ___ hrs Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> tubo-ovarian abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 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. Home health will come to your house to help you with daily IV antibiotic administration, coumadin management as well as your sternal wound infection. Please follow-up with your primary care doctor as you had anemia and elevated blood sugars during our hospital stay. Please follow-up with your PCP for ___ colonoscopy since there were some inflammatory changes in your abdomen. Please call us with any fevers, increased pain or anything that concerns you at ___ or go to the nearest Emergency Room. 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 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 drain site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from your procedure, 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 presenting to the ED for abdominal pain and having an pelvic US which showed a multilocular cystic mass with septations. She was started on Zosyn for possible abscess. On admission, her INR was supratherapeutic so her coumadin was held. Her pain was controlled with percocet and IV dilaudid for breakthrough. Her other home medications were continued. On hospital day #2, Ms. ___ was seen by cardiology and medicine for recommendations regarding her supratherapeutic INR. Per their recommendations, Coumadin was held and INR trended down without intervention. On hospital day #3, Ms. ___ had a pelvic MRI. She was continued on Zosyn, and her INR remained supratherapeutic. On hospital day #4, the MRI results indicated that she had an 11cm dilated right fallopian tube with 6cm pelvic abscess and endometrial implants in the cul-de-sac. Her antibiotics were switched to oral levofloxacin and flagyl. On hospital day #5, her INR was 2.3. She was started on heparin bridging given anticipated procedural intervention, after we confirmed that she has been able to tolerate heparin in the past despite testing positive for HIT type 2. Ms. ___ underwent CT-guided drainage of the pelvic abscess. 250cc of pus were drained from the left and 15cc of pus were drained from the right. 2 JP drains were placed. Please see the operative report for full details. Following her procedure, Coumadin 3mg was started per Pharmacy recommendations. On hospital day #6, INR was 2.1. Ms. ___ was continued on her Coumadin. On hospital day #7, her INR was therapeutic at 2.8 so her heparin was discontinued. The patient had abdominal distention and KUB was consistent with ileus. She was made NPO/IVF for bowel rest, and she was transitioned to IV cefipime and flagyl per Infectious disease recommendations. She also had a TVUS which showed interval decompression of bilateral abscesses where the drains were. On hospital day ___, the patient had bowel movements and was passing flatus. Her diet was advanced to regular. Her coumadin was held for 3 days while it was infratherapeutic. On Day 10, we also obtained a MRI that showed multiloculated fluid collection up to 4.5cm consistent with residual tubo-ovarian abscess. The two drains were contained in phlegmons with the right side with roughly 2.9cm residual pocket. Her left drain was removed. We discussed with the patient that there is an abscess that is amenable to drainage in her pelvis; however, given her co-morbidities, it may be difficult to proceed with another abscess drainage. The patient was thoroughly counselled and she chose to pursue conservative management with IV antibiotics and follow-up with MRI imaging in 2 weeks. During her whole stay, the wound care team and nursing changed her dressing as instructed by the wound care team. The final infectious disease team recommend 14 days of IV ceftriaxone 2g and po flagyl 500mg TID. We continued to manage her INR with coumadin. ___ services were obtained for the patient to manage her sternal wound care, IV antibiotic administration and INR management. A midline was placed on the day of discharge, and the patient received her first dose of ceftriaxone without issues. Ms. ___ was tolerating a regular diet, voiding spontaneously, and ambulating independently. She was then discharged home in stable condition with a MRI scheduled in 2 weeks, ID appointment in 2 week and follow-up appointment with Dr. ___ in 3 weeks.
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ACE Inhibitors <ATTENDING> ___ <CHIEF COMPLAINT> pelvic cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> attempted ___ drainage of pelvic mass <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo F with a complicated PMH presents with abdominal pain and was found to have a right hemorrhagic adnexal cyst and a large peritoneal inclusion cyst with hemorrhagic products. Ms. ___ medical history includes mitral valve replacement x 3, most recently in ___ ___omplicated by post-operative sternal dehiscence and superficial wound infection treated with short course of antibiotics and wound care follow up, pulmonary HTN, anemia who was previously admitted here on ___ for further work up of recently diagnosed pelvic mass which was consistent with cystic loculated collection thought to be a tubo-ovarian abscess which was initially treated with antibiotics alone given complex co-morbidities: pip tazo followed by levofloxacin and metronidazole with subsequent ___ guided drainage on ___ with R and L drains initially with 250mls purulent fluid output which subsequently tailed off with all cultures growing E coli. Given rising leukocytosis on oral antibiotics, on ___ she was changed to cefepime/metronidazole. Repeat MRI on ___ demonstrated that collections being drained were resolving however also showed multiloculated fluid collection up to 4.5cm consistent with residual tubo-ovarian abscess which was amenable to ___ guided drainage and antibiotics. Repeat MRI ___ demonstrated thick-walled collections bilaterally compatible with residual collections from tubo-ovarian abscesses as well as residual loculated fluid collection measuring 4cm and 2.6cm in different aspects. CT Scan, ___ showed increase in size of the right adnexal fluid collection currently measuring 6.6 x 2.3 cm. Decrease in size of the left adnexal fluid collection currently measuring 4.8 x 4.1 cm. Overall similar size of the simple fluid collections in the left anterior pelvis and in the cul-de-sac. Gallbladder stones, without evidence of cholecystitis. She was again put on antibiotics. She completed abx course and was feeling well. On ___ she underwent an MRI showing an enlarging peritoneal inclusion cyst with evidence of internal hemorrhage. Improving and almost resolved, pyosalpinges and tubo-ovarian abscesses, with minimal residual liquid component within the largest, previously drained, midline pelvic collection. Suggestion of cul-de-sac endometriosis. Multifibroid uterus. She reports LMP ___. She was feeling well until two days ago when she developed lower back pain, which then became diffuse bilateral lower quadrant pain. Reports pain was ___, achy. Also reports area of firmness on her left side. She took an oxycodone yesterday, which helped, but then pain persisted and she became concerned and presented for care. She denies HA, lightheadedness, dizziness, CP, SOB. Denies nausea/vomiting, but does report decreased appetite and has not eaten all day secondary to pain. Reports that she feels that voiding is somewhat difficult because of "pressure" in her abdomen, but that she is able to void. Reports usual normal daily bowel movements but none for 3 days. Currently after two Percocets patient reports pain as ___. Reports being told in the past that she had a cyst/fibroids that potentially required surgery (?at ___. She had a Pap test yesterday but has not had regular gyn care. No intercourse in ___ years. Menses are monthly. Denies hx STIs. <PAST MEDICAL HISTORY> Ob/Gyn Hx: G0, last intercourse ___ ago. Underwent initial Pap ___ (result pending). Previous pelvic exam attempted ___ ago. No Hx STIs. Menarche ___. Monthly menses. No intermenstrual bleeding. PMedHx: Pulm HTN (since ___. Hx of rheumatic heart disease s/p mitral valve replacement x 3 (most recently ___. PSurgHx: Cardiac valve replacement x3 - mechanical valve on coumadin. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FamHx: No hx of colon, breast or gyn cancer. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, non-tender, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ Pelvis U/S: 16x7x7cm likely peritoneal inclusion cyst w/ hemorrhagic products ___ MRI pelvis : 16cm post collection, hemorrhagic contents, b/l hydronephrosis ___: Renal U/S : mild to moderate hydronephrosis ___: CT Abd/Pelvis 1. Multiloculated pelvic fluid collection with peripheral enhancement, enlarged since ___ CT, most consistent with recurrent/worsening tubo-ovarian abscess. The largest loculated fluid component in the cul-de-sac has features of hematoma, in keeping with venous hemorrhage identified on recent MRI. No current active site of bleeding is identified on this exam. 2. Mild bilateral hydroureteronephrosis, similar to ultrasound of the previous day, most likely attributable to mass effect from pelvic fluid collections. 3. Cholelithiasis. 4. Evidence of prior sternotomy and mitral valve replacement. ___ 06: 00AM BLOOD WBC-8.0 RBC-3.62* Hgb-9.7* Hct-29.5* MCV-82 MCH-26.7* MCHC-32.7 RDW-15.8* Plt ___ ___ 06: 00AM BLOOD Neuts-73.1* Lymphs-17.1* Monos-7.2 Eos-2.1 Baso-0.5 ___ 06: 00AM BLOOD Plt ___ ___ 06: 00AM BLOOD Glucose-85 UreaN-12 Creat-0.9 Na-136 K-4.3 Cl-96 HCO3-30 AnGap-14 ___ 12: 11PM BLOOD ALT-18 AST-28 LD(LDH)-394* AlkPhos-69 TotBili-1.2 ___ 06: 00AM BLOOD Calcium-9.9 Phos-4.6* Mg-2.0 <MEDICATIONS ON ADMISSION> warfarin 8 mg M-Sa, 5 mg ___, furosemide 40 mg daily, metoprolol succ 50 mg daily <DISCHARGE MEDICATIONS> 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Warfarin 5 mg PO 1X/WEEK (___) 3. Warfarin 8 mg PO 6X/WEEK (___) 4. Furosemide 40 mg PO DAILY 5. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *2 6. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills: *0 7. Warfarin 8 mg PO 6X/WEEK (___) 8. Ferrous Sulfate 325 mg PO DAILY 9. Enoxaparin Sodium 100 mg SC Q24H Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 100 mg/mL 100 mg subcutaneous q24 Disp #*30 Syringe Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> tuboovarian abscess acute kidney injury urosepsis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after presenting with a large pelvic abscess, and were found to have kidney injury and an infection in your blood stream. Surgery was recommended which you declined against medical advice. You received a heparin drip until your INR was therapeutic on your coumadin. 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 follow-up appontment. * 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 ___. . *You were advised to have surgery for removal of the pelvic collections and refused to have this which was against medical advice *You were also advised to take a medication called Lupron to stabilize bleeding of the pelvic collection which you also refused. This was against medical advice
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Ms. ___ was admitted to the gynecologic oncology service after presenting with pelvic masses and pain. Before admission, she had had a pelvic U/S which showed 6x7x7cm likely peritoneal inclusion cyst w/ hemorrhagic products. . On HD#1, she had serial abdomnial exam and her pain was controlled with IV dilaudid, oxycodone and tylenol. She had ___ which was thought to be likely due to post renal obstruction given large pelvic mass or was prerenal. Her FENA was 0.3% and her lasix were held. Medicine was consulted to help with risk of stopping coumadin in the event patient needed ___ drainage vs surgery. They were also consulted to help with her ___ and to evaluate what the risks would be of holding her lasix. Per medicine, they recommended stopping coumadin to reverse her INR which was at 3.2 and bridging her to heparin when INR was less than 2.5. For the ___, they recommended daily weights, 2L bolus and holding lasix. If there was no improvement in the ___, a renal U/S would be advised. Patient also had MRI pelvis which showed 16cm hemorrhagic collection with active extravasation and b/l hydronephrosis. . On HD#2, ___ was consulted for possible ___ drainage. ___ recommended waiting on drainage until her INR was 2.5. Given the active extravasation, there was need to quickly reverse her INR. Her HCT remained stable at around 30. Per medicicine, she was given vitamin K and had BID CBC/INR labs. They recommended not giving FFP as that would potentially make her pro-coagulated. Overnight, her INR was 4.2 and she was given an additional vitamin K 10mg. In terms of her ___, her Cr went up to 1.7 and renal U/S was obtained which showed mild to moderate hydronephrosis. She had adequate UOP. . On HD#3, she had a temp 100.8, HR 104 at around 0100 with no localizing symptoms. Her urine was cloudy and UA/UCx, CBC/diff were sent. Her UA was positive for nitrites and leuks and had WBC 25. She had WBC 9.6 with left shift. ID was consulted who recommended on holding off abx until cultures of the pelvic mass had been obtained. At around 1630, patient had another temp 103, HR 108. Per ID, she was started on empiric cefepime as the prelim cultures were growing GNR. In terms of her ___, her Cr dropped to 1.3 and she continued to have adequate UOP. . Her INR on HD#3 was 1.6 and her hct dropped to 24.6 from 30. Medicine recommended starting heparin drip if ___ drainage would not be done urgently. ___ was informed of this development and they wanted to know where the source of hemorrhaging was before proceeding with drainage. She was sent for STAT CT Abd/pel which showed 17cm hematoma with no active bleeding which would not be a candidate for ___ drainage. Per medicine, she was then started on heparin drip with plan for possible OR the following day. . On HD #4, patient had temp 103.1, HR 125 RR 36. She received 1U pRBC and was transferred to FICU from ___ - ___. She was started on vanc/zosyn and defervesed, VSS and was well-appearing for the rest of the day. UCx and Blood Cx both grew Klebsiella which was concerning for urosepsis in the setting of obstructive renal failure. On ___, ___ attempted drainage of her pelvic fluid collection without success. On ___, sensitivities returned and antibiotics were narrowed to cefepime. Given her rapid improvement, it was most likely that her infection was secondary to her UTI, and less likely due to a pelvic abscess. Her Cr continued to downtrend during her FICU stay and was 1.1 on the day of transfer ___. Her lasix was also restarted on ___. Although patient had MVR, ID was consulted and recommended that TTE/TEE was not currently indicated. She was maintained on a heparin gtt for anticoagulation. . From HD# 6 - 11, she was continued on regular diet and heparin gtt. Her Cr continued to improved and was stable at 0.8. Per ID, IV cefepime was continued with duration depended upon post-op course. She also had diarrhea for which Cdiff was negative. Her pelvic culture had no growth. Per ID, cefepime was discontinued on ___ and she was switched to PO ciprofloxacin until ___. . Patient refused to have bilateral salpingo-oophorecetomy on ___ which was against medical advice. Her coumadin was then restarted on ___ using heparin as a bridge. Dr. ___ minimally invasive gynecology surgery was asked to see the patient on ___ to explain the need of surgery. Patient expressed understanding of this and declined surgery. Patient was offered Lupron for endometriosis suppression for which she declined which was against medical advice. Patient was initially on heparin bridge but had not reached her INR goal by time of discharge which was 1.6. Patient requested to be discharged early and was put on lovenox for bridging per medicine recs. She will be followed for her INR at the ___ ___ clinic . By HD# 16, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home against medical advice with outpatient follow-up scheduled.
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10862401-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Heterotopic pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnostic laparoscoy Laparotomy Excision of left cornual/adnexal heterotopic pregnancy <HISTORY OF PRESENT ILLNESS> ___ yo G4P1 at 5 weeks by IVF dating presenting with likely heterotopic pregnancy. Has had prior ultrasounds at ___ IVF that showed a live IUP and left ectopic pregnancy; initially thought to be cornual but now imaging is more consistent with adnexal/tubal ectopic. She has mild LLQ pain but is otherwise feeling well. <PAST MEDICAL HISTORY> OBHx: G4P1 - ectopic x 2 -> spontaneous resolution x 1, MTX x 1 - SVD x 1 MedHx: denies SurgHx: - open appendectomy (appendix was ruptured) - hysteroscopic uterine septum resection <SOCIAL HISTORY> denies T/E/D, is a ___ <PHYSICAL EXAM> Vitals - T: 97.0 BP: 122/82 HR: 80 General: NAD, resting comfortably CV: RRR Lungs: CTAB Abdomen: soft, non-distended, no TTP Pelvic: deferred Exam on discharge: NAD RRR CTAB abd soft, NT, ND, +BS, dressings C/D/I ext NT NE <PERTINENT RESULTS> ___ 03: 28PM BLOOD WBC-7.3 RBC-4.43 Hgb-13.4 Hct-38.6 MCV-87 MCH-30.4 MCHC-34.9 RDW-12.1 Plt ___ ___ 03: 28PM BLOOD Neuts-68.9 ___ Monos-7.9 Eos-0.4 Baso-0.4 ___ 03: 28PM BLOOD ___ PTT-26.8 ___ . TVUS ___: A retroverted uterus is present that measures 10 x 4.8 x 7.7 cm. It has an arcuate shape. Within the right portion of the arcuate uterus, a gestational sac is present, and embryo is seen with a heart beat at 127 beats per minute. This places the pregnancy at around 5 to ___ weeks. In the right side of the arcuate uterus, some blood is present. Both right and left ovaries are normal, both containing corpus luteal cysts.In the left adnexa, adjacent to the uterus, a further gestational sac is present, consistent with a left-sided ectopic pregnancy. This is thought to lie within the tube as at least two-thirds of the sac shows no adjacent myometrium. No evidence of embryonic cardiac motion is seen within this ectopic. <MEDICATIONS ON ADMISSION> Multi-vitamins Tylenol prn <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: do not drive while taking this. Disp: *30 Tablet(s)* Refills: *0* 2. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: do not take more than 4000mg tylenol/acetaminophen in 24h. Disp: *40 Tablet(s)* Refills: *0* 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *28 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> heterotopic left adnexal pregnancy live intrauterine pregnancy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure to take care of you while you were hospitalized at ___. You were admitted following the operation for ectopic pregnancy. You recovered well without complications. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs until approved by your doctor. * 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. * Take your dressings off tonight but leave the steri-strips 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. ___ presented to the hospital on ___ with a heteroscopic pregnancy in the setting of IVF, at approximately 5 weeks GA. She underwent diagnostic laparoscopy, laparotomy, and excision of the approximately 2-cm unruptured left cornual ectopic pregnancy at the junction of left fallopian tube and cornu. Please see the operative note for details. She had an uncomplicated recovery, voiding and ambulating without difficulty and tolerating a regular diet. She was discharged on post-operative day #1 in stable condition.
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10862401-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Atypical proteinuria <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery on ___ <HISTORY OF PRESENT ILLNESS> HPI: ___ yo G5P1 @ 29+2 weeks by ___ ___ with di di twins by IVF dating presents for admission due to new onset proteinuria confirmed by 24 our urine returned late ___. Dnies sx of PIH, mild hand swelling and over w/e noted one BP 140/100, did not call MD on call. <PAST MEDICAL HISTORY> OBHx: G5P1 - ectopic x 2 -> spontaneous resolution x 1, MTX x 1 - SVD x 1 MedHx: denies SurgHx: - open appendectomy (appendix was ruptured) - hysteroscopic uterine septum resection <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/c <PHYSICAL EXAM> PE: T 98.7 R 18 P 76 BP 105/77 HEENT: wears glasses, EOMI CV: NSR w/o m/g/r Chest: CTA B Abd: gravid, NT Ext: no c/c/e <PERTINENT RESULTS> ___ 01: 45PM CREAT-0.6 ___ 01: 45PM estGFR-Using this ___ 01: 45PM ALT(SGPT)-18 ___ 01: 45PM URIC ACID-4.8 ___ 01: 45PM WBC-8.1 RBC-3.73* HGB-12.1 HCT-34.7* MCV-93# MCH-32.5* MCHC-34.9 RDW-13.9 ___ 01: 45PM PLT COUNT-187 <MEDICATIONS ON ADMISSION> pnv <DISCHARGE MEDICATIONS> 1. breast pump Sig: One (1) every four (4) hours: hospital grade, babie sin NICU. Disp: *1 1* Refills: *0* 2. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *0* 3. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as needed for anxiety. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> CS twins <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> given
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She was admitted and had atypical preeclampsia that was stable and underwent a CS on ___ due to lack of growth of twin B and gestational age of 32 weeks. Her post partum course was uncomplicated and she was discharged home POD#4 with close follow up in the office
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10863878-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lisinopril / banana / shellfish derived <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic uterine fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy, endometrial biopsy, endocervical curettage, Mirena removal and insertion of new device <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G0 with h/o HTN, bariatric surgery in ___ who presents due to symptomatic fibroids. Patient states that beginning early this year, she began having heavy and continuous vaginal bleeding for months. She characterized the bleeding as initially light, but progressed to heavy bleeding. She was seen in ___ in ___ clinic at which time an endometrial biopsy was obtained which demonstrated a proliferative endometrium and a Mirena IUD was placed. She had little improvement in her bleeding until last month, at which time her period became lighter, and only lasted 10 days. A Pelvic US on ___ showed an anteverted and enlarged uterus measuring 6.5x7.5x10.9cm, multiple uterine fibroids were present with the largest measuring 8.4x6.7x7.6cm. The endometrium is distorted by adjacent fibroids and measures 11cm. Her IUD was present. In addition to the vaginal bleeding, she endorses frequent urination, and constipation as a result of the fibroids. She states she "can feel them in the vaginal area when she wipes". She also endorsed a clear, non odorous, intermittent vaginal discharge since the beginning of this year. Of note, she also endorsed severe lower back pain in ___, non-radiating, dull, ___ in severity that has since resolved since discontinuation of her BP medication and increasing her Iron supplementation. Finally she also endorses numbness and tingling in hands and feet, being follow up by ___ clinic. She otherwise denies dysuria, fever, chills, HA, CP, SOB, changes in appetite. ROS: Other than what is mentioned in the HPI, 14 pt ROS is negative <PAST MEDICAL HISTORY> Gynecologic History: - Menarche age ___ yo - Menses Qmonth, no breakthrough bleeding - Denies menorrhagia, dysmenorrhea - LMP: ___ - Last pap ___ normal - No history of abnormal paps - Sexually active: not currently - History of STIs: none - GYN procedures: EBx in ___, nl, and Mirena IUD in place OBHx: G0 <PAST MEDICAL HISTORY> - HTN - asthma as child Past Surgical History: - bariatric surgery in ___ -> followed by ___ clinic here in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Maternal cousin with breast ca dx ___, maternal aunt with ovarian ca ___, mother multiple myeloma ___, maternal uncle colon ca, and leukemia ___ - Denies family history of bleeding/clotting disorders, CVA or MI - maternal GM with DM <PHYSICAL EXAM> Physical Exam on Initial Presentation: GENERAL: No acute distress, well developed, well nourished, younger than stated age. HEENT: NC/AT EYES: sclera anicteric SKIN: Warm and dry. NEURO/PSYCH: Alert and oriented x 4. NECK: Supple no mass LYMPHATICS: No palpable supraclavicular, cervical, or inguinofemoral lymphadenopathy. RESPIRATORY: Lungs clear to auscultation bilaterally. CARDIOVASCULAR: Heart regular rate and rhythm. MUSCULOSKELETAL: No spinal or cva tenderness. GASTROINTESTINAL: Abdomen soft, nontender, nondistended, normoactive bowel sounds, without palpable masses or hepatosplenomegaly. EXTREMITIES: Nontender, no edema bilaterally. GENITOURINARY: External female genitalia: normal Vagina: no lesions Cervix: no lesions, not expanded, Mirena IUD strings in place Uterus: bulky fibroid uterus Adnexa: no palpable masses RECTAL: deferred Physical Exam on Day of Discharge: General: NAD, A&Ox3 CV: RRR, no m/r/g RESP: CTAB, no respiratory distress, normal work of breathing Abd: soft, nontender Incision: Transverse incision across lower abdomen, ___. Clean and dry. Dressings: None GU: Foley absent, moderate lochia. Extremities: no calf tenderness, wwp, pboots on and active bilaterally <PERTINENT RESULTS> ___ 01: 18PM BLOOD WBC-7.7 RBC-3.70* Hgb-10.2* Hct-31.0* MCV-84 MCH-27.6 MCHC-32.9 RDW-14.2 RDWSD-43.3 Plt ___ ___ 01: 18PM BLOOD Plt ___ ___ 06: 39AM BLOOD WBC-7.6# RBC-3.48* Hgb-9.7* Hct-29.1*# MCV-84 MCH-27.9 MCHC-33.3 RDW-14.2 RDWSD-43.0 Plt ___ ___ 06: 39AM BLOOD Plt ___ <MEDICATIONS ON ADMISSION> Medications - Prescription CHLORTHALIDONE - chlorthalidone 50 mg tablet. 1 tablet(s) by mouth once per day EPINEPHRINE [EPIPEN 2-PAK] - EpiPen 2-Pak 0.3 mg/0.3 mL injection, auto-injector. 0.3 mg im prn anaphylaxis Medications - OTC ASCORBIC ACID (VITAMIN C) [CHEWABLE VITAMIN C] - Chewable Vitamin C 250 mg tablet. 1 tablet(s) by mouth three times a day Take with iron supplement CALCIUM CITRATE - calcium citrate 250 mg tablet. Take 500mg by mouth twice daily - (Prescribed by Other Provider) CETIRIZINE - cetirizine 10 mg tablet. 1 tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 1,000 unit tablet. tablet(s) by mouth daily - (Prescribed by Other Provider; ___) CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Vitamin B-12 500 mcg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) FERROUS SULFATE [IRON] - iron 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth daily MULTIVITAMIN - multivitamin capsule. 2 capsule(s) by mouth once a day - (___) <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *2 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drink or drive while taking. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 4. Chlorthalidone 50 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus, abnormal uterine bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing an abdominal myomectomy, endometrial biopsy, endocervical curretage, and Mirena IUD removal and reinsertion. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV Dilaudid and Toradol. Her diet was advanced without difficulty and she was transitioned to oral oxycodone and acetaminophen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She was continued on her home medication of chlorthalidone for hypertension. She received Lovenox and wore pneumoboots bilaterally for prophylaxis. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10869315-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: epigastric pain pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> LTCS <HISTORY OF PRESENT ILLNESS> ___ yo G1 P0 at 34w 0d with epigastric pain which she woke up with am ___ PNC: - ___ ___ by early ultrasound - Labs Rh + /Abs neg /Rub /RPR neg /HBsAg neg /HIV neg /GBS pend - Screening ERA DS risk ___ NIPT low risk - FFS normal - OBGCT normal - U/S ___ EFW 37% 1706 - Issues Anxious about vaginal exams OBHx: - G1 <PAST MEDICAL HISTORY> GynHx: - abnormal Pap, fibroids, Gyn surgery, STIs; all negative PMH: negative Meds: PNV (gummy bears) All: None SHx: ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> Physical Exam BP 141/99, 99.6, 18, 72 (EW) BP range in triage 134/93 to 154/98 Gen: A&O, comfortable upright CV: RRR PULM: CTAB- not breathing deeply Abd: soft, gravid, nontender EFW by Leopolds 4 lbs Ext: no calf tenderness, ___ edema DTR's flat ___ O2 sat 100% on RA Toco FHT /moderate variability/+accels/-decels Occasional contractions On day of discharge VSS Gen: NAD, well-appearing CV: RRR Resp: CTAB Abd: non-tender, soft, incision clean/dry/intact Ext: non-tender <PERTINENT RESULTS> ___ 09: 03PM WBC-10.2* RBC-3.47* HGB-11.0* HCT-33.3* MCV-96 MCH-31.7 MCHC-33.0 RDW-13.1 RDWSD-46.1 ___ 09: 03PM PLT COUNT-159 ___ 08: 53AM URINE HOURS-RANDOM CREAT-203 TOT PROT-179 PROT/CREA-0.9* ___ 08: 53AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 08: 53AM URINE BLOOD-TR NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG ___ 08: 53AM URINE RBC-11* WBC-95* BACTERIA-MOD YEAST-NONE EPI-12 ___ 08: 52AM CREAT-0.6 ___ 08: 52AM estGFR-Using this ___ 08: 52AM ALT(SGPT)-16 AST(SGOT)-29 ___ 08: 52AM URIC ACID-5.1 ___ 08: 52AM WBC-10.7* RBC-3.57* HGB-11.2 HCT-33.8* MCV-95 MCH-31.4 MCHC-33.1 RDW-13.0 RDWSD-45.1 ___ 08: 52AM PLT COUNT-165 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000 mg acetaminophen (Tylenol) per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation Take with oxycodone. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 4. NIFEdipine CR 30 mg PO DAILY RX *nifedipine 30 mg 1 tablet(s) by mouth once per day Disp #*30 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours Disp #*35 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preeclampsia, LTCS <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per written instructions reviewed by nursing and ___ rounder Call for any headache, blurred vision, signs of preeclampsia to be reviewed
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Ms. ___ is a ___ G1, P0 at 34 weeks 3 days gestational age, who presented to Labor and Delivery on ___ and was found to have elevated blood pressures. She was admitted to the antepartum service where a 24 hour urine collection returned with 2616 mg of protein consistent with a diagnosis of pre-eclampsia. She was monitored with daily labs and fetal testing, which was reassuring. She received a betamethasone course. On ___, she had several severe range blood pressure readings and complained of a headache and epigastric pain. Labs showed elevated LFTs. She was brought to L&D for delivery for severe pre-eclampsia. She was started on magnesium for seizure prophylaxis. The patient received a total of 1 vaginal Cytotec and 5 p.o. Cytotecs in an attempt to induce her labor. However, her last cervical exam remained only 1.5 cm dilated. Pitocin was attempted; however, the fetal heart rate tracing was noted to be category 2, and as the patient was remote from delivery with decreasing platelets and the concern for worsening HELLP syndrome, the decision was made to proceed with primary cesarean section. She underwent a primary low transverse C-section. Of note, 10mg hydralazine was given intraoperatively for moderate to severe range blood pressures with immediate improvement, and pt was given 1000mcg cytotec per rectum at the end of the case for lower uterine segment atony. Postpartum, Ms. ___ received nifedipine 30mg CR daily with good blood pressure control. Her platelets trended upwards (nadir 55 -> 168 at discharge) and her Hct stabilized. On PPD5, she had an acute episode of tachypnea (RR to ___ and tachycardia (HR to 130s, max 150s). EKG showed sinus tachycardia, troponins were negative, HELLP labs were within normal limits, and CTA was negative for pulmonary embolus. Cardiac echo did not reveal any evidence of cardiomyopathy, and was normal apart from mild left ventricular hypertrophy, LVEF=65%. The remainder of her postpartum course was uneventful, and her tachycardia and tachypnea resolved prior to discharge. She passed all postpartum milestones and was discharged to home in stable condition.
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10878868-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> inability to urinate for 24 hours <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G0 presenting to ED with inability to urinate and abdominal pressure. Patient reports diagnosis of uterine fibroids "years ago" on routine pelvic exam, however has had no complaints or symptoms related to this for several years. For the past 24 hours, patient has had difficulty urinating with the need to strain to release urine, and only being able to urinate minimal amounts. She also has noticed increasing abdominal distention over the past few weeks. Denies dysuria/vaginal bleeding/unusual vaginal discharge/fever/chills/nausea/vomiting/change in bowel habits. On arrival to the ED, patient initially had a bedside US performed by ED team concerning for ?fibroid causing urinary obstruction. A foley catheter was placed with 700cc of urine that immediately drained. Following placement of the foley, patient reported significant improvement in her symptoms. <PAST MEDICAL HISTORY> OB-GYN Hx: G0. LMP ___. Has monthly periods, however periods have recently gone from lasting ___ days to close to 10 days. Last Pap ___ year ago, no hx of abnl Paps. Does not see a gynecologist. Remote hx of chlamydia. Hx of uterine fibroids as described above (pt only recalls pelvic ultrasound performed "years ago" to confirm this diagnosis) PMH: HTN PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Fam Hx: Father had multiple myeloma. Denies hx of breast/GYN cancer. <PHYSICAL EXAM> On admission <PHYSICAL EXAM> 98 81 157/93 16 100 Gen: NAD, appears comfortable Abd: soft, ND, NT, large firm palpable mass with superior most portion slightly above and to the left of umbilicus. Spec: normal vaginal mucosa. Cervix extremely anterior, w/o lesions or discharge. BME: Enlarged firm uterus with limited mobility,extending laterally to both pelvic side walls, fundus palpated at umbilicus with ?fibroid extension to patient's left. Unable to appreciate adnexa. On day of discharge VSS CTAB RRR Gen: NAD, appears comfortable Abd: soft, ND, NT, large firm palpable mass with superior most portion slightly above and to the left of umbilicus. ___: nt, ne <PERTINENT RESULTS> ___ 09: 45AM GLUCOSE-116* UREA N-17 CREAT-1.1 SODIUM-141 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13 ___ 09: 45AM WBC-10.7 RBC-3.79* HGB-9.6* HCT-31.2* MCV-82 MCH-25.2* MCHC-30.7* RDW-15.5 ___ 09: 45AM NEUTS-81.9* LYMPHS-12.1* MONOS-5.1 EOS-0.7 BASOS-0.3 ___ 09: 45AM PLT COUNT-213 ___ 06: 49AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06: 49AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM ___ 06: 49AM URINE MUCOUS-RARE ___ 06: 49AM URINE RBC-9* WBC-14* BACTERIA-NONE YEAST-NONE EPI-0 ___ 09: 09PM GLUCOSE-127* UREA N-19 CREAT-1.5* SODIUM-136 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-21* ANION GAP-21* ___ 09: 09PM estGFR-Using this ___ 09: 09PM URINE HOURS-RANDOM ___ 09: 09PM URINE UCG-NEGATIVE ___ 09: 09PM WBC-11.8*# RBC-4.12* HGB-10.7* HCT-33.8* MCV-82 MCH-25.9* MCHC-31.6 RDW-15.1 ___ 09: 09PM NEUTS-84.2* LYMPHS-10.0* MONOS-5.4 EOS-0.2 BASOS-0.2 ___ 09: 09PM PLT COUNT-213 ___ 09: 09PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 09: 09PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 09: 09PM URINE RBC-30* WBC-2 BACTERIA-NONE YEAST-NONE EPI-11 ___: Abd/Pelvic U/S FINDINGS: The uterus is enlarged. There are multiple masses consistent with fibroids. The largest measures 15.5 x 15.2 x 9.7 cm. Evaluation of the ovaries is limited. There is no free fluid. IMPRESSION: Fibroid uterus. Limited evaluation of the ovaries. ___: Renal U/S FINDINGS: The right kidney measures 12.2 cm. The left kidney measures 11.6 cm. There is mild hydronephrosis bilaterally. There are no renal stones or masses. Renal echogenicity and corticomedullary architecture is within normal limits. Limited evaluation of the bladder. IMPRESSION: Mild bilateral hydronephrosis. No evidence of stones or renal masses. ___: MRI A/P: FINDINGS: The uterus is massively enlarged, measuring up to 22.2 x 11.8 x 14.6 cm, essentially filling the entire pelvis. There are multiple T2 hypointense well-defined masses throughout the uterus, most compatible with fibroids, the largest of which is predominantly exophytic, extending from the right aspect of the lower uterus, measuring 14.6 x 10.4 x 10.6 cm (CC x AP x TV). This fibroid markedly distorts the adjacent cervix and endometrium, which are displaced to the left. Several additional heterogeneously enhancing fibroids are seen within the uterine fundus, measuring up to 5.0 cm (4: 13), some of which demonstrate submucosal components. The ovaries are displaced superiorly, but otherwise normal. The bladder is markedly compressed and displaced anteriorly by the enlarged fibroid uterus. A Foley catheter is seen within the bladder. There is bilateral hydronephrosis and hydroureter, as seen on the prior ultrasound dated ___. T2 hyperintense nonenhancing lesions within both kidneys measure up to 9 mm in the left interpolar region, compatible with simple cysts. Limited assessment of the liver, pancreas, adrenal glands, stomach, small bowel, and colon is unremarkable. There are no pathologically enlarged abdominal or pelvic lymph nodes. The abdominal aorta is normal in caliber. There is minimal free fluid in the pelvis. IMPRESSION: 1. Massively enlarged fibroid uterus with a dominant 14.6 cm fibroid along the right aspect of the lower uterine body, causing distortion and displacement of the cervix and adjacent endometrium. Multiple additional smaller fibroids throughout the remainder of the uterus, some of which have submucosal components. 2. Bilateral hydronephrosis and hydroureter, as seen on prior ultrasound from ___, almost certainly secondary to compression from the enlarged uterus. 3. Bilateral simple renal cysts <MEDICATIONS ON ADMISSION> HCTZ and "cholesterol medication" <DISCHARGE MEDICATIONS> same <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus causing obstruction of your bladder and acute kidney injury <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * You may eat a regular diet Call your doctor for: * fever > 100.4, chills * severe abdominal pain * changes in the appearance of your urine * 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 may need to keep this catheter in place until your surgery.
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Ms ___ was seen in the emergency department with acute urinary retention. A foley catheter was placed for 700cc urine. On ultrasound evaluation her multifibroid uterus was seen to be severely compressing her urinary bladder and there was bilateral mild hydronephrosis and hydroureter. Her creatinine was 1.5 at this time. She was thus admitted overnight for IVF and observation. An MRI was also done, given the rapid time course of onset of symptoms to r/o leimyosarcoma. MRI was c/w prior ultrasound results and fibriods did not have the appreance of leiomyosarcomas. Please see separate MRI report for full details. On the morning of hospital day number 2 her Cr had fallen to 1.1. She was discharged on HD#2 with a urinary foley catheter to prevent further urinary retention. She was discharge with a plan for likely hysterectomy and close outpatient follow-up to further discuss management.
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10878868-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Abdominal Hysterectomy, cystoscopy Blood Transfusion of 3U PRBCs <HISTORY OF PRESENT ILLNESS> ___ G1P0 with known fibroid uterus previously asymptomatic, presented to ED last week with ___ days of urinary retention, foley drained 700cc and has been left in place. Imaging showed bilateral hydroureteronephrosis. ROS: occ stress urinary incontinence, no painful or firm BM's, not sexually active x ___ years, no abdominal pain, no intermenstrual bleeding. <PAST MEDICAL HISTORY> OB-GYN Hx: G0. LMP ___. Has monthly periods, however periods have recently gone from lasting ___ days to close to 10 days. Last Pap ___ year ago, no hx of abnl Paps. Does not see a gynecologist. Remote hx of chlamydia. Hx of uterine fibroids as described above (pt only recalls pelvic ultrasound performed "years ago" to confirm this diagnosis) PMH: HTN PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Fam Hx: Father had multiple myeloma. Denies hx of breast/GYN cancer. <PHYSICAL EXAM> On day of discharge AFVSS CTAB RRR abd s, nt,nd, incision c/d/i ___: nt, ne <PERTINENT RESULTS> ___ 08: 15PM GLUCOSE-134* UREA N-15 CREAT-0.8 SODIUM-138 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14 ___ 08: 15PM CALCIUM-7.8* PHOSPHATE-4.0 MAGNESIUM-1.6 ___ 08: 15PM WBC-13.9*# RBC-4.24 HGB-11.7* HCT-36.6 MCV-86 MCH-27.7 MCHC-32.1 RDW-14.6 ___ 08: 15PM PLT COUNT-189 ___ 11: 10AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 11: 10AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 11: 10AM URINE RBC-17* WBC->182* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 ___ 11: 10AM URINE WBCCLUMP-MOD MUCOUS-MOD ___ 09: 55AM UREA N-20 CREAT-1.0 ___ 09: 55AM WBC-6.5 RBC-3.73* HGB-9.7* HCT-31.5* MCV-84 MCH-26.0* MCHC-30.8* RDW-15.2 ___ 09: 55AM NEUTS-76.6* LYMPHS-17.9* MONOS-3.2 EOS-2.1 BASOS-0.2 ___ 09: 55AM PLT COUNT-211 ___ 09: 55AM ___ PTT-29.3 ___ <MEDICATIONS ON ADMISSION> Meds: HCTZ and Pravastatin <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN constipation take while taking narcotics (oxycodone/acetominophen). RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*50 Capsule Refills: *2 2. Hydrochlorothiazide 25 mg PO DAILY 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not exceed 4000mg acetominophen in 24 hours. Do not drive. Take w food. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 4. 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: *1 5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth every 12 hours Disp #*12 Capsule 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> Ms. ___, It was a pleasure caring for you after your surgery here at ___. You had an normal post-operative recovery and were felt to be safe to be discharged to home. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will be removed at your follow-up visit on ___ ___. 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 total abdominal hysterectomy complicated by a large EBL of 1300 cc's requiring transfusion of 3 units pRBC intraoperatively; see operative report for further details. The need for transfusion was not unexpected given the patient's large uterus and pre-existing blood loss anemia from menorrhagia. She had previously been counseled that she would likely require transfusion intraoperatively. She was found to have developed a coag + staph aureus UTI postop and was started on a 7 day course of macrobid. She had an otherwise uncomplicated surgery and recovery and was discharged home on postoperative day #2 in good condition: ambulating and urinating without difficulty, passing flatus, tolerating a regular diet, and with adequate pain control using PO medication.
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10881183-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Macrobid <ATTENDING> ___. <CHIEF COMPLAINT> myalgias, fevers after D&C <MAJOR SURGICAL OR INVASIVE PROCEDURE> D&C <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G2P0020 who presented to the emergency room on POD ___ s/p 11wk D&E on ___ at ___, done for T21 found on NIPT. She reports the procedure was uncomplicated. She was placed on routine doxycycline prophylaxis for a planned 7 day course. On ___, she had one episode of emesis associated with taking doxy on empty stomach and tolerated subsequent doses. On ___ am, she awoke with total body myalgias and fever to 102.5. An ultrasound at ___ showed possible retained products and she was transferred to ___. On presentation at ___, she denied any abdominal pain, nausea/vomiting, CP/SOB/palp/dizziness. She had no urinary sxs, no abnl vag d/c. She reported her vaginal bleeding had been light to scant since D&E. She had not resumed intercourse. She denied diarrhea, she was constipated in pregnancy with BM's strained ___ times weekly. She reported non-productive cough throughout pregnancy attributed to postnasal drip, no other URI sxs recently, no sick contacts. <PAST MEDICAL HISTORY> OB Hx: G2P0 19wk D&E in ___ for 47XXX 11wk D&E on ___ for T21 Gyn Hx: denies abnl Pap/STI, neg GC/Chlam on ___, monogamous with husband ___: denies Surg Hx: D&E x2 as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On discharge: Gen: NAD CV: RRR Lungs: CTAB Abd: soft, NT, ND, no r/gu GU: voiding spontaneously, minimal spotting on pad Ext: NT, nonedematous <PERTINENT RESULTS> Pelvic US ___ HISTORY: Lower abdominal pain and fever for 2 days. Status post D&C on ___. TECHNIQUE: Grayscale and color Doppler ultrasound images of the pelvis via a transabdominal and transvaginal approach. COMPARISON: Outside hospital pelvic ultrasound ___. FINDINGS: The uterus measures 12.4 x 4.9 x 8.1 cm. Heterogeneous material within the endometrial cavity demonstrates no flow on both color and power Doppler evaluation. On the outside hospital CT performed 1 day prior the heterogeneous material in the endometrial cavity also did not show flow on both color and power Doppler. The ovaries appear normal. There is no free fluid. IMPRESSION: Heterogeneous material within the endometrial cavity shows no flow on color and power doppler which is consistent with blood clot or devascularized retained products of conception. ___ 07: 39AM BLOOD WBC-5.3 RBC-3.24* Hgb-9.3* Hct-27.7* MCV-86 MCH-28.8 MCHC-33.7 RDW-12.5 Plt ___ ___ 11: 40PM BLOOD WBC-6.7 RBC-3.53* Hgb-10.2* Hct-30.6* MCV-87 MCH-29.0 MCHC-33.4 RDW-12.5 Plt ___ <MEDICATIONS ON ADMISSION> PNV, doxycycline <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN pain Do not take more than 4000 mg acetaminophen in 24 hr. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days Complete a 7 day course (started ___. RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*5 Capsule Refills: *0 3. Ibuprofen 400-600 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> retained products versus clot in the endometrial cavity <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure taking care of you on the gynecology service. The team feels you are now safe to discharge home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks * You may eat a regular diet * Finish your prescribed 7 day antibiotic course (started ___. 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 for close monitoring. She was counseled on her options and was given buccal cytotec for medical management. She passed some clot spontaneously. However given her recent fevers, the the decision was made to proceed with an ultrasound guided dilation and curettage to evacuate the uterus. She underwent an uncomplicated dilation and curettage on ___ 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, with minimal vaginal bleeding, and with adequate pain control using PO medication. She was instructed to complete a 7 day course of doxycycline for infection prophylaxis.
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10881788-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Vulvar cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Radical anterior hemivulvectomy, left-sided inguinal femoral lymph node dissection, and a right-sided sentinel node biopsy by Dr. ___. <HISTORY OF PRESENT ILLNESS> This patient is a ___ who was having diffuse vulvar itching and was seen and had an exam revealing an exophytic vulvar mass that was biopsy revealing invasive squamous cell carcinoma with 2.3 mm of depth of invasion. She subsequently had a PET scan which revealed no evidence of metastatic disease otherwise, and she presents today for definitive surgical management. <PAST MEDICAL HISTORY> ObGyn Hx: LMP ___, no postmenopausal sx or bleeding SVD x 3 no complications Monogamous with husband x ___ years, not currently sexually active Regular Paps no hx abnl, most recent this year neg No hx STI, fibroids, or cysts HCM: ___ ___ birads 1 ___ ___ two polyps, one hyperplastic, one tubular adenoma Med Hx: HTN HL Osteoarthritis knees Colonic adenoma Seasonal allergies <SOCIAL HISTORY> never smoker, rare EtOH, no illicit drugs. Lives with husband, married ___ years. <PHYSICAL EXAM> On DAY OF DISCHARGE: General: NAD, well appearing HEENT: mmm CV: RRR PULM: CTA b/l ABD: soft, non tender Incisions: dressings in place, C/D/I Drain in place on L inguinal area, draining serosanguinous fluid Extremities: NT, non edematous <PERTINENT RESULTS> ___ 07: 45AM BLOOD WBC-16.0*# RBC-3.88* Hgb-12.5 Hct-35.0* MCV-90 MCH-32.2* MCHC-35.7* RDW-12.9 Plt ___ ___ 07: 45AM BLOOD Glucose-118* UreaN-16 Creat-0.7 Na-141 K-4.4 Cl-102 HCO3-31 AnGap-12 <MEDICATIONS ON ADMISSION> Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID Lisinopril 10 mg PO DAILY Simvastatin 20 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4-6 hours Disp #*60 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN pain TAKE WITH FOOD RX *ibuprofen 600 mg 1 tablet(s) by mouth q6 hours Disp #*50 Tablet Refills: *1 5. Cephalexin 500 mg PO Q12H while drain in place RX *cephalexin 500 mg 1 capsule(s) by mouth twice a day Disp #*24 Capsule Refills: *0 6. Lisinopril 10 mg PO DAILY 7. Simvastatin 20 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> vulvar cancer, final pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * 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 4 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. * ___ bath 3 times a day until follow up appointment * You will have a visiting home nurse take off your surgical dressings and monitor the drain and incision. You will receive teaching on how to manage the drain . 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 _____. 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/APAP. Her diet was advanced without difficulty and she was transitioned to PO percocet/ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10881932-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> right flank pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound guided stent placement <HISTORY OF PRESENT ILLNESS> ___ yo G4P1 at ___ presenting with right flank pain radiating to her right groin and right anterior thigh. This is similar to her previous episodes of kidney stones during this pregnancy, and she was seen in OB triage 4 days ago for the same symptoms. At that time she had a renal US showing mildly increased right hydronephrosis and hydroureter with a 1.2cm obstructive stone at the proximal right ureter. No left hydronephrosis. The pain is intermittent with exacerbations of severe, sharp/cramping pain with associated nausea and vomiting (although the patient is tolerating some PO). She denies fevers and chills. During the past week she had gross hematuria, which has improved overall. Denies dysuria or increased urinary frequency or urgency. She is having rare sporadic, intermittent contractions, which are not regular or increasing in severity, and she denies vaginal bleeding and leakage of fluid. She reports active fetal movement. <PAST MEDICAL HISTORY> PNC: ___ ___ - AB+/Ab-/RPRNR/RI/HBsAg- - low-risk ERA, normal AFP, normal FFS - GLT 84 - nephrolithiasis with several episodes during this pregnancy OBHx: G4P1 - C/S x 1 for NRFHT, h/o nephrolithiasis and pyelo - 1 SAB - 1 TAB MedHx: nephrolithiasis, bipolar (pt denies), seizure d/o (not active) SurgHx: C/S x 1, breast reduction <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 98.4, HR 112, RR 20, BP 126/88 GENERAL: NAD, uncomfortable CV: RRR LUNGS: CTAB ABDOMEN: soft, gravid, mild right groin tenderness to deep palpation, by ___ 7# baby BACK: +CVAT on the right SVE: L/C/P per Dr. ___: ___, AFI ___ FHT: 135/mod var/+accels/no decels --> reactive TOCO: no contractions IMPRESSION: Allowing for measurement differences, stable right-sided hydronephrosis and hydroureter with 1.5 cm obstructive stone at the proximal right ureter. No left-sided hydronephrosis is noted. <PERTINENT RESULTS> ___ WBC-6.4 RBC-3.26 Hgb-10.4 Hct-28.9 MCV-89 Plt-110 ___ Neuts-70.8 ___ Monos-7.8 Eos-2.0 Baso-0.3 ___ WBC-6.5 RBC-3.26 Hgb-10.0 Hct-29.5 MCV-90 Plt-11 ___ Glu-90 BUN-7 Cre-1.0 Na-138 K-3.7 Cl-106 HCO3-23 ___ Glu-70 BUN-7 Creat-0.9 Na-139 K-3.7 Cl-106 HCO3-24 ___ ALT-16 UricAcd-6.3 ___ ALT-14 AST-20 UricAcd-5.2 ___ URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM ___ URINE RBC-7 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 ___ URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ OTHER BODY FLUID Creat-2.1 SURF/AL-35 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. URINE CULTURE (Final ___: NO GROWTH <MEDICATIONS ON ADMISSION> PNV iron supplement <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *60 Capsule(s)* Refills: *0* 2. Nephrocaps 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp: *9 Tablet(s)* Refills: *0* 5. Nitrofurantoin Macrocrystal 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 6 doses. Disp: *6 Capsule(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 <DISCHARGE DIAGNOSIS> Kidney Stone <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Keep well hydrated. Continue to take your medications as prescribed. Contact Dr. ___ with any concerns.
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Ms ___ is a ___ yo G4P1 admitted at 36w3d with nephrolithiasis. She was afebrile and without any evidence of pyelonephritis. Fetal testing was reassuring. She had occasional contractions, however, no evidence of labor. Her cervix was closed and long. She was admitted to the antepartum service for observation, IV fluids, and pain control. Her pain intially was controlled with a Dilaudid PCA. Since she was tolerating po's, she was transitioned to po Dilaudid on hospital day #2. ___ was consulted and Ms ___ consented to an amniocentesis to assess fetal lung maturity. Unfortunately, the FLM was immature (35). She remained hospitalized for pain control, however, the Dilaudid became less effective in controlling her pain. In addition, Ms ___ was quite concerned about prolonged use of narcotics and its effect on her fetus. The NICU was consulted to discuss these concerns. Repeat ultrasound on ___ revealed a persistent right proximal ureter stone, approximately 1.5cm in size. Urology was consulted and the decision was made to proceed with ureteral stent placement (on ___. See consult note and operative notes in OMR for details. Following the procedure, she was monitored on labor and delivery. Fetal testing was reassuring and she was not contracting. She was transferred back to antep___ and denied any further pain. On ___, she was discharged home in stable condition. She will have close outpatient followup. . Of note, Ms ___ was noted to have low platelets, suspected gestational thrombocytopenia, with her platelets ranging from 107-112,000. She was normotensive and otherwise without any evidence of preeclampsia.
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10882364-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Pyridium <ATTENDING> ___. <CHIEF COMPLAINT> scheduled procedure for ureteral stones <MAJOR SURGICAL OR INVASIVE PROCEDURE> ureteroscopy, stent removal (by Urology) <HISTORY OF PRESENT ILLNESS> Ms. ___ has a history of right sided flank pain and sinus tach in ___ and was diagnosed with a 1 cm right UVJ stone. She was seen at an OSH and was sent to ___. She ultimately had a right ureteral stent placed by ___. She is stented now, has some hematuria and is having some mild stent sxs. She presented on ___ for planned ureteroscopy with LASER lithotripsy. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w ___ trimester ultrasound - Labs A neg /Abs neg/RubvImm /RPR NR/HBsAg neg/HIV neg /GCCT neg/GBS unk - Screening LR ERA - FFS no anomalies - GTT (early 2 hr GTT) elevated - Issues: Atrial fibrillation, Nephrolithiasis, GDMA2 OBHx: G7P4 - G1- ___ - VAVD 41 wks, 8#11oz - G2- ___ - SVD 41 wks, 7#8oz - G3- TAB - G4- TAB - G5- ___ - SVD 39 wks, 8#3 oz - G6- ___ - SVD 39 wks, 7#3oz Last three deliveries complicated by GDM GynHx: - remote hx abnormal Pap, most recent normal ___ - denies fibroids, Gyn surgery, STIs PMH: - nephrolithiasis - psoriasis PSH: - wisdom teeth - ear tubes - right ureteral stent placement <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: AF VSS General: NARD, comfortable Abd: nontender, gravid, FH 120 beats/min SVE: Deferred Ext: contender On discharge: AF VSS General: NARD, comfortable Abd: nontender, gravid, FH 120 beats/min SVE: Deferred Ext: contender <PERTINENT RESULTS> none <MEDICATIONS ON ADMISSION> prenatal vitamins, homolog, NPH <DISCHARGE MEDICATIONS> 1. Humalog 7 Units Lunch Humalog 8 Units Dinner NPH 16 Units Bedtime <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ureteral stones <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ You were admitted for observation after your procedure with Urology. Your have recovered well and are stable to be discharged home. You had reassuring fetal testing throughout your stay. You should followup with Dr. ___ as scheduled and with Urology.
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Ms ___ underwent a ureteroscopy with right stent removal by Urology on ___. This was performed under general anesthesia with continuous intraoperative fetal monitoring. Please see the operative report for full details of the procedure. Fetal monitoring was reassuring throughout her procedure. She underwent 20 minutes of fetal monitoring in the PACU without issue. She was admitted to the ___ service overnight for observation. Her pain was controlled with tylenol. Her diet was advanced without difficulty and she voided. She received oxybutynin for bladder spasm. She underwent a total of 3 NSTs while admitted without decelerations. She underwent an ultrasound with ___ BPP, EFW in 20%ile with the abdominal circumference in 17%ile. Her finger sticks were adequately controlled on her current home insulin regimen. On postoperative day #1, she was discharged home in stable condition with close outpatient followup with her primary OB and followup with Urology. Repeat biometry was recommended in two weeks.
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10882364-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> transfer for A-fib <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ureteral stent placement <HISTORY OF PRESENT ILLNESS> ___ yo G7P___ at 25w2d transferred from ___ for management of atrial fibrillation refractory to medical management. Ms ___ has a known history of nephrolithiasis. She was initially managed as an outpatient but pain worsened yesterday with associated nausea and vomiting so it was recommended she go to ___ for evaluation. At ___ her heart rate was noted to be in the 200s, initially suspected to be SVT. She noted onset of chest fluttering at 3 AM. She had had this sensation in early pregnancy when she had vomiting, but did not seek medical attention at that time. She was given adenosine 6 mg IV which decreased her heart rate to the 160s and on closer evaluation the rhythm was noted to be atrial fibrillation. She was given Dilaudid 0.5 mg x 3 doses, diltiazem 10mg IV x 2, Lopressor 2.5mg IV x 2, and was then started on a diltiazem drip without cardioversion. She also got 1 L of IV hydration. She was evaluated by cardiology, urology and the ICU team at ___, who felt that transfer to ___ (tertiary care ___ with NICU) was warranted given her gestational age. On arrival to the ER, her flank pain is still present. Her nausea and vomiting have improved with Zofran. She notes continued chest fluttering. She denies chest pain, shortness of breath or dizziness. She has no obstetric symptoms; she denies contractions, vaginal bleeding, loss of fluid or decreased fetal movement. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w ___ trimester ultrasound - Labs A neg /Abs neg/RubvImm /RPR NR/HBsAg neg/HIV neg /GCCT neg/GBS unk - Screening LR ERA - FFS no anomalies - GTT (early 2 hr GTT) elevated - Issues: Atrial fibrillation, Nephrolithiasis, A1GDM OBHx: G7P4 - G1- ___ - VAVD 41 wks, 8#11oz - G2- ___ - SVD 41 wks, 7#8oz - G3- TAB - G4- TAB - G5- ___ - SVD 39 wks, 8#3 oz - G6- ___ - SVD 39 wks, 7#3oz Last three deliveries complicated by GDM GynHx: - remote hx abnormal Pap, most recent normal ___ - denies fibroids, Gyn surgery, STIs PMH: - nephrolithiasis - psoriasis PSH: - wisdom teeth - ear tubes <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Gen: A&O, comfortable Vital signs: HR 140 in ER, BP 100/58 CV: tachycardia, no murmurs noted PULM: CTA B Abd: soft, gravid, nontender Back: +CVA right side Ext: psoriasis on bilateral shins SVE: closed/long/high Bedside transabdominal ultrasound: Fetus breech. FHR 158 BPM. Active fetal movement visualized. Normal amniotic fluid. Toco no contractions TTE (___) The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Preserved biventricular systolic function. No clinically significant valvular disease. Indeterminate pulmonary artery systolic pressure. <PERTINENT RESULTS> ___ WBC-13.1 RBC-3.67 Hgb-11.0 Hct-32.9 MCV-90 Plt-171 ___ Neuts-86.8 ___ Monos-4.7 Eos-0.1 Baso-0.2 Im ___ AbsNeut-11.40 AbsLymp-0.97 AbsMono-0.61 AbsEos-0.01 AbsBaso-0.02 ___ Glu-115 BUN-8 Creat-0.5 Na-136 K-3.5 Cl-106 HCO3-18 AnGap-16 ___ Glu-171 BUN-11 Creat-0.4 Na-137 K-3.2 Cl-105 HCO3-20 AnGap-15 ___ Calcium-8.6 Phos-2.3 Mg-1.6 ___ BLOOD TSH-0.60 ___ BLOOD Type-MIX pH-7.39 Comment-GREEN TOP ___ BLOOD freeCa-1.07 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ URINE Color-Straw Appear-Clear Sp ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION URINE CULTURE (Final ___: NO GROWTH. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> nephrolithiasis atrial fibrillation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with a kidney stone and atrial fibrillation (abnormal heartbeat). Urology and Cardiology were consulted. Your kidney stone was treated with placement of a ureteral stent. Your atrial fibrillation was treated with medication. You received betamethasone for fetal lung maturity in case of need for premature delivery. You are doing well and are being discharged home. Please call with any questions or concerns. It is very important that you complete all recommended follow-up.
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___ ___ transferred at 25w2d for management of rapid atrial fibrillation refractory to medical management, in the setting of severe nephrolithiasis pain. . *) A-fib: On admission, her heartrate was in the 140-150 range. She was normotensive and in no distress. Her cbc, electrolytes, and TSH were unremarkable. Fetal testing was reassuring. Cardiology was consulted and although she initially remained in a-fib on the Diltiazem drip, she did eventually convert to normal sinus rhythm. Echocardiogram was normal with no evidence of valvular disease. The cardiology team felt that the most likely etiology was vagal-induced atrial fibrillation in the setting of pain and vomiting secondary to the ureteral stone. They recommended continued rate control with a beta blocker (metoprolol) and no anti-coagulation given this is likely an isolated event. She remained in normal sinus rhythm and was taking Metolprolol Tartrate 12.5mg BID at the time of discharge. Arrangements were made for ___ Hearts monitor to be done after discharge. She will have outpatient follow up with cardiology in 2 weeks. . In regards to her obstructing right ureteral stone, her pain was initially treated with a Dilaudid PCA. Urology was consulted and the decision was made to proceed with stent placement. She underwent an uncomplicated stent placement on ___ and her pain resolved. Her urine culture was negative. She will need a stent exchange in ___ weeks which can be performed at ___ or at ___. . Fetal testing was reassuring throughout this admission. She had no evidence of preterm labor. She received a course of betamethasone (complete ___ for fetal lung maturity. In regards to her GDMA1, her fingersticks were followed and were mildly elevated as expected in the setting of betamethasone. She will continue checking these at home. . Ms ___ was discharged home in stable condition oin ___ and she will have close outpatient follow up with her primary ob/gyn.
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10882423-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> +flu, fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G4P2 at 8w1d who has had a productive cough and fevers since ___. She presented to the emergency room this morning and was diagnosed with flu. She was started on Tamiflu as of this morning and was discharged home. At home, she continued to have fevers up to 102. She was not due for tylenol at the time, and was also feeling subjectively like her breathing rate was fast. She was asked to present to triage. In triage, she reports feeling +myalgias, back pain. Denies shortness of breath or chest pain. Slight nausea, but this was relieved with some crackers. No vaginal bleeding or abdominal pain. <PAST MEDICAL HISTORY> PNC: - ___ ___ by first trimester U/S - Labs B+/ab neg; other labs not yet done - Issues: *pregnancy conceived with Nexplanon in place *+flu diagnosed (as above this AM in ED) OB HISTORY: G4P2 G1 ___ FT SVD male 6#12oz G2 ___ terminated at "5 months" after aneuploidy confirmed by amniocentesis and fetal heart defect on US; had abnormal serum screening; termination at ___ ___ ___ FT SVD female 3640g G4 current GYN HISTORY: - LMP ___, but first menses since start of Nexplanon - Denies hx of abnl pap, last ___ neg - Denies hx of STDs - Sexually active with husband only PMH: anxiety, depression, OCD (sees psychiatrist Dr. ___ acne PSH: D&E <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On admission: Physical exam: VS: T 101.0 -> 100.7 HR 115 -> 100 BP 108/60 RR 18 O2sat 100% Gen: NAD, A&O x 3. Mask on, unable to talk in full sentences CV: RRR Pulm: CTAB Abd: soft, non-tender SSE: deferred TAUS: +FH at 167 ___: CXR IMPRESSION: No pneumonia -------------- On discharge: Gen- NAD CV- RRR Lungs- CTAB Abd- soft, NT Ext- calves nontender <PERTINENT RESULTS> ___ WBC-5.9 RBC-3.66 Hgb-10.6 Hct-31.8 MCV-87 Plt-195 ___ Neuts-79.8 ___ Monos-7.2 Eos-0.6 Baso-0.2 ___ WBC-4.6 RBC-3.76 Hgb-11.0 Hct-32.1 MCV-85 Plt-181 ___ Neuts-60.6 ___ Monos-11.2 Eos-0.6 Baso-0.2 ___ Glu-90 BUN-9 Cre-0.4 Na-137 K-3.6 Cl-102 HCO3-24 ___ ALT-47 AST-32 AlkPhos-50 TotBili-0.2 ___ Albumin-4.0 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ OTHER BODY FLUID FluAPCR-POSITIVE * FluBPCR-NEGATIVE <MEDICATIONS ON ADMISSION> sertraline 150mg daily, PNV <DISCHARGE MEDICATIONS> 1. Sertraline 150 mg PO DAILY 2. Acetaminophen 1000 mg PO Q6H: PRN fever Do not take more than 4000 mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*25 Tablet Refills: *0 3. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills: *0 4. OSELTAMivir 75 mg PO Q12H RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a day Disp #*8 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> flu possible pneumonia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted after being diagnosed with the flu and possible early pneumonia in early pregnancy. You have been started on medications to treat these conditions and have improved. At home, it is important to complete all your prescribed medications, rest, and keep hydrated.
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___ year old G4P2 admitted at 8w6d with confirmed influenza and possible superimposed pneumonia. She was admitted for supportive care and close observation. Although the final read of her chest xray showed no pneumonia, she continued the course of Azithromycin and was treated with Tamiflu. Her symptoms improved significantly and she remained afebrile. She was discharged home in stable condition on HD#2.
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10884244-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> menorrhagia, near syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion <HISTORY OF PRESENT ILLNESS> ___ G1P1 presents after being seen in the office today by Dr. ___ vaginal bleeding and referred to the ED for further evaluation. Pt has been perimenapausal for approximately ___ with erratic bleeding. In ___ pt underwent D&C with benign pathology for menorrhagia which presented similarly. Pt has had light episodes of bleeding since but over the past month has had increasing persistent bleeding. Pt reports changing her pad once every two hours for the past two weeks. Pt was sent at the ED at ___ on ___ for bleeding. At the time a Hct was checked and found to be 29. Pt reports persistent bleeding since then. This am, she had a near syncopal episode in the shower, took an iron pill which caused her to vomit, and felt very weak. She was seen by Dr. ___ in the office who recommended that she come to the ED for further evaluation. Pt denies any chest pain, shortness of breath, fevers, chills. <PAST MEDICAL HISTORY> GynHx: infertility work ups in the 1990s, including laparoscopy denies abnl paps PMHx: denies PSHx: D&C ___, laparoscopy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> 76, 96/50, 16, 100% Pt appears tired and pale RRR, no M/R/G CTAB Abd: soft, NT, ND, no rebound, no guarding, no CVA tenderness Ext: no calf tenderness SSE: Normal external genitalia 3 Scopettes of dark red blood in vault, blood does not re-accumulate after it is removed Cervical os is closed and blood is slowly coming from os Normal sized uterus, no tender, no masses, ovaries non-palpable, no CMT <PERTINENT RESULTS> ___ 07: 20PM WBC-5.9 RBC-3.04* HGB-9.1* HCT-25.9* MCV-85 MCH-29.8 MCHC-34.9 RDW-13.6 ___ 07: 20PM NEUTS-81.4* LYMPHS-14.8* MONOS-2.5 EOS-1.1 BASOS-0.2 ___ 07: 20PM PLT COUNT-337 ___ 07: 20PM ___ PTT-23.9 ___ ___ 07: 20PM FSH-23* TSH-0.85 ___ 08: 54PM URINE UCG-NEGATIVE ___ 11: 05AM WBC-6.1 RBC-3.64* HGB-11.1* HCT-32.3* MCV-89 MCH-30.5 MCHC-34.4 RDW-13.7 ___ 11: 05AM PLT COUNT-302 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Norethindrone-Ethin Estradiol ___ mg-mcg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days: Following one week of three times a day, then reduce to twice a day until your appointment with Dr. ___. Disp: *3 packs* Refills: *0* 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *60 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Symptommatic blood loss anemia <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. - Please keep your follow-up appointments as outlined below.
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Patient was admitted to the gynecology service and received two units pRBCs. Hematocrit rose appropriately from 25.9 to 32.3. She had no dizziness, syncope, or near-syncope with ambulation. Vital signs were stable. She was started on an ocp taper and discharged with a prescription. She is to follow up in clinic for an endometrial biopsy, and for discussion of possible D&C with or without ablation. Endometrial biopsy was not undertaken during this hospitalization in an effort not to provoke further bleeding.
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10885033-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> leaking fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary cesarean section at 35w1d GA for placenta previa in setting of PPROM post placental paragard IUD placement <HISTORY OF PRESENT ILLNESS> Asked to see this ___ yo G2P0010 at 25+4 weeks gestation who presents with a gush of clear fluid at 8: 30 am followed by a gush of blood mixed with fluid; she then stated that she soaked a panty liner and a full pad of bright red blood. She denies cramping and reports good FM <PAST MEDICAL HISTORY> Dating: LMP: ___, ___: ___, Preg c/b: (1) known complete placenta previa (2) ZIKA exposure (___): HC has been followed; fetus overall well grown at 23% Per past OB hx is significant for a MAB last year requiring a D&C. Her past medical history is significant for hypothyroisism Her past surgical history is significant for a D&C for missed AB. She has no hx of STD or abnl paps <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <MEDICATIONS ON ADMISSION> levoxyl 88mcg, PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every 4 hours Disp #*24 Tablet Refills: *0 6. Polyethylene Glycol 17 g PO DAILY: PRN Constipation - Second Line RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s) by mouth daily Refills: *0 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> PPROM, placenta previa primary cesarean section at 35w1d GA post placental paragard IUD placement <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please refer to your discharge packet and the instructions below: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking narcotics (i.e. Oxycodone, Percocet) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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She was admitted to the antepartum service with complete posterior placenta previa after premature preterm rupture of membranes on ___. She received a course of latency antibiotics and betamethasone for fetal lung maturity. Her vaginal swabs were negative. She received routine ultrasounds to monitor fetal well-being and her previa, and had no further episodes of bleeding after ___. She also endorsed intermittent right upper quadrant pain. Right upper quadrant ultrasounds revealed non-obstructing gallstones, and was stable on repeat ultrasound. Preeclampsia labs were within normal limits. Her right upper quadrant pain was believed to be musculoskeletal versus biliary in etiology. For her hypothyroidism, she was continued on Levoxyl 88 mcg daily. For prophylaxis, she declined subcutaneous heparin but ambulated frequently. On ___, she underwent a primary low transverse cesarean section at 35 weeks 1 day for placenta previa. She also had a post-placental ParaGard IUD placed at the time of surgery. She received a MMR vaccine postpartum. By postoperative day 4, she was tolerating her diet, ambulating independently, voiding spontaneously, and her pain was controlled with oral pain medications. She was discharged home in stable condition with close follow-up.
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10885385-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G3P1 at 5w1d by embryo transfer on ___ who presents to ED with heavy vaginal bleeding where saturating pads and passing large clots. Of note, patient is a gestational carrier. She has had a normally rising HCG as follows: 124.3 on ___ on ___ on ___ ROS positive only for abdominal cramping. She denies any chest pain, shortness of breath, nausea or vomiting. <PAST MEDICAL HISTORY> POBHx- G3P1011 PGYNHx- D&E for missed AB last year, regular menses, hx abnl pap with ___ on colpo bx, no hx of STDs PMHx- Asthma, Hx of clubbed feet PSHx- D&E, foot surgery x3 for clubbed feet, colpo bx, hysteroscopy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Time Pain Temp HR BP RR Pox Glucose + Triage ___ 90 125/67 18 100% Yest 21: 07 97.9 67 111/58 16 100% RA Today 00: 22 98.2 81 118/63 16 99% RA Today 00: 22 98.2 81 118/63 16 99% RA No acute distress Abdomen is soft and non-tender, non-distended Pelvic: On insertion of speculum, brisk bleeding is initially identified followed by the passage of 2 golf sized clots with some tissue. The vagina is cleaned out with 4 scopettes and the cervix is then visualized. Mild blood trickling is then noted. On bimanual examination, the uterus feels 7cm and anteverted and unable to express any more clots. There is no CMT. The internal os is 1cm dilated. There is no adnexal tenderness to palpation. Extremities are warm and well perfused. DISCHARGE EXAM AVSS RRR CTAB ABD: soft, NT, ND, no rebound/guarding Ext: wwp, no edema, no calf tenderness <PERTINENT RESULTS> ___ 06: 13AM HCG-1371 ___ 06: 13AM WBC-7.0 RBC-3.54* HGB-9.2* HCT-30.2* MCV-85 MCH-26.1* MCHC-30.5* RDW-14.4 ___ 06: 13AM PLT COUNT-152 ___ 11: 00PM HGB-9.4* HCT-30.2* ___ 05: 25PM GLUCOSE-88 UREA N-9 CREAT-0.7 SODIUM-142 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 ___ 05: 25PM HCG-2321 ___ 05: 25PM WBC-7.3 RBC-4.29 HGB-10.9* HCT-36.7 MCV-85 MCH-25.3* MCHC-29.7* RDW-14.7 ___ 05: 25PM NEUTS-53.3 ___ MONOS-5.0 EOS-6.2* BASOS-0.3 ___ 05: 25PM PLT COUNT-191 <MEDICATIONS ON ADMISSION> PNV, Vivelle patch 100mcg every 3 days, Crinonone 90mg PV BID, Estrace 2mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> miscarriage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> monitor vaginal bleeding call with: - increased bleeding - abdominal pain - feeling dizzy or lightheaded, chest pain or shortness of breath - any other concerns or questions
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On ___, Ms. ___ was admitted to the gynecology service after presenting to ___ ED with heavy vaginal bleeding. Initially, her Hct was 36.7 and dropped to 30.2. She was admitted for observation and ongoing miscarriage. She was given cytotec 600mg buccally. Patient tolerated a regular diet and was voiding spontaneously and vaginal bleeding improved. Her Hct was stable at 30.2. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10885744-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abnormal uterine bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> PAP SMEAR, EUA, ABDOMINAL MYOMECTOMY <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ ___ who underwent a hysteroscopic myomectomy, D&C for abnormal uterine bleeding on ___ that was complicated by only partial resection of a uterine fibroid who has continued to experience heavy vaginal bleeding. She presents to chief ___ clinic for discussion of next steps in management. Operative Notes: Hysteroscopic myomectomy, D&C FINDINGS: Cavity sounded to 7 cm. Right ostia visualized, as normal uterine cavity due to a septate versus arcuate uterus making the right portion of the cavity separate and distinct, left lower segment fibroid impinging on half of the left lower uterine cavity, left ostia seen See operative note that in detail describes difficulties of the hysteroscopic resection. Postoperatively the patient was discharged with Provera 20 mg daily which she reports helped to stop her vaginal bleeding immediately postoperatively. She had presented to her postoperative appointment on ___ and was transitioned to OCPs. However, on OCPs she is continued to experience heavy vaginal bleeding. The bleeding was daily and on its heaviest day required changing 3 pads per day. Each pad was soaked upon changing. The patient also reports dizziness when she stands up. She has since restarted Provera 30 mg daily which only in the last few days has reduced the volume of bleeding. Due to the difficulties of her case it was recommended that she undergo a follow-up pelvic MRI to better visualize uterine pelvic structures. The pelvic MRI demonstrated a 7.6 cm intramural fibroid with a broad serosal and mucosal contact. It is also noted that there is distortion of the uterine anatomy secondary to the large fibroid but also likely an arcuate versus septate uterine morphology. Dr. ___, a minimally invasive gynecologist, has been curb sided and management of the patient's bleeding and recommends proceeding with an abdominal myomectomy. The patient and her husband emphasized that there primary goal is fertility and are happy to follow any recommendations that would improve the patient's vaginal bleeding and improve her chances for fertility. The ___ medical history is largely unchanged except for the most recent history and symptoms experienced above. <PAST MEDICAL HISTORY> PMH: Menorrhagia, GERD Surgical History: Hysteroscopic myomectomy, D&C ___ OB HISTORY: G1 - 7mo SVD in ___, infant died soon after birth GYN HISTORY: Menses as above Sexually active: not recently given bleeding Monogamous: yes with male partner History of STIs: no History of abnl paps: no Sexual function: no concerns <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> 24 HR Data (last updated ___ @ 2258) Temp: 98.3 (Tm 99.6), BP: 102/63 (100-115/63-74), HR: 79 (79-100), RR: 18, O2 sat: 99% (98-100), O2 delivery: Ra Fluid Balance (last updated ___ @ 410) Last 8 hours Total cumulative -400ml IN: Total 0ml OUT: Total 400ml, Urine Amt 400ml Last 24 hours Total cumulative 440ml IN: Total 840ml, PO Amt 840ml OUT: Total 400ml, Urine Amt 400ml <PHYSICAL EXAM> General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, incision clean/dry/intact GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> N/A <MEDICATIONS ON ADMISSION> iron, Colace, Provera <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not take more than 4000mg (8 tablets) per day. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID Stop taking if you have loose bowel movements. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drive or drink alcohol while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*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> 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 Resident Practice with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking opioids (e.g. oxycodone, hydromorphone) * Take a stool softener such as colace while taking opioids to prevent constipation. * Do not combine opioid and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Leave the steri-strips in place. They will fall off on their own. If they have not fallen off by 7 days post-op, you may remove them. 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 an abdominal myomectomy for a symptomatic fibroid uterus, as well as a pap smear in the OR (had unsatisfactory pap smear done at pre-op appointment). Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, ibuprofen, and acetaminophen By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10886389-DS-24
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Tetracycline / Lisinopril / Cipro <ATTENDING> ___. <CHIEF COMPLAINT> Heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> ROBOTIC ASSISTED TOTAL LAPAROSCOPIC HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY,OMENTAL BIOPSY, CYSTOSCOPY <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with a past medical history notable for diabetes, morbid obestity, h/o a subarachnoid hemorrhage s/p coiling, hypertension, and asthma who presented to the emergency room at ___ on ___ for heavy vaginal bleeding. Patient reported approximately 2 weeks of postmenopausal bleeding.She denied any early satiety, unintentional weight changes, nausea/vomiting,SOB/CP, increased abdominal girth, abdominal or pelvic pain,vaginal discharge, or change in her bowel or bladder habits She underwent a pelvic US which demonstrated a 9 cm in length case x 5.6 cm AP x 7.5 cm transverse uterus. The endometrium appeared thickened measuring 2.8 cm. There was complex fluid in the endometrial canal in the lower uterine segment and cervix. Neither ovary identified on this exam. No abnormal adnexal mass or freefluid identified in the pelvis. She was referred to ___ where she was found to have a tumor prolapsing from the cervix. Biopsies returned showing high grade serous carcinoma. She was then scheduled for a PET CT and pelvic MRI. On ___, PET CT showed increased uptake in the upper vagina, extending into the uterus. There was an enlarged 1.3 cm FDG avid right inguinal lymph node concerning for metastatic disease. There was also noted to be an FDG avid 1.1 right axillary lymph node. On ___ she had a MRI which showed endometrial mass without definite myometrial extension as well as prominent right inguinal lymph node with FGD avidity on previous imaging concerning for disease involvement. There is no clear cervical stromal or parametrial involvement. She was then referred to Dr. ___. <PAST MEDICAL HISTORY> Past OB History: G8P3; SVD x 3; 1 TAB, 3 SAB Past GYN History: - Premature ovarian failure in ___ - No OCP or HRT use. - Denies history of pelvic infections or STIs - Denies history of fibroids or cysts PMH: Diabetes Mellitus Hypertension Asthma Colon Polyps DJD left knee Dyslipidemia Gastritis Iron deficiency anemia Morbid Obesity Sleep Apnea History of subarachnoid hemorrhage s/p coiling premature ovarian failure PSH: surgical coiling for ___ - ___ carpel tunnel surgery ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> sister with breast cancer, no family history of ovarian, colon, or endometrial cancer <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM (___) --======== Gen: no acute distress GYN: speculum exam the walls of the vagina were smooth and without lesions, the ectocervix was dilated by a large papillary, friable mass which measured approximately 3-4cm. There was a small amount of blood in the vault but no active bleeding. bimanual exam revealed a slightly enlarged mobile uterus without adnexal masses, the cervix and LUS were expanded. Normal parametria. --======== PHYSICAL EXAM ON DISCHARGE: --======== On day of discharge: Gen: Afebrile, vitals stable. No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision sites clean/dry/intact, no rebound/guarding, positive bowel sounds ___: trace nontender bilateral lower extremity edema <PERTINENT RESULTS> ___ 01: 41PM BLOOD Glucose-152* UreaN-21* Creat-0.9 Na-139 K-4.2 Cl-102 HCO3-28 AnGap-13 ___ 06: 45AM BLOOD Glucose-155* UreaN-23* Creat-1.2* Na-135 K-4.3 Cl-98 HCO3-28 AnGap-13 ___ 01: 00PM BLOOD Glucose-123* UreaN-22* Creat-1.3* Na-136 K-4.5 Cl-100 HCO3-28 AnGap-13 ___ 06: 50AM BLOOD Glucose-124* UreaN-19 Creat-1.0 Na-136 K-4.4 Cl-102 HCO3-29 AnGap-9 ___ 01: 41PM BLOOD WBC-10.2*# RBC-3.88* Hgb-10.3* Hct-34.1 MCV-88 MCH-26.5 MCHC-30.2* RDW-14.5 RDWSD-46.1 Plt ___ ___ 06: 45AM BLOOD WBC-6.7 RBC-3.21* Hgb-8.6* Hct-28.1* MCV-88 MCH-26.8 MCHC-30.6* RDW-14.4 RDWSD-46.0 Plt ___ ___ 01: 00PM BLOOD WBC-6.5 RBC-3.12* Hgb-8.5* Hct-27.0* MCV-87 MCH-27.2 MCHC-31.5* RDW-14.4 RDWSD-45.3 Plt ___ ___ 06: 50AM BLOOD WBC-6.7 RBC-3.22* Hgb-8.4* Hct-27.9* MCV-87 MCH-26.1 MCHC-30.1* RDW-14.4 RDWSD-45.6 Plt ___ Urine Analysis ___: straw colored, clear, negative nitrites, trace protein, negative glucose, negative ketones, negative bilirubin, PH 6.5, ___ WBCs/hpf, ___ WBCs/hps, 0 bacteria, ___ epithelial cells Urine Culture ___: pending <MEDICATIONS ON ADMISSION> albuterol sulfate [Ventolin HFA] Ventolin HFA 90 mcg/actuation aerosol inhaler: 2 puffs inh three times a day as needed for shortness of breath amlodipine 10 mg tablet: 1 tablet(s) by mouth daily for BP atorvastatin 20 mg tablet: 1 tablet(s) by mouth once a day Flovent HFA 220 mcg/actuation aerosol inhaler: 1 puff ih twice a day hydrochlorothiazide 25 mg tablet: 1 tablet(s) by mouth qam for blood pressure Lantus 100 unit/mL subcutaneous solution: 50 units SC qpm losartan 100 mg tablet: 1 tablet(s) by mouth DAILY metformin 500 mg tablet: 2 tablet(s) by mouth bid and 1 at noon for diabetes metoprolol tartrate 100 mg tablet: 1 Tablet(s) by mouth twice a day ferrous sulfate 325 mg (65 mg iron) tablet: 1 tablet(s) by mouth q day for anemia <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 q6hr Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *1 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Do not drink alcohol and drive. ___ cause sedation. Partial fill on request. RX *oxycodone 5 mg ___ tablet(s) by mouth Q4HR Disp #*50 Tablet Refills: *0 4. Albuterol Inhaler 2 PUFF IH Q6H: PRN SOB 5. amLODIPine 10 mg PO DAILY 6. Hydrochlorothiazide 25 mg PO DAILY 7. Glargine 50 Units Bedtime 8. MetFORMIN (Glucophage) 500 mg PO BID 2 tablets by mouth BID and 1 in the afternoon. 9. Metoprolol Tartrate 100 mg PO BID <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Endometrial Cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks. * No heavy lifting of objects >10 lbs for 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 ***Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omental biopsy for endometrial cancer . Please see the operative report for full details. 1) Postoperative course Immediately postoperatively, her pain was controlled with IV dilaudid and toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone and acetaminophen. On post-operative day #1, her urine output was adequate so her foley catheter was removed and she voided spontaneously. She was also tolerating a regular diet, voiding spontaneously, and her pain was controlled with oral medications. On post-operative day 1, she was not ambulating independently, so physical therapy was consulted. Physical therapy saw her on post-operative day #2, and gave recommendations for Ms. ___ to be discharged to a rehabilitation facility because she was not able to walk at her baseline. She was discharged to ___ ___ in stable condition with outpatient follow-up scheduled. 2) Acute Kidney Injury: Ms. ___ preoperative creatinine was 0.9. On posteropative day 1, her creatinine went up to 1.2 in the AM and then 1.3. Nephrotoxic medications such as ibuprofen and her metformin were held. She had adequate urine output at that time. On postoperative day 2, her creatinine came back up to 1.0. Her baseline is between 0.8 and 1.1. Continued to have adequate urine output. 3)Postoperative fever: On postoperative day 2, Ms. ___ had a temperature of 100.5 F that defervesced on its own. Urine analysis was negative for infection. Urine culture was also obtained. 4) Diabetes mellitus: Her home metformin and lantus were hold while inpatient. Her blood sugar was maintained on a humolog insulin sliding scale while inpatient. Patient said she has not been taking lantus for past two weeks. We recommended following up with her PCP about this medication. 5) Asthma: Ms. ___ was continued on her albuterol prn and fluticasone. 6) Hyperlipidemia: atorvastatin held while inpatient. can continue upon discharge.
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10886445-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Motrin <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ultrasound-guided transvaginal drainage of pelvic abscess <HISTORY OF PRESENT ILLNESS> ___ s/p TLH, bilat salpingectomy ___ for menorrhagia, adenomyosis presenting with abdominal pain starting ___, one day prior to presentation. Post-op course complicated by suspected vaginal cuff cellulitis treated with course of cipro/flagyl started ___. Pt's worsening pain was evaluated by PCP today and pt was sent to emergency room for evaluation and CT scan. CT shows pelvic fluid collection. Had been scheduled for outpt CT ___ to evaluate for etiology of sxs. Pt reports nausea accompanying her pain, but no vomiting. Also reports decreased appetite and discomfort in her abdomen with eating and drinking. Pain exacerbated by urination and bowel movements. Diarrhea x 10 days since starting abx. Denies fevers/chills at home, but reports a fever in PCP's office today and then here in the ED (100.9 documented in ED). Has been taking motrin, tylenol with codeine and more recently oxycodone for pain. Patient has received morphine 5mg IV x 1 and IV Zofran in ED. CT abd/pelvis showing rim enhancing organizing fluid collection in pelvis. Study equivocal for appendicitis. Also ? enhancing diverticulum associated woth fluid collection (per verbal report). Pt seen by general surgery who feel there is no clinical evidence for appendicitis at this time (case discussed directly with gen surg). Pt denies personal hx of diverticulitis or other GI issues. <PAST MEDICAL HISTORY> POb/Gyn: - G2P2, SVD x 2 - denies hx of STIs, +abnl Pap w/ nl follow up PMH: HTN, GERD and as above PSH: - endometrial ablation - ___ TLH, bilat salpingectomy as above -> adenomyosis - knee surgery x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> denies hx of gyn, breast and GI cancers <PHYSICAL EXAM> Admission Exam: O: Tm 100.9 Tc 99.8 HR 108-114 BP 120s/70s-80s RR ___ 97-100%RA NAD RRR Abd obese, ND, diffusely TTP, +rebound, no guarding Pelvic: thin pale yellow vaginal discharge without odor, no blood, vaginal cuff intact, no tenderness with palpation of vaginal cuff on exam, diffusely tender lower abdomen on bimanual Ext without edema, NT Exam on Discharge: Afebrile General: Patient appears comfortable an in no acute distress. Lungs: CTA bilaterally Cardiac: RRR w/ no murmurs of extra sounds Abdomen: Soft and non-distended. Mildly TTP R>L. No rebound or guarding Ext: No edema, pain, or signs of DVT <PERTINENT RESULTS> ON ADMISSION LAB VALUES - ___ WBC-12.6*# RBC-3.97* Hgb-12.6 Hct-36.0 MCV-91 MCH-31.7# MCHC-34.9 RDW-12.0 Plt ___ - ___ Neuts-80.7* Lymphs-12.5* Monos-5.4 Eos-1.0 Baso-0.4 - ___ Plt ___ - ___ Glucose-95 UreaN-6 Creat-0.7 Na-134 K-3.1* Cl-95* HCO3-25 AnGap-___ Lactate-1.0 URINE - ___ Color-Straw Appear-Clear Sp ___ - ___ Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 ___ HOSPITAL COURSE LAB VALUES - ___ WBC-10.2 RBC-3.47* Hgb-10.7* Hct-32.4* MCV-94 MCH-30.9 MCHC-33.0 RDW-12.3 Plt ___ - ___ WBC-7.1 RBC-3.25* Hgb-10.3* Hct-30.7* MCV-95 MCH-31.7 MCHC-33.5 RDW-12.2 Plt ___ - ___ WBC-5.3 RBC-3.45* Hgb-11.1* Hct-32.1* MCV-93 MCH-32.0 MCHC-34.4 RDW-12.0 Plt ___ MICROBIOLOGY GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: LACTOBACILLUS SPECIES. SPARSE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. - ___ 6: 15 pm BLOOD CULTURE #2 SOURCE: VENIPUNCTURE. Blood Culture, Routine (Pending): RADIOLOGY - CT ABD & PELVIS WITH CONTRAST Study Date of ___ 6: 54 ___ IMPRESSION: 1. Rim-enhancing fluid collection in the pelvis with adjacent inflamed loops of small bowel. These findings are concerning for an infected fluid collection. 2. Small amount of free air adjacent to the liver without a clear identifiable source. Query integrity of the recent hysterectomy surgical closure. 3. Appendix with equivocal findings for acute appendicitis. The study and the report were reviewed by the staff radiologist. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Lisinopril 10 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Hydrochlorothiazide 25 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*22 Tablet Refills: *0 4. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*33 Tablet Refills: *0 5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not take more than 4000mg acetaminophen in 24 hours RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the gynecology service with abdominal pain and were found to have an abscess. You were started on IV antibiotics and the abdominal pain improved and you underwent ultrasound-guided drainage of abscess. You were observed for 48 hours on IV antibiotics and then transitioned to oral antibiotics. Given your continued improvement on oral antibiotics we felt it was safe to discharge you home. Please follow these 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) until follow-up appointment * No heavy lifting of objects >10lbs 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 * 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. ___ presented to the emergency department with a fever of 100.9, pelvic pain, and a fluid collection concerning for possible pelvic abscess. She was admitted to gynecology on ___ and was started on IV Ampicillin/Gentamicin/Clindamycin and IV dilaudid was started as needed for pain control. On hospital day 1 (___), she underwent U/S guided drainage of pelvic fluid collection, which was noted to be small (~5cc) and multiloculated. A culture was sent, which ultimately grew out sparse growth of lactobacillus species. Her pain markedly improved after the drainage procedure, and she was continued on IV antibiotics until hospital day 3, at which point she had been afebrile x 48 hours and her white blood count had decreased from 12.6 to a normal level. She was thus transitioned to oral Augmentin/Flagyl. Her pain was controlled with oral percocet. With respect to her hypertension, she was continued on her home medications HCTZ and Lisinopril and her blood pressure was well controlled. She was observed on oral antibiotics until hospital day #4, at which point she was tolerating a regular diet, pain was controlled on oral medications, and she remained afebrile. She was discharged for plan to complete a 14 day course of antibiotics, and outpatient follow-up was arranged.
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10886587-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic pain, vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, mild TTP in b/l lower quadrants (L>R), no rebound/guarding Ext: no TTP <PERTINENT RESULTS> LABS -== ___ 06: 10AM BLOOD WBC-7.2 RBC-4.11 Hgb-11.6 Hct-35.9 MCV-87 MCH-28.2 MCHC-32.3 RDW-14.4 RDWSD-46.0 Plt ___ ___ 07: 42AM BLOOD WBC-12.7* RBC-4.31 Hgb-12.4 Hct-37.4 MCV-87 MCH-28.8 MCHC-33.2 RDW-14.3 RDWSD-45.6 Plt ___ ___ 07: 42AM BLOOD Neuts-67.6 ___ Monos-5.8 Eos-2.2 Baso-0.6 Im ___ AbsNeut-8.57* AbsLymp-2.97 AbsMono-0.73 AbsEos-0.28 AbsBaso-0.07 ___ 06: 10AM BLOOD Plt ___ ___ 06: 10AM BLOOD ___ PTT-30.1 ___ ___ 07: 42AM BLOOD Plt ___ ___ 07: 42AM BLOOD ___ PTT-29.0 ___ ___ 07: 42AM BLOOD Glucose-112* UreaN-7 Creat-0.7 Na-138 K-3.2* Cl-103 HCO3-20* AnGap-18 ___ 07: 52AM BLOOD Lactate-0.7 ___ 11: 00AM URINE Color-Straw Appear-Hazy Sp ___ ___ 11: 00AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 11: 00AM URINE RBC-23* WBC-14* Bacteri-NONE Yeast-NONE Epi-14 ___ 11: 00AM URINE UCG-NEGATIVE MICROBIOLOGY -== ___ 4: 34 pm URINE Source: ___. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Pending): NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Pending): ___ 11: 00 am URINE URINE CULTURE (Pending): ___ 7: 20 am BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING -== ___ PELVIC ULTRASOUND EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman s/p TAH ___ c/b pelvic abscess s/p drainage and IV antiobitics x 2 weeks, readmitted with LLQ pain, mild leukocytosis, light VB and CT with hemorrhagic cyst vs abscess.// assess ovarian cyst vs pelvic abscess seen on CT, assess for ovarian flow TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: Reference outside ultrasound and CT both dated ___ FINDINGS: The uterus is surgically absent. The region of the vaginal cuff is unremarkable. The right ovary is normal and contains a hemorrhagic cyst measuring 1.6 x 1.7 x 1.1 cm which is within physiologic range. With color and spectral Doppler, normal arterial and venous flow is demonstrated within the right ovary. The left ovary contains a hemorrhagic cyst measuring 4.6 x 4.0 x 4.0 cm. Although minimal flow is demonstrated with color Doppler within the left ovary, this is difficult to assess due to the size of the hemorrhagic cyst. There is no evidence of an enlarged or edematous left ovary to suggest torsion. There is no free fluid. IMPRESSION: Bilateral hemorrhagic ovarian cysts which are unchanged in appearance when compared to prior ultrasound and CT. No free fluid or focal fluid collections demonstrated. ___ : EXAMINATION: SECOND OPINION CT INDICATION: ___ year old woman POD ___ s/p total abdominal hysterectomy, post-op course c/b pelvic abscess s/p drainage, re-presented with L>R pelvic pain// ?pelvic fluid collection ?adnexal masses TECHNIQUE: MDCT images of the abdomen and pelvis with IV and oral contrast was uploaded into PACs and reviewed. DOSE: Total exam DLP: 570 mGy-cm COMPARISON: None. FINDINGS: LOWER CHEST: Minimal subsegmental atelectasis is noted at the lung bases. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 1.2 x 1.1 cm hypodensity is seen in segment 6 of the liver (02: 24). An additional hypoattenuating lesion is seen adjacent to the falciform ligament, which is likely related to altered perfusion. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. A subcentimeter cortical hypodensity is seen in the interpolar region of the left kidney, too small to characterize but likely represent a simple cyst. There is no hydronephrosis or perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis or organized fluid collections. REPRODUCTIVE ORGANS: The patient is status post total abdominal hysterectomy. A 4.9 x 3.9 cm hyperdense cyst is noted in the left ovary. Subsequent ultrasound performed on the same day demonstrates this to be a hemorrhagic cyst. A 2.2 x 1.6 cm cyst with an enhancing rim is seen in the right ovary, likely representing a corpus luteal cyst. This also appears hemorrhagic on the recent ultrasound. No additional adnexal masses are identified. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. A prominent right common iliac lymph node is seen measuring 1.3 x 0.7 cm (02: 46). There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Mild fat stranding is noted along anterior pelvic wall, in keeping with residual postsurgical changes. IMPRESSION: 1. No free fluid or pelvic fluid collections. 2. Bilateral hemorrhagic ovarian cysts, left greater than right. 3. 1.2 cm indeterminate hypoattenuating lesion in hepatic segment 6. This likely represents a hemangioma but is not well characterized on this single phase CT. Further evaluation with a non-urgent ultrasound of the liver is recommended. RECOMMENDATION(S): Non urgent ultrasound of the liver is recommended. <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the Gynecology Service with pelvic pain. You underwent a CT scan at an outside hospital which demonstrated a left ovarian cyst. You were briefly on IV Zosyn (an antibiotic) until we ruled out a pelvic infection as a potential source of your pain. You received Tylenol, Ibuprofen, and Dilaudid/Oxycodone for your pelvic pain. A pelvic ultrasound performed prior to your discharge showed hemorrhagic cysts on both of your ovaries. Please follow-up with your primary OBGYN regarding management of these cysts. The team feels like it is now safe for you to be discharged. Please refer to the following 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) until your follow-up appointment * No heavy lifting of objects >10 lbs until your follow-up appointment * You may eat a regular diet * You may walk up and down stairs To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Dr. ___ has requested that you have your hospital records faxed to her office (fax number listed below)
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Ms. ___ is a ___ yo s/p total abdominal hysterectomy on ___ for fibroids and abnormal uterine bleeding, with post-operative course complicated by a pelvic abscess requiring drainage (drain removed 2 weeks ago). She presented with 1 day of worsening left lower quadrant pain, flank pain, and vaginal bleeding. On admission, she was afebrile with stable vital signs. Her labs were notable for a leukocytosis (WBC = 12.7). Based on prelim read of OSH CT scan results, she was started on IV zosyn to treat a presumed pelvic infection. She received PO Acetaminophen, PO Tylenol, and PO Dilaudid prn pelvic pain. She was continued on her home medications for anxiety and depression. Pelvic ultrasound on ___ showed bilateral hemorrhagic ovarian cysts, unchanged in appearance when compared to prior ultrasound and CT. There was no free fluid or focal fluid collection. ___ read of the OSH CT scan revealed bilateral hemorrhagic ovarian cysts, left greater than right, and a 1.2cm indeterminate hypoattenuating lesion in hepatic segment (further evaluation with a non-urgent liver ultrasound was recommended). Given that she was afebrile with imaging read not concerning for pelvic infection, her IV antibiotics were discontinued on ___. On ___, pt's pain was well-controlled. She was tolerating a regular diet, and ambulating and voiding without issues. She was discharged to home in good condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 3. Ibuprofen 600 mg PO Q6H take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate may cause sedation. do not drink alcohol or drive while taking oxycodone RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*18 Tablet Refills:*0 5. ALPRAZolam 1 mg PO DAILY:PRN anxiety 6. Gabapentin 800 mg PO TID 7. MethylPHENIDATE (Ritalin) 20 mg PO TID 8. Omeprazole 20 mg PO DAILY 9. TraZODone 200 mg PO QHS:PRN insomnia, anxiety 10. Venlafaxine XR 75 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Ovarian cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10886673-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> LLQ pain, pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1 presents to ED with one day of acute onset LLQ pain, constant with periods of intensity, +N/V x1 episode, and vaginal bleeding. No F/C, CP/SOB. HCG positive (858) in ED. <PAST MEDICAL HISTORY> mild asthma <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> T: 98.2 BP: 132/71 (128-132/71-75) HR: 98 (98-125) RR: 16 O2: 100%RA General: NAD, resting comfortably on arrival into room CV: Mild tachycardia, normal rhythm Pulm: CTAB Abd: Soft, +BS, non-distended, TTP suprapubically and LLQ, + rebound in LLQ, but no guarding, no rigidity SVE: No CMT, exquisite tenderness on palpation in posterior cul-de-sac with moderate TTP in left adnexa, but no palpable masses. No TTP in RLQ. <PERTINENT RESULTS> ___ 04: 00PM WBC-10.2 RBC-3.77* HGB-11.6* HCT-33.3* MCV-88 MCH-30.7 MCHC-34.7 RDW-12.7 ___ 07: 30PM WBC-10.6 RBC-4.29 HGB-13.4 HCT-37.9 MCV-89 MCH-31.3 MCHC-35.4* RDW-12.2 ___ 07: 30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG ___ 07: 30PM GLUCOSE-101* UREA N-15 CREAT-0.7 SODIUM-136 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-19* ANION GAP-18 ___ 08: 16PM ___ PTT-25.1 ___ ___ 11: 21PM HGB-12.0 HCT-34.4* <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> likely miscarriage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, you were admitted for observation of abdominal pain in the setting of a positive pregnancy test and fluid seen on ultrasound. Your HCG level was 858 then decreased to 690. This likely represents a very early miscarriage. The fluid was likely due to a ruptured ovarian cyst. Your blood levels (hematocrit) were followed and were stable when you were discharged.
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___ yo G1 presents to ED with 1 day of abd pain, incidentally found to have +HCG. On pelvic US, complex free fluid and no IUP seen, could not r/o ectopic so admitted. Serial abdominal exams benign, pain improved, hematocrit stable. Repeat hcg fallen from 858 to 690. Discharged to home with likely spontaneous abortion, to call outpatient provider for repeat hct in 2 days.
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10887024-DS-26
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Rocephin <ATTENDING> ___. <CHIEF COMPLAINT> pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G5P2 with history of 1 c-section and 1 spontaneous vaginal delivery, presenting with severe pelvic pain that is worse with menses. She has heavy menses. She also has pain with intercourse and has not had intercourse for over ___ years. She has an IUD in place. Strings not visible. She notes bleeding improved with IUD but pain worsened. Most recent hematocrit 38. She has failed multiple attempts at medical management of her pelvic pain. In the past she has been advised to undergo hysterectomy but "was too scared." She presents in consultation regarding surgical management of same. <PAST MEDICAL HISTORY> ? MENORRHAGIA ABNORMAL PAP SMEAR DEPRESSION DOMESTIC ABUSE DYSMENORRHEA GYNECOLOGIC HEADACHE HYPOTHYROIDISM INSOMNIA OVERWEIGHT PELVIC PAIN TOBACCO ABUSE ATYPICAL CHEST PAIN CONTRACEPTION <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother is dead. She had DM and had CABG x 3 and died perioperatively during the bypass. She had toe amputations <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> levothyroxine 175mcg, omeprazole 20mg daily PRN, albuterol PRN, fluticason NS PRN, toperimate 25mg PRN headache <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H: PRN pain 3. Levothyroxine Sodium 175 mcg PO DAILY 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain do not drive or drink alcohol while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills: *0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic pain adenomyosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * 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 total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid/toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, ibuprofen, acetaminophen. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10887275-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Darvocet-N 100 <ATTENDING> ___. <CHIEF COMPLAINT> Advanced ovarian cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> EXPLORATORY LAPAROTOMY, TOTAL ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, APPENECTOMY, OMENTECTOMY, TUMOR DEBULKING <HISTORY OF PRESENT ILLNESS> The patient is a lovely ___, who began demonstrating abdominal discomfort in ___. She underwent an abdominal ultrasound, which demonstrated multiple liver lesions and new moderate ascites. She had a CT of the abdomen and pelvis that showed a heterogeneously enhancing left adnexal mass measuring 11.___s hypodense liver lesions, splenic lesions, omental caking, and peritoneal soft tissue deposits concerning for carcinomatosis. She underwent an ultrasound-guided paracentesis on ___ with removal of 4.25 liters of fluid. Cytologic analysis of the fluid was positive for malignant cells consistent with an ovarian origin. Tumor markers were notable for an elevated CA-125 and CA ___. She had a chest CT, which was negative for malignancy. She then began neoadjuvant carboplatin and paclitaxel on ___. She received three cycles; however, was diagnosed with an iliac vein DVT. Decision was made to give an additional cycle of chemotherapy in order to initiate anticoagulation. She then had a loss in the family and therefore proceeded with her fifth cycle of chemotherapy and presents today for interval surgical management. <PAST MEDICAL HISTORY> - HTN - Depression - GERD - Malignant Ascites (s/p paracentesis) - DVT (apixaban started ___ - s/p C-sections x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father died from lung cancer (smoker). Sister living with stage IV lung cancer (on oral chemo). Sister died from HD complications, history of drug abuse. Brother died from CVA, aneruysm ___. Mother died of failure to thrive in ___. Maternal cousin died from "stomach cancer". Maternal uncle died from bladder cancer. <PHYSICAL EXAM> 24 HR Data (last updated ___ @ 516) Temp: 98.1 (Tm 98.6), BP: 121/78 (105-121/69-78), HR: 78 (71-88), RR: 18 (___), O2 sat: 96% (95-97), O2 delivery: Ra Fluid Balance (last updated ___ @ 2337) Last 8 hours Total cumulative -100ml IN: Total 120ml, PO Amt 120ml OUT: Total 220ml, Urine Amt 220ml Last 24 hours Total cumulative -50ml IN: Total 720ml, PO Amt 720ml OUT: Total 770ml, Urine Amt 770ml General: NAD, comfortable CV: RRR, normal s1 and s2 Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, incision clean/dry/intact Extremities: no edema, non-tender, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 05: 45PM ___ PO2-31* PCO2-54* PH-7.33* TOTAL CO2-30 BASE XS-0 ___ 05: 45PM GLUCOSE-122* LACTATE-1.9 NA+-139 K+-3.6 CL--104 ___ 05: 45PM HGB-8.9* calcHCT-27 O2 SAT-42 ___ 05: 45PM freeCa-1.17 ___ 05: 30PM WBC-11.1* RBC-2.68* HGB-8.7* HCT-27.7* MCV-103* MCH-32.5* MCHC-31.4* RDW-17.9* RDWSD-67.6* ___ 05: 30PM PLT COUNT-119* ___ 05: 30PM ___ PTT-26.7 ___ ___ 05: 30PM ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Citalopram 10 mg PO DAILY 3. LORazepam 0.5 mg PO QHS: PRN anxiety, insomnia 4. Polyethylene Glycol 17 g PO QHS: PRN Constipation - First Line 5. Famotidine 20 mg PO BID <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 2. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills: *1 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 4. Enoxaparin Sodium 30 mg SC Q12H Duration: 7 Days RX *enoxaparin 30 mg/0.3 mL 1 twice a day Disp #*7 Syringe Refills: *0 5. Ibuprofen 400 mg PO Q8H: PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 6. OxyCODONE (Immediate Release) 5 mg PO Q6H: PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 7. Simethicone 40-80 mg PO QID: PRN gas pain RX *simethicone [Gas-X Extra Strength] 125 mg 1 tablet(s) by mouth once a day Disp #*50 Tablet Refills: *0 8. Citalopram 10 mg PO DAILY 9. Famotidine 20 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___ ___ were admitted to the gynecologic oncology service after undergoing the procedures listed below. ___ have recovered well after your operation, and the team feels that ___ are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Your staples will be removed within 2 weeks from your surgery. This appointment should already been scheduled for ___. Please call if ___ do not have an appointment scheduled. * Take your medications as prescribed. We recommend ___ take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As ___ start to feel better and need less medication, ___ should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. ___ were prescribed Colace. If ___ continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital ___ can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet. * It is safe to walk up stairs. Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * ___ should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, ___ may remove them. * If ___ have staples, they will be removed at your follow-up visit. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if ___ are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where ___ are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. ___ will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist ___ in administering these injections.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, and tumor debulking. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with a dilaudid PCA. Her diet was advanced without difficulty and she was transitioned to oral pain meds. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. For her history of an iliac vein DVT, she was started on low molecular weight heparin post-op for anticoagulation. She continued on LMWH 30mg SC Q12H for seven days until her transition to her home abixaban on POD7. By post-operative day 5, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10887355-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Dilantin <ATTENDING> ___ <CHIEF COMPLAINT> Seizure <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ YO P1 POD #9, s/p LTCS for failed induction of labor and nonreassuring fetal heart tracing, presented on ___ via ambulance from OSH s/p seizure. She was induced for elevated blood pressures, headache and, given her history of epilepsy and craniostomy, presumed low seizure threshold. She did not receive magnesium sulfate postpartum. She had a severe headache that started on ___ that was refractory to percocet and excedrin. Noted visual changes, spots, and did "not feel right." She was having some motor difficulty with bilateral hands, which resolved on presentation to the ED. Given feeling unwell overall, her partner called an ambulance, and on its arrival the patient had a witnessed seizure. She had a second seizure episode in the ambulance on route to OSH. At the OSH, she was given ativan 1mg IV and noted to have BPs 150/95. On arrival to ED at ___, she received magnesium sulfate 2g IV and tylenol ___ po for HA. Neurology and OB/GYN consults were called. <PAST MEDICAL HISTORY> POBHx: G1P1, LTCS for failed IOL PGYNHx: Benign PMH: migraines, epilepsy - last sz ___ prior to today, dermoid tumor of L frontal lobe - resected. PSH: Left frontal temporal craniostomy, wisdom teeth, LTCS. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal aunt died of ruptured brain aneurysm at age ___ after suffering from severe headache and vomiting of sudden onset; maternal GM died of CAD at young age; no FH of epilepsy. <PHYSICAL EXAM> Physical exam: VITALS 97.5 129/95 76 20 100(3L) on arrival to ED 132/94 82 15 97 RA ___ 98 RA GENERAL Anxious, A+Ox3, NAD HEENT NC/AT, neck supple LUNGS CTAB HEART RRR ABDOMEN Soft, tender over RUQ and epigastrium, no R/G, pfannensteil incision c/d/i, no erythema. GU No staining on pad LOW EXT Nontender/edematous, DTR 2+ bilaterally NEURO CN ___ grossly intact <PERTINENT RESULTS> Labs: 144 108 12 AGap=15 -------------< 86 3.9 25 0.8 ALT: 6 AST: 17 UricA: 10.3 9.5 >--< 504 ___ 35.1 N: 86.0 L: 10.9 M: 2.0 E: 0.9 Bas: 0.2 UA trace protein Pr/Cr 0.5* <MEDICATIONS ON ADMISSION> KEPPRA 2500mg BID NORTRIPTYLINE 75mg by mouth at bedtime PROPRANOLOL - 60 mg Tablet - 2 Tablet(s) by mouth bedtime ACETAMINOPHEN-CAFFEINE [EXCEDRIN TENSION HEADACHE] - (OTC) - 500 mg-65 mg Tablet - 2 Tablet(s) by mouth daily or PRN HA PERCOCET PRENATAL VIT <DISCHARGE MEDICATIONS> Medications - Prescription BUTALBITAL-ACETAMINOPHEN-CAFF - (Prescribed by Other Provider) - 50 mg-325 mg-40 mg Tablet - 1 Tablet(s) by mouth 4 as needed for headache LEVETIRACETAM [KEPPRA] - 1,000 mg Tablet - ___ Tablet(s) by mouth twice a day increase as directed. - No Substitution LEVETIRACETAM [KEPPRA] - 250 mg Tablet - ___ Tablet(s) by mouth twice a day increase as directed - No Substitution NORTRIPTYLINE - 25 mg Capsule - 3 Capsule(s) by mouth at bedtime PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed by Other Provider: 1 2 tabs by mouth once daily) - Dosage uncertain PROPRANOLOL - (reconciliation ) - 60 mg Tablet - 2 Tablet(s) by mouth bedtime Medications - OTC ACETAMINOPHEN-CAFFEINE [EXCEDRIN TENSION HEADACHE] - (OTC) - 500 mg-65 mg Tablet - 2 Tablet(s) by mouth daily or PRN HA <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p c/s delivery re-admitted with presumed eclamptic seizure <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> continue to follow routine post-partum and neurology recommnedations
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In the ED, Ms. ___ was normotensive and without focal neurological signs. She was found to have PRES on MRI, and was admitted to L+D for management of eclampsia. She was given magnesium for 24 hours. An MFM consult was obtained on L+D. The patient's blood pressures were controlled with propanolol during her hospital course. She was continued on Keppra, which she takes at home. Following magnesium therapy, she was transferred to the post-partum floor where she was monitored. She had no further seizures and her blood pressure remained within normal limits. Neurology continued to follow, and recommended follow-up MRIs in 1 and 6 months, as well as out-patient neurology follow-up. She was discharged home on hospital day four in stable condition.
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10888095-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> azithromycin / morphine <ATTENDING> ___. <CHIEF COMPLAINT> Epigastric pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 22w3d with hx RNY presented with three weeks of intermittent abdominal pain since she had her wisdom teeth removed. Patient reports that three weeks ago she had wisdom teeth extraction and later that same day reports severe mid epigastic pain. It does not radiate. She experiences nausea and vomiting. Pain is worse with eating. Has been taking pepcid, zofran and one percocet per day without relief. She reports two contractions today. She initially was seen 3 weeks ago at OSH where she reports normal CT scan. Yesterday she presented to ___ where she had a KUB. She was then transferred to ___ for evaluation by bariatrics. Denies fever, chills, diarrhea, dysuria, constipation, VB, LOF. +FM. <PAST MEDICAL HISTORY> OBHx: - G1: current GynHx: - Denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - Mild asthma: no hospitalizations or intubations PSH: - Open Roux en Y - LSC CCY - Wisdom teeth extraction <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Physical Exam on Admission T98.0 HR-60 BP-90/44 RR-18 O2-99% Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: +BS, soft, gravid, mild epigastric tenderness, no fundal tenderness, no rebound or guarding. fundus 1-2 cm above umbilicus Ext: no calf tenderness Physical Examination on Discharge VSS Gen: NAD, comfortable CV: RRR Pulm: CTAB Abd: Soft, nondistended, nontender, gravid Ext: warm well perfused, nontender <PERTINENT RESULTS> ___ 01: 25AM BLOOD WBC-7.0 RBC-3.14* Hgb-9.7* Hct-27.8* MCV-89 MCH-30.7 MCHC-34.7 RDW-13.9 Plt ___ ___ 01: 25AM BLOOD Neuts-63.2 ___ Monos-5.1 Eos-1.0 Baso-0.3 ___ 01: 25AM BLOOD Glucose-74 UreaN-10 Creat-0.5 Na-136 K-3.6 Cl-105 HCO3-24 AnGap-11 ___ 01: 25AM BLOOD ALT-19 AST-38 AlkPhos-59 TotBili-0.2 ___ 04: 30PM BLOOD Albumin-3.1* Iron-154 ___ 04: 30PM BLOOD calTIBC-403 VitB12-413 Folate-16.7 Ferritn-9.2* TRF-310 Abdominal Ultrasound ___: There is a single live intrauterine gestation. The fetus is in vertex position. The placenta is normal. There is no evidence of previa. There is a normal amount of amniotic fluid. No fetal morphologic abnormalities are detected. The uterus is normal. The ovaries are not visualized; however, no adnexal abnormalities are seen. Limited single views of the right and left upper quadrant are included which are grossly unremarkable. No free fluid is identified. Single intrauterine pregnancy, size equal to dates. No abdominal free fluid. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN pain 2. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet,delayed release (___) by mouth twice a day Disp #*60 Tablet Refills: *3 3. Prenatal Vitamins 1 TAB PO DAILY RX *PNV with ___ 27 mg iron-1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *2 4. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth Twice a day Disp #*8 Tablet Refills: *0 5. Sucralfate 1 gm PO QID RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp #*120 Tablet Refills: *2 6. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pregnancy at 22 weeks Epigastric pain, presumed peptic ulcer disease Iron-deficiency 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 ___ with epigastric pain in pregnancy. Because you have had a gastric bypass we were concerned you may have peptic ulcer disease. Your symptoms improved with medications for peptic ulcers and with adjusting your eating patterns (small slow meals). It is now safe for you to be discharged home. While you were in the hospital we also noted that your iron was low, causing anemia. You should take iron supplements twice daily in addition to your prenatal vitamin.
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Ms ___ is a ___ yo G1 at 22weeks gestation with hx of Roux en Y bypass who was transferred from OSH due to epigastric pain. Bariatric surgery was consulted who felt this likely secondary to ulcer and recommended GI consult for possible endoscopy. GI was consulted and agreed her discomfort was likely caused by an ulcer and felt endoscopy would not aid in management at this time and recommended optimal medical management with PPI, sucralfate and H2blocker. During admission patient with anemia- HCT of 27. Folate, B12 and iron levels checked with normal b12 and folate levels and decreased ferritin. Patient given iron and instructed to take increased iron BID at home. Patient improved with medical treatment of presumed PUD (PPI, small slow meals) and on hospital day #2 reported symptoms resolved. The patient was tolerating a regular diet. GI and bariatric surgery both evaluated the patient who felt discharge was reasonable. She has outpatient followup with Bariatric surgery. Patient discharged in stable condition on HD 2 tolerating regular diet with no abdominal pain. She had reassuring fetal testing throughout admission.
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10889507-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Reglan <ATTENDING> ___. <CHIEF COMPLAINT> preterm contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ presents with preterm ctx. Reports onset of ctx this afternoon, while shopping at outlets. Went home and attempted rest and snack with no improvement in ctx. Some ctx are painful and taking her breath away, but not consistently. Intensity has been about the same throughout the day, but ctx have become more intense while here in triage. Denies VB, LOF. Active FM. Denies fevers, chills, sweats, malaise, N/V, dysuria, hematuria, vaginal itching or vulvar irritation. Denies illicit drug use or abdominal trauma. <PAST MEDICAL HISTORY> PNC: -___: ___ by ___ US -Labs: O+/Ab-/RI/VI/RPRNR/HbsAg-/HIV-/GBS- -Screening: NIPT -FFS: wnl, girl -GLT: deferred, 1wk FSBG wnl -Vaccines: s/p tdap ___ -___ (cMFM): cephalic, ant plac, nl AF, 2219g (47%) -___: cephalic, ant placenta, nl AF, BPP ___ -Issues: #triage eval for PTC 3 weeks ago #EIF, with low risk NIPT #carrier for Ga___ disease, declined FOB testing #hx gastric bypass #elevated AFP ObHx: G1 current GynHx: normal periods, no STIs, no abnl paps PMH: obesity, hx gastric ulcer (none since stopped NSAIDs), hx recurrent c diff PSH: gastric bypass, cholecystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS: 103/77, 79, 98.5 Gen: mildly uncomfortable with ctx, NAD, non-diaphoretic Resp: nl resp effort Abd: soft, gravid, no fundal tenderness SVE @ 0030: ___ (last ext os 1/int os closed/long/posterior 2+ weeks ago) SVE @ 0230: ___ SSE: deferred Toco: ___ FHT: 140/mod var/+accels/-decels TAUS: vtx <PERTINENT RESULTS> ___ WBC-10.8 RBC-4.14 Hgb-12.1 Hct-35.6 MCV-86 Plt-254 ___ WBC-9.5 RBC-3.99 Hgb-11.7 Hct-35.6 MCV-89 Plt-251 ___ ALT-10 AST-16 LD(LDH)-148 Lipase-25 ___ LD(LDH)-252 ___ BLOOD ___ Comment-GREEN TOP ___ BLOOD Lactate-1.7 ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-2 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> Ca Vit D3 B12 omeprazole PNV <DISCHARGE MEDICATIONS> Ca Vit D3 B12 omeprazole PNV <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm contractions <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the Antepartum service with painful contractions. You have been monitored closely and underwent multiple cervical exams. We do not think you are in active labor. Given your history of gastric bypass, we consulted General Surgery who recommended an MRI. You have declined the MRI. We feel that you are safe for discharge home. Please call Dr. ___ office with any further questions or concerns.
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___ G1 admitted at 35w6d with preterm contractions. She was afebrile and without any evidence of infection or abruption. Fetal testing was reassuring. She reported persistent painful contractions, however, made very little change over time. She underwent therapeutic rest with morphine and was monitored on the antepartum floor. She continued to required intermittent doses of narcotics due to her painful contractions with minimal cervical change. On HD#3, she reported right sided abdominal pain in between her contractions and was mildly tender on exam. She remained afebrile and tolerating a regular diet throughout the admission. ACS was consulted and recommended an MRI, however, Ms ___ declined. She was discharged home on ___ with precautions and will have close outpatient follow up. Of note, she had a reassuring ultrasound in the CMFM on ___.
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10889507-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Reglan <ATTENDING> ___. <CHIEF COMPLAINT> decreased fetal movement contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a lovely ___ G2P1 at ___ presenting with DFM and tightening for the past few hours. She states she has felt a little nauseated over the past few days but has not been throwing up. Has had decreased appetite but does feel like she is drinking good amount of water. No urinary symptoms. No diarrhea. No VB, LOF, abnormal discharge. Reports tightening is uncomfortable and occurring about every 10 minutes. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w ___ trimester U/S - Labs Rh pos/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS PND - Screening - Aneuploidy screening: abnl Panorama - ___ 46XY - FFS - wnl - GLT - screened with FBS fasting and 1hr PP x 1wk - wnl - U/S - ___: ant placenta, nl AF, 2143g (60%), cephalic - Issues - She is known ___ carrier, but couple have elected not to have FOB tested - h/o gastric bypass - getting growth scans q4wk OB Hx: - G1 SVD - IOL 37wk for persistent DFM, 2970g - G2 current GYN Hx - due for repeat pap postpartum. No known h/o fibroids, STIs. PMH: - h/o recurrent c. diff - h/o anemia requiring IV iron Past Surgical Hx: - gastric bypass (cannot have NSAIDs) - cholecystectomy <PHYSICAL EXAM> Admission <PHYSICAL EXAM> ___ ___: 94 ___ 17: 40BP: 108/69 (79) ___ ___: 93 ___ 17: 48Temp.: 98.3°F ___ ___: 94 Gen: NAD CV: RRR Lungs: nl respiratory effort Abd: soft, gravid, NT SVE: LCP Spec: visually closed, no blood in vault or abnormal discharge, no pooling TAUS: vtx, BPP ___ FHT: 150/mod/+accels/-decels toco: q7m . . . Discharge Physical Exam VS: 98.2, 94/57, 87, 18, O2 95% Gen: NAD, appears comfortable Resp: nl respiratory effort Abd: soft, gravid, nontender Ext: nontender w/o edema Date/Time: ___ at ___ FHT 130/mod var/+accels/no decels -> reactive Toco q ___ min <PERTINENT RESULTS> ___ 01: 10PM BLOOD WBC-14.0* RBC-3.72* Hgb-10.6* Hct-32.9* MCV-88 MCH-28.5 MCHC-32.2 RDW-14.0 RDWSD-45.1 Plt ___ ___ 06: 38PM BLOOD WBC-12.2* RBC-3.76* Hgb-11.0* Hct-32.3* MCV-86 MCH-29.3 MCHC-34.1 RDW-13.6 RDWSD-42.2 Plt ___ ___ 01: 10PM BLOOD Neuts-68.2 ___ Monos-5.7 Eos-0.5* Baso-0.4 Im ___ AbsNeut-9.57* AbsLymp-3.45 AbsMono-0.80 AbsEos-0.07 AbsBaso-0.06 ___ 06: 38PM BLOOD Neuts-70.7 ___ Monos-5.2 Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.61* AbsLymp-2.82 AbsMono-0.63 AbsEos-0.03* AbsBaso-0.03 ___ 01: 10PM BLOOD Plt ___ ___ 06: 38PM BLOOD Plt ___ ___ 01: 10PM BLOOD ALT-10 AST-15 ___ 12: 15PM URINE Color-Straw Appear-Clear Sp ___ ___ 06: 53PM URINE Color-Straw Appear-Clear Sp ___ ___ 12: 15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR* ___ 06: 53PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 12: 15PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-4 TransE-<1 ___ 06: 50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 06: 08PM OTHER BODY FLUID CT-NEG NG-NEG. ___ 6: 53 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 6: 08 pm ANORECTAL/VAGINAL Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: Negative for Group B beta streptococci. ___ 6: 08 pm SWAB Site: VAGINA Source: Vaginal. **FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. ___ 1: 10 pm BLOOD CULTURE Blood Culture, Routine (Pending): <MEDICATIONS ON ADMISSION> PNV, B12, calcium, vitamin D3 <DISCHARGE MEDICATIONS> PNV, B12, calcium, vitamin D3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pre-term contractions <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital for preterm contractions. You were given betamethasone, a steroid which helps the baby's lungs among other benefits. Your contractions and cervical exam remained stable and you are now safe to be discharged home. Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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On ___, Ms. ___ was admitted at ___ with decrased fetal movement and abdominal tightening. On presentation she had a reactive NST and BPP ___ on ultrasound. For her preterm contractions she had a FFN collected which was unable to be processed. She was noted to make cervical change from closed to 1cm. She was therefore started on a course of betamethasone for fetal lung maturity. Tocolytics were deferred given gestational age. She was monitored on L&D and made slow cervical change to 1.5cm/50% effaced/posterior with no further changes. She was then monitored on the antepartum service. She continued to have intermittently painful contractions and received IV dilaudid with subsequent relief. She was seen by the NICU given prematurity. On HD#3, she reported abdominal tenderness that was nonreproducible on exam. Labs were drawn which showed normal white count with no bandemia, normal LFTs and negative urinalysis. She had blood cultures drawn which had no growth to date. By hospital day #4 patient was stable with unchanged cervical exam and reassuring fetal testing. She was therefore discharged home with close outpatient follow up scheduled.
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10890897-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> codeine <ATTENDING> ___. <CHIEF COMPLAINT> Contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean section <HISTORY OF PRESENT ILLNESS> ___ G1 at ___+0 who presents to triage for labor check. Upon arrival it was noted that she had elevated BPs for the first time in pregnancy. Currently denies HA, visual changes, RUQ/epigastric pain. Denies VB or LOF. +AFM. <PAST MEDICAL HISTORY> PNC: -___: ___ -Labs: A+/Ab-/HBsAg-/RPRNR/RI/HIV-/GBS- -Screening: declined aneupoloidy screening -FFS: WNL, posterior placenta, SURPRISE! -GLT: passed OBHx; G1 current GynHx: 3 small anterior fibroids (2.4cm, 2.8cm and 1.6cm) seen at 14w U/S PMH: anxiety/depression, h/o nephorlithiasis, palpitations (seen by cards, ?PACs vs PVCs, on propranalol for about a year after her father passed away, d/c when discovered she was pregnant, no issues in pregnancy) PSH: open cholecystectomy, rental stent, lithotripsy Meds: Wellbutrin 400mg daily, PNV All: codeine (?numbness as a child) - has taken other narcotics without issues <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Physical Exam on Admission: -VS: ___ 09: 20 BP: 152/112 (122) ___ ___ MHR: 92 ___ 09: 31 BP: 148/89 (105) ___ 09: 35 Temp.: ___ 09: 49 BP: 136/93 (102) ___ 10: 00 BP: 131/94 (103) ___ 10: 15 BP: 144/86 (101) ___ 10: 30 BP: 137/100 (109) ___ 11: 23 BP: 145/94 (107) ___ 11: 25 MSpO2: 99% -Gen: anxious -Abd: gravid, soft, NT -NST: 140, mod var, +accels, occasional variables -Toco: irritable with irregular ctx -TAUS: VTX -SVE: FT/50/-3/post @ 0930 per RN ___________________________________________________________ Physical Exam on Discharge: VS: Afebrile, Vital signs stable Neuro/Psych: no acute distress, Oriented x3, Affect Normal Heart: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft, appropriately tender, fundus firm, incision clean/dry/intact Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 09: 45AM BLOOD WBC-8.8 RBC-3.75* Hgb-10.8* Hct-32.8* MCV-88 MCH-28.8 MCHC-32.9 RDW-13.2 RDWSD-42.2 Plt ___ ___ 12: 53PM BLOOD WBC-21.6* RBC-3.41* Hgb-10.0* Hct-31.5* MCV-92 MCH-29.3 MCHC-31.7* RDW-13.4 RDWSD-45.2 Plt ___ ___ 01: 10PM BLOOD WBC-11.7* RBC-2.84* Hgb-8.3* Hct-26.4* MCV-93 MCH-29.2 MCHC-31.4* RDW-14.1 RDWSD-47.6* Plt ___ ___ 04: 45PM BLOOD Glucose-92 UreaN-7 Creat-0.7 Na-136 K-3.9 Cl-101 HCO3-22 AnGap-13 ___ 09: 40PM BLOOD Glucose-115* UreaN-13 Creat-1.3* Na-131* K-4.3 Cl-99 HCO3-19* AnGap-13 ___ 01: 10PM BLOOD Creat-0.6 ___ 09: 45AM BLOOD ALT-21 AST-23 ___ 08: 40AM BLOOD ALT-41* AST-33 ___ 01: 10PM BLOOD ALT-24 AST-18 ___ 09: 33AM URINE Blood-SM* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD* ___ 09: 33AM URINE RBC-3* WBC-12* Bacteri-NONE Yeast-NONE Epi-1 <MEDICATIONS ON ADMISSION> Buproprion 400mg daily Prenatal vitamins <DISCHARGE MEDICATIONS> 1. BuPROPion XL (Once Daily) 450 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Labetalol 400 mg PO Q8H RX *labetalol 200 mg 2 tablet(s) by mouth q8 hr Disp #*60 Tablet Refills: *0 4. NIFEdipine (Extended Release) 30 mg PO BID RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 5. OxyCODONE (Immediate Release) 5 mg PO Q8H: PRN Pain - Moderate Duration: 10 Doses Do not operate heavy machinary while taking this medication. RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cesarean delivery <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see OB discharge summary
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Ms. ___ presented to the Labor and Delivery floor with prodromal labor, with elevated blood pressures for the first time in pregnancy. She was evaluated and deemed to be a good candidate for induction of labor given her prolonged prodromal course and new diagnosis for preeclampsia with severe features by blood pressure. During induction, she was treated with magnesium for neuroprotection. After several hours on pitocin, her cervix was examined and found to be making no change, so was counseled on primary cesarean section versus continued labor with IUPC and elected for a primary low transverse Caesarean section on ___. During the operation, she had one episode of hematemesis, for which she was given famotidine daily postpartum. Postpartum, Ms. ___ magnesium course continued for approximately 16 hours, but was discontinued early due to oliguria and evidence ___ by rising creatinine to maximum of 1.3, resovled to 0.7 on ___. Her preeclampsia labs were trended throughout this time, demonstrating a resolution in ALT/AST from 41/33 to ___ on ___. In addition, her blood pressure regimen required titration over several days, finally demonstrating good control on a regimen of nifedipine 30mg BID after several days on labetalol and one dose of furosemide on ___. Throughout this time, she was also continued on her home dose of buproprion. Her postpartum course was otherwise uncomplicated. Her pain was treated with oral pain medications. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced without incident. By postpartum day 5, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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10892801-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> HA, ___ swelling, wound infection <MAJOR SURGICAL OR INVASIVE PROCEDURE> IV magnesium IV antibiotics <HISTORY OF PRESENT ILLNESS> ___ s/p LTCS/PPTL ___ p/w HA and worsening wound infection. Pt reports that she was seen at ___ last ___ and was noted to have ___ erythema concerning for cellulitis. She was started on cephalexin, which she took once daily (instead of QID as prescribed), until yesterday when she took it four times. She has noted spreading erythema since starting antibiotics, and this morning noted 'pus-like drainage' from her incision. Denies fevers and chills. Denies h/o skin infections or h/o MRSA. Received 2g cephazolin at time of LTCS. Also reports ___ headache since this AM. She took APAP and ibuprofen earlier without relief. She has a h/o migraines, but this is unlike her prior migraines. Was on medication prior to pregnancy but unsure of the name of the medication. While in the ED, she received 5mg oxycodone which reduced her headache to ___. Denies visual changes, though her vision is blurry when her headache is really severe. No floaters. Denies epigastric pain and SOB. Denies h/o hypertension. Pt also reports bilateral and symmetric lower extremity swelling x 1 week, which has been resolving over the course of the week. Has pain in her feet bilaterally due to the swelling. Denies fevers, chills, N/V/D. Breastfeeding. Denies vaginal bleeding. <PAST MEDICAL HISTORY> OBHx: G2P2 -G1 prior primary C/S due to severe HSV outbreak -G2 rLTCS with PPTL GynHx: HSV PMH: migraines PSH: LTCS, LTCS with PPTL <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Admission PE BPs 154/94, 171/92, 145/81, 148/92 General: NAD, alert Lungs: No respiratory distress. CTAB. Abdomen: ~8x3cm area of erythema and induration with some pockets of underlying fluctuance in areas extending from right of incision toward pt's right side. incision well closed. palpation of indurated areas produces foul smell but not able to produce drainage from mostly closed incision. pt with significant TTP on palpation of areas of erythema. GU: No pad Neuro: DTRs 2+ Extr: 1+ edema B/L Discharge PE VSS General: NAD, alert Lungs: No respiratory distress. CTAB. Abdomen: Erythema and induration resolved, incision well closed. GU: No pad Neuro: DTRs 2+ Extr: no ___ edema or tenderness <MEDICATIONS ON ADMISSION> acyclovir, ibupfrofen, acetaminophen, cephalexin <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain do not exceed 4000 mg in 24 hours RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *2 3. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *3 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain do not drive or drink while taking RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 5. Clindamycin 450 mg PO Q8H Duration: 10 Days Be sure to complete full course of antibiotics even if symptoms improve. RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every eight (8) hours Disp #*93 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Postpartum severe preeclampsia Pfannensteil wound infection Lower extremity swelling <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were readmitted to the hospital for elevated blood pressures with headache and wound infection. For your elevated blood pressures you were started on labetalol 200 mg twice a day, which you should continue upon going home. You were also treated for a wound infection with IV antibiotics and should continue oral antibiotics on discharge. Complete entire course of antibiotics even if symptoms improve. Please follow the directions below as well: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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Patient is a ___ s/p rLTCS/PPTL on ___ re-admitted with wound infection and postpartum preeclampsia, severe by HA and BPs. She was normotensive in pregnancy, but developed severe pressures ___. She was continued on labetalol 200mg PO BID. Labs were normal except for P/C 0.3 (trace blood in UA). She received Mag x24 hours. She also received a head CT for persistent headache that showed a non-specific 6mm lesion. Headache resolved with medication and rest. For her pfannensteil cellulitis, which was an 8x3cm area at right aspect of incision on presentation, she received Unasyn 3mg Q6H hours + Vanco 1g q12h (added ___, which was eventually transitioned to PO clinda as patient improved. Her blood cultures showed no growth, and she had no other signs or symptoms of systemic infection. She received an ultrasound that showed a 1.1x0.7x4.2cm fluid collection, superior/lat of right side of incision. She underwent an ___ drainage of fluid pocket ___ AM, and was then discharged on ___ in good condition with plan for outpatient follow-up.
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10892855-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> "My bladder is coming down" <MAJOR SURGICAL OR INVASIVE PROCEDURE> robot-assisted supracervical hysterectomy, bilateral salpingo-oopherectomy, sacrocolpopexy, cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 2 Para 2 who presents today in the office for a consultation requested by Dr. ___ vaginal prolapse. She is complaining of vaginal pressure that is worse at the end of the day or after long periods of standing. Her symptoms have been present for approximately 2 month after a camping trip. She reports ___ stress incontinence events. She voids 5 times per day and ___ times per night. She uses no pads per day. She admits to urgency, she denies any dysuria and reports bladder emptying with normal flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis]. Mrs. ___ admits to vaginal pressure and palpable prolapse. She also admits to constipation and denies admits to "splinting" with BM's. She is 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. HTN PAST SURGICAL HISTORY 1. BTL 2. Laminectomy & Fusion PAST OB HISTORY G2P___ Vaginal: 2 PAST GYN HISTORY She is Postmenopausal and denies post-menopausal bleeding. Her last pap smear was normal in ___ <FAMILY HISTORY> FAMILYHx: Her family history is unremarkable for Breast, Ovarian or Colon cancer. <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 Uterus: non-tender Adnexa: no masses non tender. POP-Q Exam: Aa: +2 Ba: +2 TVL: 8 D: -3 C: +1.5 ___: 4 PB: 2.5 Ap: -1.5 Bp: -1.5 ___ Exam: Cystocele: 3 Uterus/Cervix: 3 Vault: 3 Ant enterocele: Post enterocele: Rectocele: 1 VAGINAL EXAM - There was mild vaginal atrophy: Empty Supine Stress Test was: negative Her (PVR) post void residual was 190 ml assessed by straight catheterization UROFLOW: Maximum flow: 5 ml/s Average flow: 3 ml/s Voiding time: 9 sec Flow time : 9 sec Voided vol : 31 ml Comments: Point of Care Urine Dipstick sheet entries: ___: Color: Yellow. ___: Glucose (mg/dL): Negative. ___: Bilirubin: Negative. ___: Ketone (mg/dL): Negative. ___: Specific Gravity: 1.020. ___: Blood: Trace-lysed. ___: pH: 7.0. ___: Protein (mg/dL): Negative. ___: Urobilinogen (mg/dL): 1.0. ___: Nitrite: Negative. ___: Leukocytes: Trace. Exam at Discharge: Vital signs stable General: well appearing, no acute distress Abdominal: soft, nondistended, appropriately tender to palpation, incisons dry, clean, and intact <PERTINENT RESULTS> ___ 11: 26AM freeCa-1.25 ___ 11: 26AM HGB-13.0 calcHCT-39 O2 SAT-98 ___ 11: 26AM GLUCOSE-112* LACTATE-0.9 NA+-137 K+-4.3 CL--101 ___ 11: 26AM TYPE-ART RATES-/___ TIDAL VOL-500 O2-30 PO2-182* PCO2-67* PH-7.18* TOTAL CO2-26 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED ___ 01: 28PM freeCa-1.15 ___ 01: 28PM HGB-11.8* calcHCT-35 O2 SAT-98 ___ 01: 28PM GLUCOSE-97 LACTATE-0.8 NA+-136 K+-4.3 CL--105 ___ 01: 28PM TYPE-ART RATES-/___ TIDAL VOL-500 PO2-192* PCO2-47* PH-7.30* TOTAL CO2-24 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED ___ 10: 00PM HCV Ab-NEGATIVE ___ 10: 00PM HIV Ab-NEGATIVE ___ 10: 00PM HBsAg-NEGATIVE EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ year old woman on POD#1 found with RLQ trocar site bulge // Hematoma? possible hernia? TECHNIQUE: Helical acquisition of the abdomen pelvis was performed without administration of IV or oral contrast. DOSE: 230 mGy*cm COMPARISON: None FINDINGS: Trace bibasilar atelectasis. Subcutaneous gas extends from the visualized lower chest, through the anterior and right greater than left abdomen subcutaneous tissues and into the imaged upper thighs. Unremarkable nonenhanced liver. The layering cholelithiasis. Normal caliber CBD. Pancreatic parenchyma is grossly unremarkable. No main ductal dilatation. Normal spleen and adrenals. No hydronephrosis. No nephrolithiasis. 3.1 cm upper pole right renal cyst. Trace ingested material within stomach. Colonic diverticulosis. Stool within colon. A 2 cm anterior right abdominal wall defect containing loops of terminal ileum, without significant ascites, is noted. An additional 1.9 cm defect within the more superior abdominal wall containing loops of bowel beneath the external oblique, spiculated hernia, is noted. Mildly prominent loops of small bowel are noted upstream of the more inferior medial defect. Minimal calcification of normal caliber abdominal aorta. No obvious abdominal adenopathy. Nondependent gas within the bladder, likely secondary to recent catheterization. Small amount of pelvic fat stranding. Gas within vaginal fornix. Postoperative changes of the uterus. No pelvic adenopathy. Probable injection granuloma within the left gluteal subcutaneous fat. Degenerative changes of the spine are noted with grade 1 anterolisthesis of L4 oral on L5. Bilateral L4 and L5 transpedicular screws are noted with posterior longitudinal rods. IMPRESSION: -Right anteroinferior 2 cm defect with herniated small bowel into subcutaneous fat, without definite signs of ischemia. This is presumably at the trocar site. Minimal upstream dilatation of small bowel loops is noted. -More superior lateral right-sided Spigelian hernia containing decompressed small bowel loops with 1.9 cm defect. -Subcutaneous gas within the abdomen and visualized lower chest and upper thighs, likely postoperative. -Cholelithiasis. - Other findings as detailed above. The study and the report were reviewed by the staff radiologist. Intraoperative findings: Prolapse s/p suspension, calcifications in the bladder for post-discharge follow-up <MEDICATIONS ON ADMISSION> ___ (amlodipine-olmesartan ___ QD <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID Use while taking percocet to prevent constipation. RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 2. Ibuprofen 400 mg PO Q8H: PRN pain Take with food. 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 Maximum acetaminophen 4000 mg in 24 hours. Do not drive while taking. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine prolapse, bowel hernia, ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after undergoing a hysterectomy, removal of fallopian tubes and ovaries, and sacrocolpopexy for uterine prolapse. 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. On cystoscopy, there were calcifications noted in your bladder. You will need to have follow-up for these calcifications as an outpatient. Urology Appointment Line ___. 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. 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 her procedure. Please see the operative report for full details. Post-operatively, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 400 mL with 50 mL residual. 2. Instilled 300 mL, voided 350 mL with 70 mL residual. Her post-operative course was complicated by trocar site hernias requiring take back to the operating room for hernia reduction and fascial closure. She passed a second informal voiding trial. Initial pathology report from the tubes and ovaries revealed malignant tissue concerning for metastatic disease. The patient was made aware of this finding, which was pending final read at the time of the patient's discharge from the hospital. She briefly met with an attending from the GYN Oncology team to discuss these findings. By ___, 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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10892947-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right lower quadrant pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curettage <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> ___ 01: 20PM BLOOD Glucose-121* UreaN-6 Creat-0.6 Na-135 K-4.2 Cl-104 HCO3-16* AnGap-19 ___ 01: 20PM BLOOD Calcium-7.4* Phos-2.6* Mg-1.7 GC/CT: negative <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild Do not exceed 4g in 24 hours RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *2 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Take medication with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> miscarriage at 9 weeks <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. 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) until your postoperative appointment * 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. ___ is a ___ G4P0 with a history of an ectopic pregnancy s/p a laparoscopic right salpingectomy and endometriosis who was admitted to the gynecology service after undergoing a dilation and curettage for a 9-week missed abortion for monitoring for ovarian torsion in the setting of a known large right ovarian cyst. She was transferred from ___ with concern for ovarian torsion. Patient reported acute onset severe sharp right lower quadrant abdominal pain that awoke her from sleep the day of admission. She described the pain as constant and associated with nausea. She reported two episodes of emesis at the outside hospital. The pain was unrelieved after 3 mg of the Dilaudid. She reported a similar pain approximately 2 to 3 weeks prior to presentation that lasted 1.5 hours and resolved with Tylenol. In the ___ emergency room she received an additional 1 mg of Dilaudid and 2 mg IV morphine without improvement of the pain. She reported ___ pain and continued to have nausea despite an additional 4 mg of Zofran. Labs in ___ were significant for a normal white count of 8.5 and a beta-hCG of 13,238. An ultrasound was done on ___ which showed an intrauterine gestational sac with yolk sac and embryonic pole of 28 mm without cardiac activity. There was also a large right ovarian cyst that measured approximately 8 x 8 x 5.7 cm. On exam at ___ her vital signs were normal. She was described as appearing uncomfortable and resting in the fetal position. Her abdomen was soft and mildly distended with right lower quadrant and lower mid-abdominal tenderness to palpation, no rebound, and voluntary guarding. Pelvic exam was significant for no CMT and moderate tenderness to palpation of the right adnexa. A repeat pelvic ultrasound was performed at ___ which showed normal arterial and venous waveforms to the right ovarian parenchyma and again demonstrated the large right ovarian cysts measuring approximately 6.7 cm. While in the emergency room the patient's clinical exam improved. The decision was made to proceed with the D&C given the missed abortion and defer a diagnostic laparoscopy. Given the improvement in her exam the presentation was thought to be most consistent with a corpus luteum cyst that was resolving and had decreased in size over the last 48 hours. She was admitted to the gynecology service for continued observation. Please see the operative report for full details of the dilation and curettage procedure. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with Toradol and Tylenol. She was monitored overnight and her vital signs remained stable and her abdominal pain was improved. Her diet was advanced without incident and she was transitioned to PO pain medications of ibuprofen and acetaminophen. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10894128-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ___ <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Exam under anesthesia. 2. Abdominal myomectomy. 3. Total abdominal hysterectomy. <HISTORY OF PRESENT ILLNESS> ___ G0 with known fibroid uterus who due to worsening symptoms prefered definitive therapy in the form of an open supracervical hysterectomy. Her last Pap on ___ was negative and she has never had an abnormal Pap. She is a virginal woman. Last ultrasound was done on ___, which showed uterus anteverted and enlarged measuring 11.1 x 9.8 x 9.8 cm. There were multiple masses consistent with fibroids. The largest fibroid was intramural located in the body of the uterus that measured 6.9 x 6.9 x 7.0 cm. The second largest fibroid was subserosal in the fundus measuring 5.3 x 4.5 x 4.9 cm. When compared to prior ultrasound, there was no significant change in the size of the dominant fibroid. The endometrium was obscured by fibroids and could not be adequately assessed. The right ovary was not visualized. The left ovary was normal. There was no free pelvic fluid. Endometrial biopsy was done on ___, which showed proliferative endometrium. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 11. She cycles every ___ days, typically bleeds for one day, passed finger sized clots. During her heaviest bleeding period, she changes the pad every three to five hours. She does endorse dysmenorrhea. Denies any menopausal symptoms. PAST MEDICAL HISTORY: Traumatic brain injury with concussion and loss of consciousness in ___ with posttraumatic stress disorder, sleep apnea, depression, migraine headache. OPERATIVE HISTORY: Noncontributory. She has never had a bad reaction to anesthesia. The patient is very fearful of an anesthetic in terms of future cognitive functioning. ALLERGIES: Phenergan resulting in rash. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother died at ___, history of cervical cancer. Maternal grandmother died at ___ diabetic. Maternal grandmother died at ___, stroke. Father is alive, has hypertension. Paternal grandmother died at ___. ___ grandfather died at ___, dementia. <PHYSICAL EXAM> PREOPERATIVE PHYSICAL EXAMINATION: GENERAL: This is a well-developed, well-nourished woman in no apparent distress. VITAL SIGNS: Blood pressure 94/60, weight 138. LMP ___. ABDOMEN: Soft, nondistended, nontender. There was a palpable mass one fingerbreadth below her umbilicus consistent with a known irregularly contoured fibroid uterus. There was no tenderness. PELVIC: Normal female external genitalia with normal Bartholin, urethral, and Skene's glands. Vaginal vault had a normal-appearing discharge and there were no lesions. The cervix was without cervical motion tenderness and there were no lesions. Uterus consistent with a known fibroid uterus approximately 16-18 cm in maximal vertical dimension, mobile, firm, and nontender. Adnexa impossible to evaluate secondary to large pelvic abdominal mass. PHYSICAL EXAMINATION PRIOR TO DISCHARGE VSS Gen: flat affect, comfortable, no acute distress. walking comfortably in hallways Resp: CTAB CV: RRR Abd: soft, non-tender to palpation, no rebound or guarding GU: no spotting on pad Ext: thin, no edema, WWP <MEDICATIONS ON ADMISSION> - BUTALBITAL-ASPIRIN-CAFFEINE [FIORINAL] - Fiorinal 50 mg-325 mg-40mg capsule. 1 capsule(s) by mouth as needed for headache - (Prescribed by Other Provider) - DEXTROAMPHETAMINE-AMPHETAMINE [ADDERALL] - Adderall 5 mg tablet. 1 tablet(s) by mouth once a day - PROPRANOLOL - propranolol 10 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) - SUMATRIPTAN SUCCINATE [IMITREX] - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) <DISCHARGE MEDICATIONS> 1. Adderall (dextroamphetamine-amphetamine) 5 mg oral daily 2. Aspirin-Caffeine-Butalbital ___ CAP PO Q6H: PRN headache 3. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours Disp #*30 Tablet Refills: *0 RX *ibuprofen 600 mg 1 tablet(s) by mouth Q6 hours Disp #*60 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID Take while taking narcotics. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *2 5. Propranolol 10 mg PO DAILY 6. Acetaminophen ___ mg PO Q8H pain Do not take more than 3g/day. RX *acetaminophen 500 mg ___ tablet(s) by mouth Every 8 hours Disp #*30 Tablet Refills: *0 RX *acetaminophen 500 mg ___ tablet(s) by mouth Q8h hours Disp #*30 Tablet Refills: *0 7. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 8. Senna 8.6 mg PO BID: PRN constipation Use if constipation not relieved with colace. RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Uterine fibroids *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 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. 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. Bowel Regimen: * After surgery and while taking narcotics you may feel constipated, and this is normal. * You should take colace while taking narcotic pain medications such as oxycodone. * You may take Senna in addition to colace if you continue to feel constipated. * You should continue to drink fluids and to eat foods high in fiber to help with your feelings of constipation. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing an abdominal myomectomy and total abdominal hysterectomy. 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 IV dilaudid. She was placed on nightly CPAP for her OSA. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced to clears and some solids, and she was transitioned to PO oxycodone and acetaminophen, with IV dilaudid for breakthrough pain. She reported inadequate pain control and her pain regimen was transitioned to PO acetaminophen ATC, PO ibuprofen PRN, and PO oxycodone PRN with good relief. She continued to eat minimal amounts of solids but her diet had fully advanced. Once tolerating PO's, she was continued on her oral home medications. She reported positive flatus but feelings of constipation, and required an extensive bowel regimen including colace, milk of magnesia, and suppositories to achieve her desired bowel activity. 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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10894872-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> severe pre-eclampsia <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary c-section <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm, incision c/d/i Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <DISCHARGE INSTRUCTIONS> PP discharge instructions
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On ___ Ms. ___ was admitted for induction of labor for severe pre-eclampsia. She presented with persistent headache, was found to have elevated protein:creatinine of 954. On ___ she underwent a primary cesarean section for arrest of descent. Post-partum she was given magnesium for 24 hours. Blood pressures were normal range, and she was asymptomatic. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled. Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation take 1 po bid prn constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 2. Ibuprofen 600 mg PO Q6H:PRN Pain Take 1 po q6hrs prn pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 RX *ibuprofen 600 mg 1 tablet(s) by mouth q6 Disp #*30 Tablet Refills:*0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain Duration: 5 Doses Take 1 po q 4 hrs prn pain RX *oxycodone 5 mg 1 capsule(s) by mouth every ___ hours Disp #*20 Capsule Refills:*0 RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth q4 Disp #*5 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary C-section for Arrest of descent and severe preeclampsia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10897365-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> short cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> cervical cerclage <PHYSICAL EXAM> Physical exam at discharge -========= Fluid Balance (last updated ___ @ 002) Last 8 hours Total cumulative 600ml IN: Total 900ml, PO Amt 300ml, IV Amt Infused 600ml OUT: Total 300ml, Urine Amt 300ml Last 24 hours Total cumulative 875ml IN: Total 2175ml, PO Amt 700ml, IV Amt Infused 1475ml OUT: Total 1300ml, Urine Amt 1300ml 24 HR Data (last updated ___ @ ___) Temp: 97.8 (Tm 98), BP: 107/65 (95-111/57-70), HR: 72 (72-90), RR: 20, O2 sat: 100% (97-100), O2 delivery: ra, FHR: 140s (130s-140) GENR: Awake and alert, NAD RESP: normal work of breathing, no respiratory distress ___: gravid, fundus non-tender, no rebound/guarding EXTR: wwp, calves non-tender, neg ___ sign bilat FH: 140s <PERTINENT RESULTS> ___ 02: 51PM WBC-5.7 RBC-3.88* HGB-11.9 HCT-36.1 MCV-93 MCH-30.7 MCHC-33.0 RDW-14.1 RDWSD-47.7* ___ 02: 51PM PLT COUNT-206 <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with a short cervix and had a cervical cerclage. You were observed in the antepartum service, and received antibiotics for 24 hours after your procedure. We also gave you a medicine to prevent preterm contractions (indomethacin). You had no evidence of infection or preterm labor, it is now safe for you to be discharged home. ***Please continue pelvic rest for the remainder of your pregnancy*** -other than your vaginal progesterone, avoid placing anything in the vagina -avoid douching, avoid tampons -avoid vaginal sex -avoid anal sex Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Other concerns
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Ms. ___ is an ___ gravida 1 who was admitted at 21 weeks 0 days gestation for short cervix diagnosed by ultrasound. She was recommended to undergo a cervical cerclage. On ___ she underwent an uncomplicated palcment of ___ cerclage with Mersilene tape. See OMR for complete operative report. Intraoperatively her cervix was found to be 1 cm dilated and she was recommended to complete 24 hours of IV cefazolin as well as tocolysis with indomethacin. She completed this without complication. She also continued on metronidazole for bacterial vaginosis. She was observed overnight and there was no evidence of preterm contractions, preterm labor, PPROM or chorioamnionitis. On ___ she was discharged to resume antenatal care. Discharge Medications: 1. proGESTerone micronized 200 mg vaginal DAILY 2. Acetaminophen 650 mg PO Q6H:PRN Pain 3. MetroNIDAZOLE 500 mg PO/NG BID You should finish your 7-day course of this medication (through ___. 4. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Short cervix Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10898038-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> glucosamine / levofloxacin <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Patient states she had dinner as usual. She then woke up with nausea and dry heaving. She subsequently had multiple episodes of emesis. She developed severe sharp pain in the RLQ. She called urgent care who advised her to present to the ED. Here, she received 4mg IV morphine. She had CT abdomen/pelvis which showed no acute process. The right ovary was noted to be enlarged. She then had a PUS which showed a paraovarian cyst and unable to rule out ovarian torsion. OB/GYN was consulted for rule out torsion. Pt states her pain is now ___. She is starting to feel hungry again but is nervous to eat. She initially had pain with movement and that has resolved. She has not ambulated yet. <PAST MEDICAL HISTORY> HCM - colonoscopy in last ___ years POB/GYN Hx: - h/o fibroids s/p open mmy and then total hysterectomy - denies h/o STIs - denies h/o abnormal paps PMH: denies PSH: open myomectomy, TLH/BS Meds: none All: glucosamine, levofloxacin <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Vitals: stable and within normal limits General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, nontender to palpation, +BS Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 06: 52AM BLOOD WBC-7.3 RBC-4.31 Hgb-13.7 Hct-41.3 MCV-96 MCH-31.8 MCHC-33.2 RDW-11.9 RDWSD-42.2 Plt ___ ___ 06: 52AM BLOOD Neuts-69.7 ___ Monos-6.0 Eos-0.5* Baso-0.8 Im ___ AbsNeut-5.10 AbsLymp-1.66 AbsMono-0.44 AbsEos-0.04 AbsBaso-0.06 ___ 06: 52AM BLOOD Glucose-123* UreaN-14 Creat-0.8 Na-143 K-4.5 Cl-103 HCO3-23 AnGap-17 ___ 06: 52AM BLOOD ALT-15 AST-24 AlkPhos-67 TotBili-0.5 ___ 06: 52AM BLOOD Lipase-37 ___ 06: 52AM BLOOD Albumin-4.7 ___ 07: 53AM BLOOD Lactate-1.5 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Intermittent ovarian torsion <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 for pain control and observation for suspected ovarian torsion, based on imaging and your symptom profile. Your pain improved and you remained stable, with improved pain and resolution of your nausea and vomiting. The team feels you are stable and ready to be discharged home. Your imaging just indicate an enlarged right ovary with an ovarian cyst measuring approximately 3-4 cm in diameter. You should follow up with your primary OBGYN provider in the next ___ weeks to discuss management and surveillance for this. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the GYN service from the ED with right lower quadrant pain concerning for intermittent ovarian torsion. She was observed overnight and kept NPO in the event that surgery was indicated. She remained hemodynamically stable with minimal ongoing pain throughout the night and into the morning of hospital day 2. On Hospital day 2, her diet was advanced and she tolerated a regular diet without issue. She continued to ambulate independently and void, and had minimal residual pain and pain medication requirements. She was then discharged home in stable condition with outpatient follow-up scheduled, including recommendations for evaluation of incidental findings on imaging.
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10903221-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> atorvastatin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / ciprofloxacin / diuretics <ATTENDING> ___ <CHIEF COMPLAINT> ENDOMETRIAL CANCER <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, lysis of adhesions, cystoscopy <HISTORY OF PRESENT ILLNESS> Patient is a ___ gravida 2 para 0 woman who developed postmenopausal bleeding. A hysteroscopy D&C revealed a grade 1 endometrial cancer. She was noted to have a relatively normal sized uterus on ultrasound imaging. The uterus is anteverted and measures 7.5 cm x 4.0 cm x 4.1 cm. Evaluation of multiple the endometrium is limited due to nonvisualization. There is a large calcified fibroid with posterior shadowing measuring 2.8 x 2.2 x 3.3 cm. The ovaries are normal. There is no free fluid. She has no symptoms of advanced disease at this time. She had methylation of MLH-1 and she was noted to have MSH-2. <PAST MEDICAL HISTORY> CORONARY ARTERY DISEASE ATRIAL FIBRILLATION LOW BACK PAIN CERVICAL RADICULITIS CROHN'S DISEASE OBSTRUCTIVE SLEEP APNEA NSTEMI NECK PAIN HYPERTENSION <SOCIAL HISTORY> Marital status: Married Name ___ ___ ___: Work: ___ Multiple partners: ___ ___ activity: Past and Present Sexual orientation: Male Sexual Abuse: Past Domestic violence: Denies Contraception: OCPs Tobacco use: Former smoker Alcohol use: Denies Recreational drugs Denies (marijuana, heroin, crack pills or other): Seat belt/vehicle Always restraint use: <FAMILY HISTORY> No breast/ovarian/uterine/colon cancer. No clotting or bleeding disorders. Mother died at ___ of MI, had TIA 8 mos before death, at that age still menstruating (late menopause) 1 sister healthy Physical ___: On day of discharge: Afebrile, vitals stable Gen: No acute distress CV: RRR Pulm: CTAB Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: non-tender, non-edematous <PERTINENT RESULTS> --======== LABS ON ADMISSION --======== ___ 06: 11PM HBs Ab-NEG ___ 06: 11PM HIV Ab-NEG ___ 06: 11PM HIV Ab-NEG ___ 06: 11PM HCV Ab-NEG ___ 10: 30AM WBC-9.1 RBC-4.63 HGB-11.7 HCT-38.5 MCV-83 MCH-25.3* MCHC-30.4* RDW-16.0* RDWSD-47.8* --======== LABS ON DISCHARGE --======== ___ 06: 45AM BLOOD WBC-11.8* RBC-4.26 Hgb-10.7* Hct-36.0 MCV-85 MCH-25.1* MCHC-29.7* RDW-15.5 RDWSD-46.9* Plt ___ ___ 06: 45AM BLOOD Neuts-72.3* ___ Monos-6.0 Eos-1.5 Baso-0.3 Im ___ AbsNeut-8.54* AbsLymp-2.30 AbsMono-0.71 AbsEos-0.18 AbsBaso-0.03 ___ 06: 45AM BLOOD Plt ___ ___ 06: 45AM BLOOD Glucose-155* UreaN-10 Creat-0.7 Na-142 K-5.1 Cl-101 HCO3-29 AnGap-12 ___ 06: 45AM BLOOD estGFR-Using this ___ 06: 45AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.8 <MEDICATIONS ON ADMISSION> 1. Xarelto 20 mg Daily 2. Losartan 50 mg Daily 3. Metoprolol succinate ER 12.5 mg Daily 4. Enteric Coated Aspirin 81mg Daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever 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. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 4. Aspirin 81 mg PO DAILY 5. Losartan Potassium 50 mg PO DAILY 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Rivaroxaban 20 mg PO/NG DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Laparoscopic instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 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. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service after undergoing Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, lysis of adhesions, cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with V Dilaudid. Her diet was advanced without difficulty and she was transitioned to PO oxycodone/acetaminophen(pain meds). On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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| 173
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10903410-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Right IJ clot <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 8w2d with IVF/ICSI pregnancy and mod OHSS treated as an outpatient in ___ presents to the ED with neck swelling x5 days. Initially started ___ while on a business trip to ___ with pain and increasing swelling since then. She then had a massage at the airport without relief. Also took tylenol. She reports an episode of left calf pain x3 days last week which resolved. She also endorses difficutly swallowing, pain in her neck with deep inspiration. She denies any chest pain, shortness of breath, n/v, abd pain, vaginal bleeding, cramping, leg pain, leg swelling. Patient underwent single egg transfer with HCG trigger (___) for this last cycle of IVF/ICSI. Embryo transfer on ___. She then was diagnosed with moderate OHSS on ___. Patient had declined lovenox in ___ when diagnosed with OHSS. She underwent culdocentesis and received albumin on ___ as an outpatient. PNC: - ___ ___ by IVF dating c/w 6 wk u/s - Labs ___ - Issues: IVF/ICSI for male factor <PAST MEDICAL HISTORY> OBHx: - G1: current GynHx: - Hx LEEP - Denies fibroids, Gyn surgery, STIs PMH: - Hx of scarlet fever as child - Hypothyroidism PSH: - LEEP - Wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On admission: T-97.5 HR-90 BP-120/73 RR-18 O2-100% Gen: A&O, comfortable sitting up HEENT: right sided neck swelling extending into her shoulder, tender to palpation CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness, neg ___ b/l, trace b/l lower ext edema. No edema of her upper extremity. Normal capillary refill of her hands but right hand cooler to touch then left hand. 3+ radial pulses b/l. <PERTINENT RESULTS> ___ 08: 22AM WBC-11.7* RBC-3.50* HGB-11.0* HCT-32.0* MCV-91 MCH-31.5 MCHC-34.5 RDW-11.3 ___ 08: 22AM NEUTS-82.0* LYMPHS-13.2* MONOS-3.9 EOS-0.5 BASOS-0.4 ___ 08: 22AM PLT COUNT-252 ___ 08: 22AM ___ PTT-31.9 ___ <MEDICATIONS ON ADMISSION> PNV, Crinone, levothyroxine 112 mcg daily <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right IJ clot <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 antepartum service due to a right upper extremity clot. You were started on Lovenox and admitted for observation. Your pain, swelling, and shortness of breath improved while you were here. You will continue taking the Lovenox at home (twice daily) and you will need repeat bloodwork on ___ to check your level. Continue taking tylenol or Roxicet as needed for pain.
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Ms. ___ was admitted to the antepartum service. She was seen by ___ and vascular surgery in consultation. Plan was made to anti-coagulate with Lovenox for 6 months and re-evaluate clot at that time. She will have thrombophilia work-up as out-patient. Prior to discharge Lovenox was titrated with the assistance of hematology. Although a Factor Xa level was not therapeutic, hematology recommended continuing at this weight-based dose and follow-up with hematology as an out-patient.
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10903410-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Induction of labor for intolerance to heparin shots <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vaginal birth <PAST MEDICAL HISTORY> OBHx: - G1: current GynHx: - Hx LEEP - Denies fibroids, Gyn surgery, STIs PMH: - Hx of scarlet fever as child - Hypothyroidism PSH: - LEEP - Wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> VSS, afebrile Fundus appropriately tender, firm No edema of UEs or ___ ___ Results: ___ 06: 56PM BLOOD WBC-22.2*# RBC-3.30* Hgb-11.0* Hct-31.9* MCV-97 MCH-33.2* MCHC-34.4 RDW-13.7 Plt ___ ___ 12: 55AM BLOOD WBC-11.1* RBC-3.61* Hgb-12.1 Hct-33.6* MCV-93 MCH-33.4* MCHC-35.8* RDW-13.9 Plt ___ ___ 06: 56PM BLOOD Plt ___ ___ 06: 56PM BLOOD ___ PTT-29.6 ___ ___ 12: 55AM BLOOD Plt ___ ___ 06: 56PM BLOOD ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Prenatal Vitamins 1 TAB PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Heparin 24,000 UNIT SC BID <DISCHARGE MEDICATIONS> 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Prenatal Vitamins 1 TAB PO DAILY 3. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth BID pn Disp #*30 Capsule Refills: *1 4. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth Q 6 hours prn Disp #*45 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Term pregnancy, delivered Spontaneous vaginal delivey, liveborn male <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___ RN discharge packet Refer to "Warning signs" below Pelvic rest
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Ms. ___ intrapartum course was complicated by failure to delivery the placenta, with required dilation and curettage in the operating room. Please ___ the operative report for full details. Total estimated blood loss was 1000ml. She received pitocin and cytotec intraoperatively. She also received Kefzol for 24hours after the procedure as endometritis prophylaxis. Her postoperative course was uncomplicated and her hematocrit and coagulation profile remained stable. She also has a history of an upper extremity DVT, for which she was started on therapeutic lovenox 70mg SC BID 24 hours following delivery. Her postpartum course was otherwise uncomplicated.
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10904775-DS-23
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Symptomatic uterine fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> Abdominal myomectomy <HISTORY OF PRESENT ILLNESS> ___ yo G10P0 F with a history recurrent pregnancy loss and uterine fibroids (s/p MMY) and primary biliary cirrhosis who has RLQ pain (6+ months) and dysmenorrhea. She was recently evaluated in ___ at ___ for intermittent RLQ pain x ___ months. Evaluation consisted of negative cervical/vaginal cultures and pelvic u/s with enlarged fibroid uterus measuring 13.2 cm with a 9.7 x 9.0 cm posterior fibroid. R ovary normal. L ovary not seen. No free fluid. Denies fevers/chills/n/v. She underwent an open multiple myomectomy in ___ with Dr. ___ ___. A total of five fibroids were removed. She continues to have intermittent RLQ pain, which is located over the fibroid. She also reports worsening dysmenorreha over the past few months. She takes NSAIDs prn. She has not observed a change in her menstrual flow. She continues to have regular menses that last 7 days with the heaviest days on days 2 and 3. Denies dyspareunia. Has pain with bladder fullness. Also complaints of mild pelvic pressure. Pelvic u/s performed on ___: multifibroid uterus 15.3 x 10.8 x 15.5 cm w/ largest fibroid measuring 9.6 cm and exophytic R sided fibroid mesauring 4 cm <PAST MEDICAL HISTORY> POB/GYNH: Menarche age ___ LMP: ___, No h/o abnormal Pap tests, Last Pap: ___ - negative, No h/o STIs, Sexually active: Yes, Sexual preference: opposite, Current contraception: condoms, H/o uterine fibroids s/p MMY, SAB x 10 (all ___ TM; s/p consultation with BIVF/MF; neg work-up) PMH: 1) Type I diabetes 2) recurrent SAB 3) multinodular goiter 4) primary biliary cirrhosis PSH: 1) foot surgery 2) open abdominal multiple myomectom <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal aunt - breast cancer, Great aunt - ovarian cancer, Mother - DM, HTN, hyperlipidemia <PHYSICAL EXAM> ___ by Dr. ___ 132 lbs Height 5'4" BP 127/82 HR 95 General appearance: in NAD Psych: alert and oriented x 3, mood and affect appropriate Neck: No masses; no thyromegaly or nodules Lymphatic: no palpable neck or groin lymphadenopathy Lungs: clear to auscultation bilaterally, good inspiratory effort bilaterally, no wheezing CV: RRR, no murmurs/rubs/gallops Abd: soft, non-distended, no hepatosplenomegaly appreciated, no hernias; well-healed ___ incision; palpable fibroid in RLQ which is tender and reproduces her symptoms Extremities: no venous disease, no lesions, good perfusion, no edema Skin: intact, no skin changes or lesions detected Pelvic: Normal external female genitalia Urethral meatus normal in appearance Bladder and urethra normal in appearance Normal vaginal mucosa, no vaginal lesions Cervix without abnormal discharge or lesions, midline Bimanual: uterus multilobulated, 14 cm w/ prominent R-sided fibroid, tender to palpation over this fibroid; no adnexal masses or tenderness appreciated; uterosacral ligaments without nodularity or tenderness; no levator or obturator muscle tenderness Rectovaginal: deferred <PERTINENT RESULTS> ___ WBC-19.1*# RBC-3.89* Hgb-11.0* Hct-36.7 MCV-94# MCH-28.4# MCHC-30.1* RDW-20.6* Plt ___ ___ Neuts-88.9* Lymphs-8.7* Monos-2.1 Eos-0.1 Baso-0.1 ___ Glucose-174* UreaN-3* Creat-0.4 Na-136 K-4.3 Cl-107 HCO3-17* AnGap-16 ___ ALT-13 AST-24 AlkPhos-100 Amylase-36 TotBili-0.5 ___ Lipase-24 ___ TSH-1.3 ___ EKG: Sinus tachycardia. Non-diagnostic inferior and lateral Q waves. T wave abnormalities. Since the previous tracing of ___ the rate is faster <MEDICATIONS ON ADMISSION> 1. INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - Dosage uncertain 2. URSODIOL - 300 mg Capsule - two Capsule(s) by mouth twice daily two month supply 3. NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other Provider) - 100 unit/mL Suspension - 12 U q am and 15 U q pm <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *1* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 3. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 4. Humalog Subcutaneous 5. NPH insulin human recomb Subcutaneous 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 weeks. Disp: *60 Capsule(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> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * For the 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 to the GYN service post-operatively. Her post-operative course was complicated by fever to 100.7 degrees celsius and tachycardia (to 110's) most likely secondary to the myomectomy versus atelectasis. She had a normal EKG and her oxygen saturation remained normal on room air during her admission and her TSH and chem7 were normal as well. Of note, her pre-operative heart rate was in the high 90's. Post-op Hct was stable. She also had some epigastric pain that was relieved with antacids and simethicone. Otherwise, her post-operative course was uncomplicated and she was discharged on post-operative day 2 with follow-up with Dr. ___.
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10905663-DS-24
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right adnexal mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic -> laparotomy salpingo-oophorectomy, small bowel resection and reanastomosis, appendectomy for right adnexal mass with significant small bowel adhesions <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___ with history of Stage III colon cancer s/p L hemicolectomy 3 months ago, found to have R adnexal mass now s/p laparatomy b/l salpingo-oophorectomy and small bowel resection. It was initially planned to have laparascopic b/l salpingo-oophorectomy, however, because of small bowel adhesions, the case was converted to open laparatomy. Colorectal surgery was also consulted, and assisted with small bowel resection. Frozen path from the OR showed evidence of metastatic colon cancer. The patient had a JP drain left in place. During the procedure, the patient dropped her pressures to the ___ systolic. She was started on phenylephrine and ultimately required 0.6 before it was weaned down; systolic pressures were as high as 150s. The patient had an intraoperative EBL of 1L, and was given 900cc LR. It was thought that her hypotension was due to not enough fluid resucitation. She also received 1U PRBC prior to arrival to the FICU. The patient had a Foley placed and made about 15cc urine during the procedure (she still makes some urine at her baseline). On arrival to the ___, the patient reports feeling tired. Denied having any chest pain or shortness of breath. Denied any abdominal pain. No pain with urination. Denied any dizziness or light-headedness. Reports having some nausea. <PAST MEDICAL HISTORY> HTN, HLD, DM, HPTH, ESRD (HD x ___ yrs, MWF schedule, on transplant list), anemia, depression . Past Surgical History: LUE AVF, C-section ___, LSC L Hemicolectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her mother has a history of diabetes and CAD. Father died of lung cancer (was a smoker). She denies any other family history of cancers, specifically no history of uterine, breast, ovarian cancer, or colon cancer. <PHYSICAL EXAM> ICU ADMISSION EXAM: VS: 97.7 125/73 76 19 96 on 2L General: lethargic, but arousable woman, NAD, laying comfortably in bed, alert and appropriate HEENT: Sclera anicteric, MMM, oropharynx clear CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, slightly decreased inspiratory effort secondary to pain Abdomen: lower abdominal dressing, with areas of bright red blood seeping through gauze, abdomen softly distended, no tenderness to soft palpation, no bowel sounds appreciated, JP full of bright red blood Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. LUE fistula <PERTINENT RESULTS> Admission: ___ 09: 13PM ___ PTT-31.0 ___ ___ 09: 13PM PLT COUNT-225 ___ 09: 13PM WBC-12.1*# RBC-3.13* HGB-9.2* HCT-28.7*# MCV-92 MCH-29.3 MCHC-32.0 RDW-17.0* ___ 09: 13PM CALCIUM-8.5 PHOSPHATE-4.4 MAGNESIUM-1.9 ___ 09: 13PM CK-MB-3 cTropnT-0.06* ___ 09: 13PM CK(CPK)-142 ___ 09: 13PM GLUCOSE-226* UREA N-24* CREAT-6.4* SODIUM-138 POTASSIUM-5.8* CHLORIDE-103 TOTAL CO2-29 ANION GAP-12 ___ 10: 47PM ___ 10: 47PM ___ 10: 47PM ___ PTT-28.1 ___ ___ 10: 47PM PLT COUNT-245 ___ 10: 47PM WBC-12.1* RBC-3.02* HGB-8.8* HCT-27.8* MCV-92 MCH-29.3 MCHC-31.8 RDW-16.4* ___ 11: 10PM LACTATE-1.7 UNILAT UP EXT VEINS US LEFT Study Date of ___ IMPRESSION: 1. No evidence of deep venous thrombosis. 2. Patent left arteriovenous dialysis fistula. If there is concern for fistula malfunction, consider fistulogram. ___ Neurophysiology EEG IMPRESSION: This is an abnormal waking EEG because of generalized slowing and infrequent generalized slow sharp waves. These findings are indicative of moderate encephalopathy which is etiologically non-specific. There are no seizures or epileptiform discharges recorded. <MEDICATIONS ON ADMISSION> Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Amlodipine 10 mg PO DAILY 2. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous 6 units at bedtime 3. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous ___ units per sliding scale 4 times a day 4. Labetalol 300 mg PO BID 5. Lisinopril 20 mg PO DAILY 6. sevelamer CARBONATE 800 mg PO TID W/MEALS 7. Simvastatin 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Renal Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral Daily <DISCHARGE MEDICATIONS> 1. Amlodipine 10 mg PO DAILY 2. Labetalol 300 mg PO BID 3. Lisinopril 20 mg PO DAILY 4. sevelamer CARBONATE 800 mg PO TID W/MEALS 5. Lantus *NF* (insulin glargine) 100 unit/mL SUBCUTANEOUS 4 UNITS AT BEDTIME 6. Renal Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral Daily 7. Simvastatin 10 mg PO DAILY 8. HumaLOG *NF* (insulin lispro) 100 unit/mL SUBCUTANEOUS ___ UNITS PER SLIDING SCALE 4 TIMES A DAY 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily Disp #*60 Capsule Refills: *0 11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Every 4 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Metastatic colon 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: 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 * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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___ is ___ with history of colon cancer, and likely new metastatic disease, ESRD on HD, HTN, DM who is s/p bilateral salpingo-oophorectomy and small bowel resection. *) Hypotension: The patient developed acute hypotension during her procedure, likely in the setting of acute blood loss. She was admitted to the ICU for close monitoring. She continued to have significant blood drainage from JP over first ___ hours, which subsequently decreased. Hematocrit was checked every 6 hours initially until blood volume stabilized. Patient was transfused as needed to keep HCT >10. She was given fluid boluses to maintain a MAP over 65 and blood pressures improved. *) Metastatic colon cancer s/p exlap: The patient had b/l salpingo-oophorectomy and small bowel resection. Patient followed by Dr ___ oncology and will follow up as outpatient. *) ESRD on HD: The patient has ESRD on HD. She was seen by renal and dialyzed as recommended. She tolerated this well. Volume status and electrolytes were monitored. Sevelemer and nephrocaps were cotinued. *) HTN: Patient has chronic hypertension. Anti-hypertensives were initially held in the setting of acute hypotension. These medications were restarted after volume resuscitation as systolic blood pressures increased to a max of 200. Hypertension likely secondary to volume resuscitation and holding anti-hypertensives. The patient remained asymptomatic without any neurological deficits. Hydralazine was administered in settting of severe hypertension. Hemodyalysis was performed the following day and systolic blood pressures improved. Patient then restarted on home dose of labetalol. *) DM: The patient is on humalog ISS and Lantus at home. Lantus was held in setting of being NPO and restarted as diet advanced. Lantus dose was decreased to 4units QHS as patient had episode of blood glucose to 40's on HD6 likely secondary to decreased PO intake following surgery. Patient was discharged on POD 6 in stable condition with follow up scheduled with Dr ___, Dr ___, and with her PCP.
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10906869-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Endometrial polyp <MAJOR SURGICAL OR INVASIVE PROCEDURE> hysteroscopy, polypectomy, D&C <PHYSICAL EXAM> Gen: Awake, alert, comfortable lying in bed. No acute distress. HEENT: MMM, no conjunctival pallor. CV: RRR, no MRG. Radial, DP, ___ pulses 2+ bilaterally. Pulm: No increased WOB, CTAB. Abd: Non-distended. Soft, nontender with no masses or organomegaly. Pelvic: Some brown spotting on pad, foley and intrauterine balloon catheter both in place. Extr: No extremity edema, no cyanosis. <PERTINENT RESULTS> ___ 06: 10AM BLOOD WBC-12.6* RBC-3.98 Hgb-11.7 Hct-35.6 MCV-89 MCH-29.4 MCHC-32.9 RDW-11.9 RDWSD-39.1 Plt ___ <MEDICATIONS ON ADMISSION> 1. Calcium citrate: 1200 mg once a day (Prescribed by Other Provider) ___ 2. Cyanocobalamin (vitamin B-12)500 mcg tablet 1 tablet(s) by mouth once a day (Prescribed by Other Provider) ___ 3. PNV cmb#95-ferrous fumarate-FA [Prenatal]: Prenatal 28 mg iron-800 mcg tablet 1 tablet(s) by mouth once a day (Prescribed by Other Provider) ___ <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Do not exceed 4000 mg in a day. RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6hr 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 #*50 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Take with food. Do not exceed 2400 mg in a day RX *ibuprofen 600 mg 1 tablet(s) by mouth Q6hr Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine polyps <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. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ yo P1 who was admitted on ___ to the gynecology service after undergoing a hysteroscopy, polypectomy, D&C for endometrial polyp. Procedure complicated by uterine bleeding likely due to atony. Patient received methergine and intrauterine foley balloon was placed. Please see web OMR for full operative report. Overnight, patient required pads to be changed twice with light spotting noted on both, but otherwise no acute events. 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 acetaminophen and ibuprofen for pain meds. Her intrauterine foley was removed and patient noted minimal spotting on her pad afterwards. Hct was reassuring 35.6 ___ AM) from 38.5 in the PACU the day prior. By the end of the morning, 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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10908257-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> postmenopausal bleeding, uterine sarcoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy with debulking of omental and pelvic tumor, cystoscopy. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old G1P1 woman who presented with postmenopausal bleeding since ___. She reports that her bleeding has been much heavier than a period with occasional blood clots. During the first week, she used ___ pads per day. Now she is having to use two pads at a time, although she reports that the bleeding is less than it used to be. She denies any abdominal or pelvic pain, bloating, or pressure. She has not had any difficulty voiding or increase in urinary frequency, and she denies any diarrhea or constipation. She continues to have a lingering cough since she was diagnosed with pneumonia in ___. She generally feels "woozy" and fatigued, but she denies any dizziness, SOB/CP, or palpitations. Per her husband's report, she is not very active at home, largely due to fatigue. Review of her records suggests that she was evaluated by urology in ___ for bleeding. Hematuria work-up including CT and cystoscopy were negative. CT did note a lobulated uterus with likely calcified fibroids, and no evidence of adenopathy. She denies any abdominal or pelvic pain, bloating, unintentional weight changes, abnormal vaginal discharge, or change in her bowel or bladder habits. <PAST MEDICAL HISTORY> Obstetrical History: G1P1 - SVD x 1, uncomplicated pregnancy and delivery Gynecologic History: - Menarche: ___ - LMP: approximately age ___ - Menses previously regular every month. Denies history of menorrhagia or dysmenorrhea - Denies history of abnormal Pap tests. Last was in ___ and was negative - Denies history of pelvic infections of sexually transmitted infections - Never used any hormonal contraception or replacement. <PAST MEDICAL HISTORY> - HTN - Atrial fibrillation (reports being on coumadin for ___ years) - Hypercholesterolemia - impaired glucose tolerance - obesity - sleep apnea - denies h/o heart attack or stroke (although Atrius record reports CAD) Past Surgical History: - breast and arm lipoma removal - cataract surgery - oral surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> -Sister had breast cancer in her ___ -Denies a known family history of ovarian, uterine, cervical, vaginal, or colon cancer -Several family members with history of heart attack and stroke <PHYSICAL EXAM> On the day of discharge: Afebrile, vital signs stable Gen: well-appearing, no acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender to palpation, non-distended, no rebound or guarding, vertical midline incision with staples appears clean/dry/intact GU: pad with no spotting Ext: trace edema bilaterally, no calf tenderness <PERTINENT RESULTS> ___ 08: 32PM BLOOD WBC-7.5 RBC-3.54* Hgb-9.8* Hct-31.4* MCV-89 MCH-27.7 MCHC-31.2 RDW-13.4 Plt ___ ___ 07: 15AM BLOOD WBC-7.6 RBC-3.17* Hgb-8.8* Hct-28.2* MCV-89 MCH-27.7 MCHC-31.2 RDW-13.4 Plt ___ ___ 03: 20PM BLOOD WBC-8.8 RBC-3.07* Hgb-8.7* Hct-27.5* MCV-90 MCH-28.4 MCHC-31.7 RDW-13.4 Plt ___ ___ 07: 00AM BLOOD WBC-7.8 RBC-3.02* Hgb-8.6* Hct-26.9* MCV-89 MCH-28.5 MCHC-32.0 RDW-13.4 Plt ___ ___ 05: 10PM BLOOD WBC-9.7 RBC-3.87*# Hgb-10.7* Hct-33.6* MCV-87 MCH-27.7 MCHC-31.9 RDW-14.0 Plt ___ ___ 06: 46AM BLOOD WBC-9.9 RBC-3.38* Hgb-9.5* Hct-29.8* MCV-88 MCH-28.2 MCHC-32.0 RDW-13.9 Plt ___ ___ 07: 30AM BLOOD WBC-7.2 RBC-3.51* Hgb-9.7* Hct-30.6* MCV-87 MCH-27.6 MCHC-31.7 RDW-13.8 Plt ___ ___ 07: 40AM BLOOD WBC-8.7 RBC-3.33* Hgb-9.4* Hct-29.6* MCV-89 MCH-28.1 MCHC-31.7 RDW-13.7 Plt ___ ___ 07: 20AM BLOOD WBC-8.2 RBC-3.20* Hgb-8.9* Hct-28.5* MCV-89 MCH-27.9 MCHC-31.4 RDW-13.8 Plt ___ ___ 07: 25PM BLOOD WBC-19.6*# RBC-3.77* Hgb-10.7* Hct-33.1* MCV-88 MCH-28.4 MCHC-32.4 RDW-14.0 Plt ___ ___ 01: 00AM BLOOD WBC-19.3* RBC-3.39* Hgb-9.8* Hct-30.6* MCV-90 MCH-28.8 MCHC-32.0 RDW-14.2 Plt ___ ___ 07: 30AM BLOOD WBC-17.2* RBC-3.03* Hgb-8.9* Hct-27.6* MCV-91 MCH-29.4 MCHC-32.2 RDW-14.3 Plt ___ ___ 09: 30AM BLOOD WBC-12.0* RBC-3.15* Hgb-9.2* Hct-28.6* MCV-91 MCH-29.0 MCHC-32.0 RDW-14.7 Plt ___ ___ 07: 00AM BLOOD WBC-11.3* RBC-3.63* Hgb-10.3* Hct-32.8* MCV-90 MCH-28.4 MCHC-31.4 RDW-14.6 Plt ___ ___ 06: 35AM BLOOD WBC-8.4 RBC-3.45* Hgb-9.8* Hct-31.1* MCV-90 MCH-28.3 MCHC-31.4 RDW-14.5 Plt ___ ___ 07: 00AM BLOOD WBC-8.4 RBC-3.51* Hgb-10.1* Hct-32.1* MCV-91 MCH-28.9 MCHC-31.6 RDW-14.4 Plt ___ ___ 06: 40AM BLOOD WBC-8.7 RBC-3.64* Hgb-10.3* Hct-33.6* MCV-92 MCH-28.3 MCHC-30.7* RDW-14.5 Plt ___ ___ 08: 32PM BLOOD ___ PTT-56.5* ___ ___ 07: 15AM BLOOD ___ PTT-56.7* ___ ___ 03: 20PM BLOOD ___ ___ 07: 00AM BLOOD ___ PTT-49.5* ___ ___ 05: 10PM BLOOD ___ PTT-49.5* ___ ___ 06: 46AM BLOOD ___ PTT-41.4* ___ ___ 07: 30AM BLOOD ___ PTT-32.8 ___ ___ 07: 40AM BLOOD ___ PTT-32.1 ___ ___ 07: 20AM BLOOD ___ PTT-29.5 ___ ___ 07: 25PM BLOOD ___ PTT-28.6 ___ ___ 01: 00AM BLOOD ___ PTT-29.0 ___ ___ 07: 30AM BLOOD ___ PTT-31.1 ___ ___ 09: 30AM BLOOD ___ PTT-35.7 ___ ___ 07: 00AM BLOOD ___ PTT-36.3 ___ ___ 09: 00AM BLOOD ___ PTT-28.2 ___ ___ 07: 00AM BLOOD ___ PTT-32.6 ___ ___ 06: 40AM BLOOD ___ PTT-27.5 ___ ___ 08: 32PM BLOOD ___ ___ 05: 10PM BLOOD ___ ___ 08: 32PM BLOOD Glucose-133* UreaN-22* Creat-1.3* Na-129* K-4.8 Cl-94* HCO3-25 AnGap-15 ___ 07: 15AM BLOOD Glucose-114* UreaN-21* Creat-1.3* Na-127* K-4.7 Cl-92* HCO3-27 AnGap-13 ___ 07: 00AM BLOOD Glucose-109* UreaN-19 Creat-1.2* Na-126* K-4.4 Cl-92* HCO3-25 AnGap-13 ___ 05: 10PM BLOOD Glucose-123* UreaN-21* Creat-1.3* Na-128* K-4.6 Cl-90* HCO3-27 AnGap-16 ___ 06: 46AM BLOOD Glucose-126* UreaN-18 Creat-1.2* Na-128* K-4.4 Cl-93* HCO3-27 AnGap-12 ___ 07: 30AM BLOOD Glucose-111* UreaN-18 Creat-1.3* Na-127* K-4.0 Cl-92* HCO3-28 AnGap-11 ___ 07: 40AM BLOOD Glucose-122* UreaN-16 Creat-1.2* Na-130* K-4.1 Cl-95* HCO3-25 AnGap-14 ___ 07: 20AM BLOOD Glucose-114* UreaN-13 Creat-1.1 Na-130* K-3.8 Cl-94* HCO3-28 AnGap-12 ___ 07: 25PM BLOOD Glucose-181* UreaN-14 Creat-1.1 Na-130* K-4.3 Cl-98 HCO3-23 AnGap-13 ___ 01: 00AM BLOOD Glucose-147* UreaN-15 Creat-1.2* Na-129* K-4.5 Cl-97 HCO3-24 AnGap-13 ___ 07: 30AM BLOOD Glucose-137* UreaN-16 Creat-1.3* Na-131* K-4.6 Cl-96 HCO3-26 AnGap-14 ___ 09: 30AM BLOOD Glucose-108* UreaN-15 Creat-1.1 Na-130* K-4.2 Cl-96 HCO3-27 AnGap-11 ___ 07: 00AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-129* K-4.2 Cl-96 HCO3-27 AnGap-10 ___ 06: 35AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-132* K-3.6 Cl-98 HCO3-25 AnGap-13 ___ 07: 00AM BLOOD Glucose-110* UreaN-9 Creat-0.9 Na-133 K-3.9 Cl-98 HCO3-30 AnGap-9 ___ 06: 40AM BLOOD Glucose-117* UreaN-9 Creat-1.0 Na-131* K-4.0 Cl-97 HCO3-27 AnGap-11 ___ 07: 15AM BLOOD ALT-10 AST-18 ___ 08: 32PM BLOOD Calcium-9.7 Phos-2.3* Mg-1.5* ___ 07: 15AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.5* ___ 07: 00AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9 ___ 05: 10PM BLOOD Calcium-9.6 Phos-2.7 Mg-1.9 ___ 06: 46AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.7 ___ 07: 30AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.6 ___ 07: 40AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.6 ___ 07: 20AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.5* ___ 07: 25PM BLOOD Calcium-8.5 Phos-4.1 Mg-1.4* ___ 01: 00AM BLOOD Calcium-8.4 Phos-4.5 Mg-2.5 ___ 07: 30AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.5 ___ 09: 30AM BLOOD Calcium-8.7 Phos-2.6*# Mg-2.0 ___ 07: 00AM BLOOD Calcium-8.9 Phos-2.0* Mg-1.8 ___ 06: 35AM BLOOD Calcium-8.1* Phos-1.7* Mg-1.8 ___ 07: 00AM BLOOD Albumin-3.0* Calcium-8.9 Phos-1.9* Mg-1.8 ___ 06: 40AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.7 ___ 07: 00AM BLOOD Osmolal-262* ___ 05: 10PM BLOOD Osmolal-270* ___ 07: 00AM BLOOD TSH-0.66 ___ 04: 51PM BLOOD Rates-/9 Tidal V-520 PEEP-5 FiO2-96 pH-7.41 AADO2-684 REQ O2-100 Intubat-INTUBATED Vent-CONTROLLED ___ 07: 01PM BLOOD Type-ART pO2-247* pCO2-45 pH-7.36 calTCO2-26 Base XS-0 Intubat-NOT INTUBA ___ 04: 51PM BLOOD Lactate-1.1 Na-129* K-4.0 calHCO3-24 ___ 07: 01PM BLOOD Lactate-0.9 ___ 04: 51PM BLOOD Hgb-9.9* calcHCT-30 O2 Sat-99 ---- ENDOMETRIAL CURRETTE ___ SURGICAL PATHOLOGY REPORT - Final PATHOLOGIC DIAGNOSIS: 1. Uterine tumor biopsy: Atypical spindle and epithelioid neoplasm with extensive necrosis, see note. Note: This lesion is difficult to classify. The morphology is similar to a prior endometrial biopsy ___ #: ___-___, outside hospital #: ___-___), which is characterized by an atypical and mitotically active spindle and epithelioid proliferation with pleomorphism, high nuclear to cytoplasmic ratio and extensive necrosis. Immunohistochemistry reveals that neoplastic cells are positive for CD10 and negative for cytokeratin AE1/3 & Cam5.2, Pax8, CD68, desmin and caldesmon. The immunoprofile is suggestive of an endometrial stromal sarcoma however, the differential diagnosis also includes undifferentiated sarcoma, leiomyosarcoma, adenosarcoma or carcinosarcoma with sarcomatous overgrowth. No epithelial component is seen in this sample. Complete excision is recommended for precise characterization. Clinical History: ___ year old with uterine sarcoma. Gross Description: The specimen is received in a formalin-filled container labeled with the patient's name, ___ and the medical record number. It consists of multiple fragments of tan-brown soft tissue that measure 5.6 x 4.0 x 1.5 cm. The fragments of tissue are extremely friable. The specimen is entirely submitted in cassettes 1A-1G. ----- ECG ___: Cardiovascular Report ECG Study Date of ___ 4: 53: 08 ___ Atrial fibrillation with moderate ventricular response and ventricular ectopy. Generalized low QRS voltage. No previous tracing available for comparison. Read by: ___. Intervals Axes Rate PR QRS QT/QTc P QRS T 93 0 88 372/429 0 ___ ----- CXR Final Report PA AND LATERAL CHEST ___ COMPARISON: Radiographs of ___: FINDINGS: Stable marked enlargement of cardiac silhouette. Pulmonary vascularity is within normal limits, and lungs are clear except for a linear area of scar or atelectasis in the mid lung region which appears unchanged. There are no pleural effusions. Degenerative changes are present within the spine. IMPRESSION: Stable marked enlargement of the cardiac silhouette, which may reflect cardiomegaly and/or pericardial effusion. No evidence of pulmonary edema. ___. ___ ___: SAT ___ 1: 56 ___ ---- ECHO ___ ECHOCARDIOGRAPHY REPORT ___ ___ MRN: ___ TTE (Complete) Done ___ at 10: 44: 40 AM FINAL Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.1 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.9 cm <= 5.2 cm Right Atrium - Four Chamber Length: *8.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.9 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Left Ventricle - Stroke Volume: 57 ml/beat Left Ventricle - Cardiac Output: 4.59 L/min Left Ventricle - Cardiac Index: 2.21 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.13 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.14 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 7 < 13 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: *3.6 cm <= 3.4 cm Aorta - Arch: *3.2 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 20 Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - E Wave deceleration time: 192 ms 140-250 ms TR Gradient (+ RA = PASP): *26 to 33 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Moderate ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Normal LV wall thickness and cavity size. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR. ___ VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. Mild PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is moderately dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses and cavity size are normal. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal regional and global left ventricular systolic function. Mildly dilated and borderline hypokinetic right ventricle with moderate to severe tricuspid regurgitation and mild to moderate pulmonary hypertension. Mild mitral regurgitation. Electronically signed by ___, MD, Interpreting physician ___ ___ 12: 41 ---- CARDIAC PERFUSION STUDY ___: Final Report RADIOPHARMACEUTICAL DATA: 32.2 mCi Tc-99m Sestamibi Rest ___ 32.4 mCi Tc-99m Sestamibi Stress ___ HISTORY: Atrial fibrillation, hypertension. Pre-operative evaluation. SUMMARY FROM THE EXERCISE LAB: For pharmacologic coronary vasodilatation dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 milligram/kilogram/min. IMAGING METHOD: Following intravenous infusion of the pharmacologic agent, Tc-99m sestamibi was administered intravenously. Stress images were obtained approximately 30 minutes following tracer injection. Resting perfusion images were obtained on a subsequent day with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: The image quality is adequate. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. The calculated left ventricular ejection fraction, the left ventricular size and wall motion were not assessed on this non-gated study. IMPRESSION: No myocardial perfusion defect. The left ventricular size, ejection fraction and wall motion were not assessed on this non-gated study. ---- CT ABD & PELVIS w IV CONTRAST ___: Final Report HISTORY: Uterine sarcoma. Evaluate for extent of disease. TECHNIQUE: Helical axial MDCT images were obtained from the bases of the lungs to the pubic symphysis after the administration of IV and oral contrast. Reformatted images in coronal and sagittal axes were generated. DLP: ___.90 mGy-cm. COMPARISON: None available. FINDINGS: Please see the CT chest report from the same day for detailed evaluation of the thorax. CT abdomen: The liver enhances homogeneously without focal lesion or intrahepatic biliary duct dilatation. The portal vein is patent. The nondistended gallbladder is without stone or wall thickening. The spleen is homogeneous and normal in size. A tiny 3 mm hypodensity in the body of the pancreas is likely focal fat. No other focal lesion is seen. There is no peripancreatic stranding or fluid collection. An 8 mm nodule in the left adrenal gland statistically likely represents an adenoma. The right adrenal gland is unremarkable. The kidneys demonstrate symmetric nephrograms. Subcentimeter hypodensities, measuring up to 7 mm, are too small to characterize but likely represent renal cysts. There is no evidence of hydronephrosis. The stomach is somewhat decompressed, but there is no gross wall abnormality. The small and large bowel are within normal limits, without wall thickening or evidence of obstruction. There is no retroperitoneal lymph node enlargement by CT size criteria. Stranding and nodularity within the mesentery (4: 65) is of uncertain significance. The right gonadal vein appears large, likely engorgement secondary to blood flow related to the pelvic mass, but the possibility of early metastatic disease cannot be excluded. An anterior abdominal wall hernia is noted. There is no ascites or free air. CT pelvis: A large heterogeneously enhancing endometrial mass measuring 6.1 x 12.6 cm is compatible with the known neoplasm and exerts mass effect on the rectosigmoid colon without clear invasion. While in large part this appears likely confined to the canal, towards the left lower uterus, it appears to involve > 50% of the endometrium, and may also be reaching the serosa and slightly distorting the outer contour of the uterus (series 9, image 31). No clear extension of tumor beyond the confines of the uterus. A small focus of air within the mass/uterus may be secondary to recent instrumentation. Calcifications within the uterine wall are likely calcified fibroids. Pelvic wall and inguinal lymph nodes are prominent but not enlarged by CT size criteria. There is no pelvic free fluid. Focal dilation of the left greater saphenous vein just before the confluence with the superficial femoral vein is not well assessed on this exam. Osseous structures: No blastic or lytic lesions suspicious for malignancy present. A sclerotic lesion in the sacrum likely represents a bone island. Mild multilevel degenerative changes of the lumbar spine are noted. IMPRESSION: 1. Large heterogeneously enhancing endometrial mass compatible with the known neoplasm. At the lower left, the mass extends to the serosa, but does not clearly extend beyond the uterus. A small focus of air is likely related to recent instrumentation; correlate with clinical history. 2. Stranding and nodularity within the mesentery and prominence of pelvic wall and inguinal lymph nodes without pathologic enlargement by CT size criteria are of indeterminate significance. An enlarged right gonadal vein is likely due to engorgement from increased uterine blood flow, but the possibility of early metastatic disease cannot be excluded. Recommend attention on followup. 3. Focal dilation of the left greater saphenous vein just before the confluence with a superficial femoral vein is not well assessed on this exam. Consider lower extremity ultrasound if clinically indicated. The study and the report were reviewed by the staff radiologist. ---- CT CHEST w CONTRAST Final Report REASON FOR EXAMINATION: Assessment of the patient with uterine sarcoma. COMPARISON: Chest radiograph from ___ and ___. TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper abdomen after administration of IV contrast. Axial images were reviewed in conjunction with coronal and sagittal reformats. FINDINGS: There is enlargement of the right thyroid gland with what appears to be approximately 15 mm thyroid nodule is seen. Aorta and pulmonary arteries are overall unremarkable. There is minimal amount of pericardial effusion, still within physiological limits. No mediastinal, hilar, or axillary lymphadenopathy is seen. Cardiomegaly is substantial predominantly involving the right heart, in particular right atrium and might be consistent with tricuspid insufficiency. The imaged portion of the upper abdomen will be reviewed separately as part of the CT abdomen in the corresponding report obtained the same day. This study was obtained with a suboptimal inspiratory effort. Within those limitations, airways are patent with no evidence of endobronchial lesions and lungs are clear with no evidence of pulmonary nodules. IMPRESSION: 1. Substantial cardiomegaly. 2. No evidence of intrathoracic metastatic disease. 3. Suboptimal inspiratory effort. Within those limitations, no evidence of pulmonary nodules. 4. Right thyroid nodule, further assessment with thyroid ultrasound is recommended. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___ 5: 16 ___ ---- Cardiovascular Report Stress Study Date of ___ EXERCISE RESULTS RESTING DATA EKG: A FIB, LOW VOLT QRS, INVERTED T'S III,AVF,V3 HEART RATE: 84 BLOOD PRESSURE: 122/64 PROTOCOL / STAGE TIME SPEED ELEVATION WATTS HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE I ___ 0.142MG/ KG/MIN 82 108/P ___ TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 59 SYMPTOMS: NONE ST DEPRESSION: NONE INTERPRETATION: This was an inactive ___ year old IDDM woman with HTN, HLD, CAD (+Pmibi ___, A fib and +Fam Hx of CAD, who was referred to the lab from the inpatient floor for an evaluation of exertional shortness of breath, fatigue and chest discomforts. She received 0.142mg/kg/min of IV Persantine infused over 4 minutes. SHe denied any chest, arm, neck or back discomforts, shortness of breath or palpitations throughout the study. There were no changes in ST segments or T waves noted during the infusion or in recovery. The rhythm was atrial fibrillation with rare PVC's seen during the infusion. The heart rate and blood pressure respnded appropriately to the Persantine infusion. At 2 minutes post infusion, 125mg IV AMinophylline was given to prevent any potential Persantine side effects. IMPRESSION: No ischemic ECG changes. No anginal type symptoms. Appropriate hemodynamic response to Persantine. Nuclear report sent separately. SIGNED: ___ ---- ___ SURGICAL PATHOLOGY REPORT - Final PATHOLOGIC DIAGNOSIS: 1. Uterus, cervix, bilateral tubes and ovaries, total abdominal hysterectomy: Uterine carcinosarcoma, see synoptic report. Leiomyomata. 2. Omentum: Metastatic carcinosarcoma (epithelial component) in two of four (___) lymph nodes. Unremarkable fibroadipose tissue. Endometrium: Hysterectomy, with or without Other Organs or Tissues Synopsis Staging according to ___ Joint Committee on Cancer Staging Manual -- ___ Edition, ___ Macroscopic Specimen Type: Hysterectomy Right salpingo-oophorectomy Left salpingo-oophorectomy Omentectomy Tumor Size: Greatest dimension: 19.5 cm. Microscopic Histologic Type: Carcinosarcoma [Predominant high-grade sarcoma and a minor component of high-grade serous carcinoma (slide 1-K-1L)] Histologic Grade: Histologic grade. Washings/Cytology: Not applicable Extent of Invasion Primary Tumor (pT): pT3b(IIIB): Parametrial involvement (via lympho-vascular invasion) Myometrial Invasion: Invasion present: 60% (slide 1-B-1); with extensive vascular invasion in the outer ___ of the myometrium Cervix: negative Ovaries: Right: metastasis (slide 1P-1), lymphovascular and serosal involvement Left: negative Fallopian Tubes: Right: implant Left: negative Serosa: negative (only fibrous adhesion to the ovary) Omentum: negative (However, 2 of 4 associated lymph nodes are positive for carcinoma, M1 disease). Regional Lymph Nodes (pN): pNX: Cannot be assessed Pelvic Lymph Nodes: None submitted Para-aortic lymph nodes: None submitted Distant metastasis: PM1: Distant metastasis (omental lymph nodes Lymphovascular invasion: Present ---- <MEDICATIONS ON ADMISSION> -warfarin 7.5mg ___, 5mg ___ -atenolol 50mg daily -simvastatin 5mg -ativan 1mg qhs PRN insomnia -omeprazole 20mg daily -vitamin B12 -Ca <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID Do not take >4000mg acetaminophen in 24 hrs. RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth three times daily Disp #*60 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID Hold for loose stools. RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Capsule Refills: *1 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: First Routine Administration Time Continue medication until INR therapeutic on lovenox. RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*21 Syringe Refills: *1 4. Metoprolol Tartrate 50 mg PO Q6H 5. Omeprazole 20 mg PO DAILY 6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H: PRN pain Do not drive or combine with alcohol. RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 7. Simvastatin 5 mg PO DAILY 8. Warfarin 7.5 mg PO 4X/WEEK (___) Take on ___. 9. Warfarin 5 mg PO 3X/WEEK (___) Take ___. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> postmenopausal bleeding, uterine sarcoma (final pathology pending) <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, ___ were admitted to the gynecologic oncology service after undergoing the procedures listed below. ___ have recovered well after your operation, and the team feels that ___ are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet. * It is safe to walk up stairs. . Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will be removed at your follow-up visit on ___. . For your atrial fibrillation: * Continue your coumadin at the same dose ___ were prescribed previously: 5mg on ___, 7.5mg on ___. * A visiting nurse ___ come to your home to check your lab work while we are transitioning ___ back to coumadin. * Call ___ NP at ___ with any questions or concerns. ___ will coordinate follow-up with her via telephone as well. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was directly admitted to the gynecology oncology service from clinic on ___ for expedited work-up and treatment of uterine sarcoma that was causing persistent vaginal bleeding. Cardiology and medicine were consulted in order to obtain pre-operative clearance. Per cardiology recommendations pre-op, her atenolol was changed to metoprolol 37.5mg q6h and titrated up to metoprolol 50mg q6h with goal pulse 60. She received 2mg Vitamin K for her elevated INR pre-operatively, and her INR was monitored and trended downward to 1.7 pre-operatively. A CXR showed stable cardiomegaly. An echocardiogram on ___ demonstrated normal left ventricular systolic function, moderate to severe tricuspid regurgitation, mild to moderate pulmonary hypertension, and mild mitral regurgitation. An EKG on ___ showed atrial fibrillation. A cardiac perfusion study showed no myocardial defect and a stress test showed no ischemic changes or angina symptoms. Anticoagulation for her atrial fibrillation was held in the setting of a supratherapeutic INR of 7.3 at the time of admission, and per cardiology recommendations, when her INR was less than 2.0, she was started lovenox for DVT prophylaxis. She was noted to be hyponatremic to 129 on admission labs, and labs were consistent with SIADH. Medicine recommended fluid restriction to 1.2 L per day, and her sodium remained stable. She had a pre-operative CT chest/abdomen/pelvis that demonstrated a large endometrial mass extending to the serosa, stranding and nodularity in the mesentery, prominent pelvic and inguinal lymph nodes. On ___, she underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy with debulking of omental and pelvic tumor, and cystoscopy. Please see Dr. ___ report for full details of the operation. Intra-operatively, she was noted to have a tubular structure in her left adnexa with purulent material, concerning for a tubo-ovarian abscess. A JP drain was left in place post-operatively. A culture demonstrated sparse bacteroides. She was treated with a 5 day course of flagyl. Prior to removal of the drain, a repeat gram stain was checked and was negative. Her JP drain was removed on post-operative day #5. The culture preliminarily grew out staphylcoccus, however, she was clinically well, afebrile with normal vital signs, and no evidence of abdominal infectious etiology, so this was felt to reflect a contaminant of the specimen. The final culture was still pending at the time of this discharge summary. She also received 2 doses of kefzol and flagyl for prophylaxis post-operatively. Her post-operative course is detailed as follows. Postoperatively, her pain was controlled with epidural analgesia, IV morphine, IV acetaminophen and IV dilaudid. Her epidural was kept in place until post-operative day #4 because she continued to have an elevated INR prohibiting epidural removal. She was given Vitamin K on post-operative day ___ and her INR decreased enough to remove the epidural without complication. Her diet was advanced gradually and she was transitioned to oxycodone and acetaminophen. Once her epidural was removed, her urine output was adequate and she was ambulating so her Foley catheter was removed and she voided spontaneously. Her diet was slowly advanced post-operatively. Nutrition was consulted and provided recommendations throughout her hospitalization. Her diet was supplemented with Glucerna. By post-operative day #5, she was tolerating a regular diet. She began passing flatus and had a bowel movement on post-operative day #5. For her atrial fibrillation, once her INR was sub-therapeutic, she was started on prophylactic lovenox dosing, which she received ___ as mentioned above. On post-operative day #5, she was restarted on her home dose of coumadin, with the plan to resume home dosing and to allow her INR to drift up gradually. She was discharged home on coumadin, with no lovenox bridging therapy. ___ was set up to monitor her INR and her ___ clinic nurse was contacted to coordinate follow-up. Throughout her hospitalization, she was monitored on telemetry. For her hypertension, coronary artery disease and hyperlipidemia, she was continued on her home statin and was started on metoprolol instead of atenolol, as mentioned above. For her OSA, she underwent continuous O2 monitoring and Respiratory Therapy was consulted. For her impaired glucose tolerance, her finger sticks were monitored and she was treated with an insulin sliding scale as needed. For her GERD, she was continued on a PPI. She received Physical Therapy evaluation and treatment throughout her hospitalization. She was recommended for and started using a rolling walker with all ambulation. She was cleared for home with home ___ services before discharge. By post-operative day #6, she was tolerating a regular diet, voiding spontaneously, ambulating independently with a rolling walker, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10909435-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> headache, fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> Lumbar Puncture <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G5P2 @ ___ who presents as a transfer from OSH with headache, fevers, neck pain, and altered mental status. She went to bed with a mild headache and woke up with fevers, chills, neck pain, and confusion. She had a few episodes of nausea and vomiting, after which point she reportedly does not remember anything. Her boyfriend states she was making statements about snow outside and seeing her grandmother who has passed. She then presented to ___, where she had a fever to 100.5, normal head CT, WBC of 22.7, and an LP which was not consistent with infection. She received ceftriaxone and acyclovir empirically and was transferred to ___ for further evaluation and management. Upon arrival to the ___, her VS were T 100.9 HR 119 BP 119/63 RR 18 POx 100%RA. A neurology consultation was obtained urgently, with no focal deficits noted. Vancomycin and ampicillin were added to her antibiotic regimen and an MRI was ordered to rule out venous sinus thrombosis as a cause for her headache. Upon my evaluation, she states that her headache is still present with ___ pain, associated neck stiffness and double vision. Also c/o low back pain. Denies chills, congestion, cough, chest pain, shortness of breath, abdominal pain, leakage of fluid. +AFM. <PAST MEDICAL HISTORY> PNC: EDC ___ Benign PNC per pt, besides "small baby" on ultrasound ObHx: LTCS at 36wks for ___, repeat LTCS at 38wks (no ___, SAB x 2 GynHx: Denies abnormal Paps, STIs, fibroids. Of note, from ___ MD ___, pt and partner were recently treated for her "vaginal infection", but she denied HSV, chlamydia, gonorrhea, syphillis, and genital warts upon my questioning. MedHx: None SurgHx: LTCS x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VS 100.9 119 119/63 18 100%RA Slumped in stretcher, but appears overall comfortable. Although pt does not speak ___, she responds appropriately to questions and is actively involved in conversation. Tachycardic, RR, nl S1/S2 CTAB Abd soft, gravid, NT Back without CVA tenderness, mildly tender midline low back Ext no C/C/E FHT: 130-140/mod var/+accels/no decels AGA <PERTINENT RESULTS> ___ 04: 03AM BLOOD WBC-8.0 RBC-3.02* Hgb-8.4* Hct-24.8* MCV-82 MCH-27.9 MCHC-34.0 RDW-13.7 Plt ___ ___ 01: 50PM BLOOD WBC-8.5 RBC-3.24* Hgb-8.9* Hct-27.2* MCV-84 MCH-27.5 MCHC-32.8 RDW-13.6 Plt ___ ___ 01: 50PM BLOOD Neuts-61.6 ___ Monos-7.9 Eos-0.8 Baso-0.1 ___ 04: 03AM BLOOD ___ PTT-28.0 ___ ___ 07: 57AM BLOOD ___ ___ 01: 50PM BLOOD ESR-30* ___ 08: 25AM BLOOD Ret Aut-1.5 ___ 04: 03AM BLOOD Glucose-70 UreaN-4* Creat-0.4 Na-138 K-3.6 Cl-108 HCO3-23 AnGap-11 ___ 01: 50PM BLOOD Glucose-70 UreaN-4* Creat-0.4 Na-142 K-3.4 Cl-112* HCO3-24 AnGap-9 ___ 08: 25AM BLOOD LD(___)-123 TotBili-0.3 DirBili-0.1 IndBili-0.2 ___ 01: 50PM BLOOD ALT-6 AST-11 LD(___)-106 AlkPhos-64 TotBili-0.2 ___ 04: 03AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.5* ___ 01: 50PM BLOOD Calcium-8.0* Phos-2.8 Mg-1.6 ___ 01: 50PM BLOOD TSH-2.0 ___ 01: 50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03: 14PM BLOOD Lactate-0.9 ___ 1: 25 am Influenza A/B by ___ DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Negative for Influenza A viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. ___ 7: 57 am RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. ___ 7: 30 pm Blood Culture, Routine (Final ___: NO GROWTH. ___ 7: 40 pm Blood Culture, Routine (Final ___: NO GROWTH. ___ 8: 25 am ___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1: 10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. ___ 6: 55 pm SWAB YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. ___ 01: 50PM BLOOD ESR-30* ___ 10: 30AM BLOOD ESR-30* ___ 03: 08PM BLOOD ANCA-NEGATIVE B ___ 01: 50PM BLOOD TSH-2.0 ___ 08: 25AM BLOOD Hapto-76 ___ 03: 08PM BLOOD dsDNA-NEGATIVE ___ 07: 57AM BLOOD HIV Ab-NEGATIVE <MEDICATIONS ON ADMISSION> prenatal vitamin <DISCHARGE MEDICATIONS> 1. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp: *30 Capsule, Sustained Release(s)* Refills: *2* 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* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 32 weeks gestation headache possible conversion disorder <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Stay well hydrated. call your doctor with fever greater than 100.4, headache not relieved with tylenol, persistent nausea/vomiting, leaking of fluid, vaginal bleeding, regular or painful contractions, decreased fetal movement, or any other concerns.
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The patient was admitted to the antepartum service with neurology consulting. She was afebrile at the time of transfer and throughout the remainder of her hospital course. CXR and MRI of the head/neck done in the ___ were followed up for final reads and found to be unremarkable. Although meningitis was thought to be unlikely, she was maintained on vanc/ceftriaxone/ampicillin/acyclovir as empiric antibiotics until CSF and blood culture results returned. She continued to have pain with neck flexion. On HD#1, following ID consult, vancomycin and ceftriaxone were discontinued. The plan was made to continue ampicillin until blood cultures were negative for listeria, and acyclovir until CSF PCR negative for HSV. She went to the ATU where BPP was ___ with AFI of 10.5cm, and EFW 1604g (35%). Prenatal records were acquired from ___. That evening, the patient received dilaudid for a headache. She was evaluated by both the primary service and infectious disease on the morning of HD#2 and found to be sleepy but without any mental status changes. The afternoon of HD#2, she was found to have a syncopal episode. She safely returned to bed, IV fluids were increased, and a dose of dilaudid administered for complaint of headache. Vitals were within normal range at that time. Approximately one hour later, the patient manifested significant mental status changes. She became obtunded, eyes closed and head rocking in bed, muttering repeated phrases in ___. Phrases were translated as "my grandmother is cold" and ___. She did not respond to commands. Vital signs remained normal throughout. The patient was given oxygen by facemask. FICU consult was called, and she was transported to the FICU for further evaluation and management. FICU COURSE: On ___ Ms. ___ was transferred to the FICU in the setting of increasing lethargy and acute AMS as well as 1 episode of witnessed syncope. Vancomycin and ceftriaxone were restarted epirically. All vital signs remained stable in the FICU and she was afebrile. Head CT and MRI/MRV were normal. After about 30 minutes in the FICU, her mental status spontaneously began to resolve and she was oriented to person and place and answering questions appropriately. She complained of a severe headache, blurred vision, vertigo, and photophobia, which were resolving overnight in the FICU. Several attempts made to repeat the LP failed. When the patient was well oriented, she inquired of her providers whether emotional trauma surrounding her grandmother's recent death, finding her grandmother unresponsive, or other psychosocial factors might be contributing to her mental status changes. Psychiatry consult, which had previously been considered, was obtained now that the patient was better oriented. The diagnosis of conversion disorder was considered, although the workup for organic etiology was continued. An EEG was obtained. After 1 night in the FICU, she was deemed stable to return to the floor with no identified acute intracranial or infectious process identified. Vancomycin and ceftriaxone were discontinued. REMAINDER OF HOSPITAL COURSE ON FLOOR: HD#3, the patient was clinically stable. She continued to be followed by ID, psychiatry, and neurology. SW consult was obtained. She had no further mental status changes. The following labs returned negative: HSV, BCx, UCx (from ___. ___ and RPR, HIV (from ___. Acylovir was discontinued given negative HSV result. Given patient's report of weakness and neuro exam significant for mild weakness vs. poor effort, a ___ consult was requested to evaluate for safety at home. She was able to ambulate without difficulty. Headache was reported to be resolved by the patient. HD#4, the patient remained in good condition. Blood cultures were negative and acyclovir was discontinued. The patient was noted to have white vaginal discharge, which was evaluated with negative wet mount, negative whiff test. Culture was sent for yeast, which was pending at the time of hospital discharge but later found to be negative. HD#5, EEG was read as normal. She was able to increase her activity level significantly and was evaluated to be without need for restriction by ___. She was discharged home in good condition on HD#5.
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10912489-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> advanced maternal age <MAJOR SURGICAL OR INVASIVE PROCEDURE> Primary low-transverse cesarean section <HISTORY OF PRESENT ILLNESS> Doing well. no contractoins. Denies vaginal bleeding, leakage of fluid. Active fetal movement. Denies headache, visual change. Some upper abdominal pain when leaning over, baby kicking. This is an IVF pregnancy with donor egg. <PAST MEDICAL HISTORY> ObHx: G1 current GynHx: - h/o primary infertility s/p IVF w/ donor egg transfer ___ (failed) and ___ - Periods are irregular, likely perimenopausal, last period ___ - Endometriosis, hx painful and heavy menses - no hx ovarian cysts - small fibroids seen on US - Last mammogram ___, nl per pt - denies abnl Pap <PAST MEDICAL HISTORY> - oral HSV - h/o H. pylori ulcer on endoscopy, s/p antibiotics, treated in ___ - peritonsillar abscess x 2, GN ___, required hospitalization and IV antibiotics and drainage - sciatica Past Surgical History: laparoscopy in ___ for endometriosis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Not contributory. <PHYSICAL EXAM> ADMISSION ___ Age: ___ 2d Fund Ht: 39 Pres: Vertex FHR: 140 Fetal Act: Present BP: 104/74 Weight: 147 Notes: P Gen: NAD Pulm: nl work of breathing Abd: soft, gravid, nontender Ext: nontender w/o edema SVE: 1/long/-3/soft/mid DISCHARGE Vitals : BP: 132/75 HR: 52 RR: 16 O2 sat: 94% General: NAD, A&Ox3 CV: RRR, no m/r/g Lungs: No respiratory distress, CTAB Abd: soft, nontender, fundus firm at 1 cm below umbilicus Incision: clean, dry, intact, no erythema/induration Lochia: minimal Extremities: no calf tenderness, 2+ edema to thigh b/l Neuro: 2+ reflexes, no clonus <PERTINENT RESULTS> -= ADMISSION LABS -= ___ 03: 07PM BLOOD WBC-14.4* RBC-4.04 Hgb-12.0 Hct-34.8 MCV-86 MCH-29.7 MCHC-34.5 RDW-14.4 RDWSD-44.6 Plt ___ ___ 02: 49PM BLOOD WBC-16.9* RBC-3.65* Hgb-10.6* Hct-31.7* MCV-87 MCH-29.0 MCHC-33.4 RDW-15.0 RDWSD-47.0* Plt ___ ___ 02: 55PM BLOOD Creat-1.0 ___ 02: 55PM BLOOD ALT-10 AST-23 ___ 02: 55PM BLOOD UricAcd-8.6* ___ 08: 04PM URINE Hours-RANDOM Creat-139 TotProt-85 Prot/Cr-0.6* -= OTHER LABS -= ___ 06: 01AM BLOOD WBC-14.7* RBC-3.25* Hgb-9.8* Hct-28.8* MCV-89 MCH-30.2 MCHC-34.0 RDW-14.9 RDWSD-47.9* Plt ___ ___ 06: 01AM BLOOD Glucose-54* UreaN-18 Creat-0.9 Na-142 K-3.9 Cl-105 HCO3-22 AnGap-15 ___ 03: 05PM BLOOD Glucose-84 UreaN-19 Creat-0.7 Na-141 K-5.0 Cl-103 HCO3-26 AnGap-12 ___ 06: 01AM BLOOD ALT-11 AST-26 ___ 03: 05PM BLOOD Calcium-9.0 Phos-4.7* Mg-1.9 -= IMAGING -= Chest X Ray ___: Pulmonary vascular congestion without overt pulmonary edema. Chest X Ray ___: Slight interval increase in mild pulmonary edema. Small bilateral pleural effusions. Transthoracic echocardiogram ___: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Moderate mitral regurgitation. <MEDICATIONS ON ADMISSION> Colace, senna, prenatal vitamins <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain Do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*60 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth bid prn Disp #*60 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*60 Tablet Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain ___ cause drowsiness. Do not drive. Partial fill on request. RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*25 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary low-transverse cesarean section, pre-eclampsia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, Congratulations! Please refer to your discharge packet and the instructions below: - Nothing in the vagina for 6 weeks (No sex, douching, tampons) - No heavy lifting for 6 weeks - Do not drive while taking narcotics (i.e. Oxycodone, Percocet) - Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs - Do not take more than 2400mg ibuprofen in 24 hrs - Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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Ms. ___ is a ___ year old G1P0 (now G1P1) who was admitted to Labor and Delivery at 40 weeks 1 day for induction of labor for advanced maternal age, now status post primary low transverse cesarean delivery for second stage arrest complicated by chorioamnionitis and severe preeclampsia. Her induction was carried out with cytotec and Pitocin. She developed chorioamnionitis and was treated with ampicillin and gentamicin intrapartum. She progressed to fully dilated, but was unable to achieve progress with pushing. Operative vaginal devliery and cesarean delivery were discussed with the patient, and she agreed to proceed with primacy cesarean delivery. At 40 weeks 3 days gestational age, she delivered a viable male infant with APGARS 2, 6, and 9; weight 3875 grams. Estimated blood loss was 900 ml. Soon after her delivery, she experienced oxygen desaturation to 93% on room air. Her BPs were in the mild range. Her serum labs were within normal, and a urine protein to creatinine ratio was elevated. Her chest x ray showed vascular congestion without pulmonary edema. She received the diagnosis of preeclampsia. She was given Lasix 10 mg IV twice. The following day, however, she was noted to have pulmonary crackles and an oxygen requirement. A repeat chest x ray showed pulmonary edema, a severe feature. Magnesium was deferred given concern for worsening pulmonary edema. She received an additional 10 mg of Lasix my mouth, with resolution of exam findings. Then again on ___, she again developed crackles and shortness of breath, which improved with 20 mg of Lasix by mouth. An echo was done to evaluate for cardiomyopathy, which showed normal ejection fraction but moderate mitral regurgitation. Throughout her course, her blood pressures were stable and she did not require antihypertensives. Postpartum, she continued on ampicillin, gentamicin, and clindamycin for 24 hours. The remainder of her postpartum course was uncomplicated. Her pain was treated with oral pain medications. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced without incident. By postpartum day 6, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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10912635-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> sent from ATU with nonreassuring fetal testing <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary low transverse cesarean section <HISTORY OF PRESENT ILLNESS> ___ G2P0 at 36w3d GA with T1DM seen three days ago in ATU for decreased fetal movement. Had reactive stress test, ___ BPP. Noticed return of fetal movement during testing and during nest two days. This morning, noted decreased movement again and came in for now bi-weekly ATU testing, which showed a NR non stress test, and ___ BPP (-2 for lack of gross fetal movement). Notes improved movement here on L and D. No vaginal bleeding, leaking of fluid, or contractions. <PAST MEDICAL HISTORY> PRENATAL COURSE 1) EDC ___ 2) B-/Ab-/RI/RPRNR/HbsAg- 3) nl FFS, ant pl 4) Screening: low risk ERA, nl AFP, nl fetal echo 4) Issues 1. T1DM - on insulin pump. Hga1c was 5.4% on ___ 2. Enlarged thyroid: normal TSH, followed by endocrine 3. Teen pregnancy: unplanned but highly desired, in school and working. Supportive mother, and husband. Pt is very organized in her care of herself and T1DM. 4. Rh negative: Recieved rhogham ___. EFWs - ___ EFW 753g, 55%, BPP ___. - ___, EFW 75%, AFI 12.2, BPP ___ - ___: EFW 2166g, 60%, AFI 11.5, BPP ___ - ___: EFW 3159g (65%), AFI 17.7cm, BPP ___ - ___: BPP ___ (- 2 for gross movement) OBSTETRIC HISTORY TAB x 1 PAST MEDICAL HISTORY Type 1 DM on pump x ___ asthma as a child SURGICAL HISTORY none <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: T 97.8, HR 97, RR 18, BP 110/69, blood sugar 99 GENERAL: Well appearing LUNGS: CTAB, no wheezing CV RRR ABDOMEN: gravid, soft, nontender EXTREMITIES: NT FHT 140/mod var/+ accels/no decels TOCO irregular electrical activity SVE not done TAUS BPP ___ (-2 for lack of breating), AFI 14.4, vtx, anterior placenta <PERTINENT RESULTS> ___ WBC-8.2 RBC-4.33 Hgb-13.1 Hct-37.2 MCV-86 Plt-183 ___ Hct-39.0 R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> insulin claritin flonase prenatal vitamins DHA <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *30 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> primary C/S <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> light activity, no driving x 2wks
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___ G2P0 with T1DM admitted at 36w1d gestation with BPP ___. . Ms ___ had a reactive NST on arrival to labor and delivery, however, the repeat BPP was ___ (-2 breathing). She was admitted with the plan for repeat testing the following day. However, on hospital day #2, her NST was nonreactive and she underwent an OCT. The OCT was negative and the pitocin was discontinued, however, she had a four minute decel following a contraction. The decision was made to proceed with delivery for nonreassuring fetal testing remote from delivery. She underwent a primary LTCS on ___ at 36+4 weeks gestation. Liveborn male delivered from ___ weighing 3505g and apgars of 9 and 9. Please see operative report for details. . In regards to her diabetes, ___ consulted and followed her closely. She was continued on her pump and her insulin was titrated per ___ recommendations. She had no postoperative complications and was discharged home on POD#5 in stable condition.
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10912890-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Morphine <ATTENDING> ___. <CHIEF COMPLAINT> Right pelvic lymph node seen on PET scan (recurrent ovarian carcinoma) <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy, pelvic washings, extensive right pelvic sidewall adhesiolysis, right pelvic lymph node excision, excision of perirectal cyst <HISTORY OF PRESENT ILLNESS> Ms. ___ has a history of stage IIIC ovarian cancer treated with optimal debulking surgery by Dr. ___, followed by standard chemotherapy. She had been disease free until recently, when her CA-125 was noted to rise slightly. This prompted a CT of the abdomen and pelvis on ___. There was a conglomeration of pericardial lymph nodes measuring 2.4 cm in largest dimension. There was a cystic mass in the pelvis, which had been present for sometime and had been followed. This is thought to be a post-surgical fluid collection. A PET-CT was performed on ___, which demonstrated an FDG avid epicardial lymph node measuring 1.7 cm. There was also an FDG avid right pelvic lymph node measuring 1.1 cm. There were no other abnormalities. The patient underwent fine needle aspiration of the thoracic lymph node, which confirmed poorly differentiated non-small cell carcinoma. She had a CTA of the chest on ___ for a complaint of chest discomfort after the FNA. This revealed no abnormalities. She states that she has had some chest heaviness, which she feels may be related to the enlarged lymph node. She also describes having a bowel movement after each meal ever since her debulking surgery, but this has not changed recently. She had no other complaints. <PAST MEDICAL HISTORY> OB HISTORY: Vaginal delivery x2. GYN HISTORY: Last Pap smear and mammogram were both recently normal. MED HISTORY: Ovarian cancer as above, hypothyroidism SURG HISTORY: Debulking surgery as above, tonsillectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Remarkable for a maternal grandmother who developed ovarian cancer in her ___. There is no history of breast cancer, uterine cancer, or colorectal cancer. She is not ___. <PHYSICAL EXAM> GENERAL: She appeared well. SKIN AND HEENT: Skin and sclerae anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. ABDOMEN: Soft and nondistended and without palpable masses. There was a well-healed vertical midline incision with no evidence of hernia. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was surgically absent. Bimanual and rectovaginal examination was normal. There was no palpable pelvic mass, cul-de-sac nodularity, or intrinsic rectal lesion. The rectal anastomosis was palpated and was normal, approximately 10 cm from the anal verge. <MEDICATIONS ON ADMISSION> Synthroid <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp: *40 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp: *40 Tablet(s)* Refills: *0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 4. Tylenol Extra Strength 500 mg Tablet Sig: ___ Tablets PO every six (6) hours. Disp: *60 Tablet(s)* Refills: *0* 5. Synthroid <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Recurrent ovarian carcinoma <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or return to the hospital if you have: -Increased pain -Redness or unusual discharge from your incision -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -You have been given prescriptions for both tylenol and percocet, if needed. Please be aware that the maximum safe tylenol dose in 24 hours is 4 GRAMS (4000MG). Each tylenol tab is 500mg and each percocet tab contains 325mg. -No intercourse, tampons, or douching for 6 weeks -No heavy lifting or vigorous activity for 6 weeks -You can shower and clean your wound, but do not use perfumed soaps or lotions. Be sure to pat completely dry after washing. -You may resume your regular diet and home medications.
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Dr. ___ is a ___ woman who was admitted after exploratory laparotomy, pelvic washings, extensive right pelvic sidewall adhesiolysis, right pelvic lymph node excision, and excision of perirectal cyst after a significant pelvic lymph node was noted on PET scan, to evaluate for recurrent ovarian cancer. Please see operative note for full details. Her postoperative course was uncomplicated and she was discharged home on POD#2 in stable condition.
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10914743-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Vicodin <ATTENDING> ___ ___ Complaint: Oligohydramnios <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery evacuation of vaginal hematoma <HISTORY OF PRESENT ILLNESS> ___ yo G1 presented for IOL at 40w5d after oligohydramnios noted on antenatal testing. Patient was having routine post dates testing and was noted to have AFI of 3.6 and BPP ___, -2 for breathing. Patient was sent to L&D for induction. Reports intermittent contractions. Denies VB, LOF. +FM. <PAST MEDICAL HISTORY> PNC: *) Dating: ___: ___ by LMP *) Labs: A+ /Ab neg /RPRNR/RI/HbsAg neg/HIV neg/ GBS negative *) Routine: - GTT: wnl - U/S: nl full fetal survey - Genetics: low risk ERA, neg CF - US on ___ EFW 3646g 66% POBHx: G1- current PGynHx: Denies STDs or abnl paps PMH: spinal stenosis, disc herniation PSH: Denies Meds: PNV All: Vicodin-> nausea <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On admission: PE: T 98 HR 68 RR 18 BP 126/82 NAD CTA bilaterally RRR Abd soft, gravid, NT EFW 8lbs by ___, vtx on ultrasound SVE: ___ <PERTINENT RESULTS> ___ 11: 05AM BLOOD WBC-15.5*# RBC-3.10*# Hgb-9.8*# Hct-28.3*# MCV-91 MCH-31.6 MCHC-34.6 RDW-14.0 Plt ___ ___ 09: 31AM BLOOD WBC-7.4 RBC-1.63*# Hgb-5.1*# Hct-15.1*# MCV-93 MCH-31.1 MCHC-33.5 RDW-14.0 Plt ___ ___ 09: 03PM BLOOD WBC-12.5* RBC-4.36 Hgb-13.5 Hct-38.3 MCV-88 MCH-31.0 MCHC-35.2* RDW-14.0 Plt ___ ___ 05: 12PM BLOOD WBC-13.0* RBC-4.35 Hgb-13.3 Hct-38.7 MCV-89 MCH-30.7 MCHC-34.5 RDW-13.9 Plt ___ ___ 09: 03PM BLOOD Creat-0.5 ___ 09: 03PM BLOOD ALT-17 AST-19 ___ 09: 03PM BLOOD UricAcd-4.6 ___ 03: 15PM BLOOD WBC-14.2* RBC-2.91* Hgb-9.3* Hct-26.4* MCV-91 MCH-32.1* MCHC-35.3* RDW-14.2 Plt ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN Pain 2. Bisacodyl ___AILY: PRN Constipation 3. Calcium Carbonate 500 mg PO QID: PRN Dyspepsia 4. Dibucaine 1 Appl TP PRN Pain 5. Docusate Sodium 100 mg PO TID Constipation 6. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg one tablet(s) by mouth q 6 hours Disp #*30 Tablet Refills: *0 7. Milk of Magnesia 30 ml PO DAILY Constipation 8. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain RX *oxycodone 5 mg one tablet(s) by mouth q 4 hours Disp #*20 Tablet Refills: *0 9. Simethicone 80 mg PO QID: PRN Dyspepsia 10. hospital grade electric breast pump hospital grade electric breast pump for indication ineffective latch <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal delivery Vaginal hematoma <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Nothing in the vagina for 6 weeks (no sex, tampons) Call if heavy bleeding, pain not relieved by pain medication or any questions or concerns.
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The patient was induced with pitocin and had an uncomplicated vaginal delivery with a 2 degree perineal laceration repaired in the usual fashion. She was stable on the postpartum floor until she reported severe rectal pain and passed a large amount of blood clots. The patient was hemodynamically stable. However on exam was noted to have a right vaginal sidewall 4-5 cm bulge concerning for a hematoma. On repeat exam, there was some brisk bleeding noted from this area and she was taken to the OR for an exam under anesthesia. On exam, a 4 cm right vaginal sidewall hematoma was identified. The hematoma was evacuated and repaired. An initial HCT after the repair was 15, this was determined to be due to a diluted sample and a repeat HCT was 28. The vaginal packing was removed the following morning. On postpartum day 1, she noted shortness of breath and tachycardia with ambulation. A repeat HCT was stable at 26. She had positive orthostatics and received a 1 liter IVF bolus with improvement of symptoms. The remainder of her recovery was uncomplicated and she was discharged home in good condition on postpartum day 2.
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10918566-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim DS <ATTENDING> ___. <CHIEF COMPLAINT> leaking fluid <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean section <PHYSICAL EXAM> On admission ___ 19: 39Temp.: 98.0°F ___ ___: 97 ___ ___: 100 ___ ___: 92 ___ ___: 96 ___ 19: 59BP: 126/80 (89) Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness On discharge: General: NAD, A&Ox3 CV: RRR Lungs: No respiratory distress, CTAB Abd: soft, nontender, fundus firm below umbilicus Incision: clean, dry, intact, no erythema/induration Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 10: 10AM BLOOD WBC-9.2 RBC-3.24* Hgb-9.5* Hct-29.6* MCV-91 MCH-29.3 MCHC-32.1 RDW-13.9 RDWSD-45.6 Plt ___ ___ 01: 10PM BLOOD WBC-9.3 RBC-3.35* Hgb-9.9* Hct-30.6* MCV-91 MCH-29.6 MCHC-32.4 RDW-13.6 RDWSD-44.3 Plt ___ ___ 06: 50AM BLOOD WBC-16.4* RBC-3.67* Hgb-10.9* Hct-32.2* MCV-88 MCH-29.7 MCHC-33.9 RDW-13.4 RDWSD-43.1 Plt ___ ___ 12: 19AM BLOOD WBC-10.0 RBC-3.91 Hgb-11.6 Hct-34.5 MCV-88 MCH-29.7 MCHC-33.6 RDW-13.5 RDWSD-42.9 Plt ___ ___ 10: 10AM BLOOD Creat-0.9 ___ 01: 10PM BLOOD Creat-0.9 ___ 08: 35AM BLOOD Creat-1.0 ___ 08: 00PM BLOOD Creat-1.4* ___ 06: 50AM BLOOD Creat-1.6* ___ 10: 10AM BLOOD ALT-11 AST-16 ___ 01: 10PM BLOOD ALT-9 AST-19 ___ 06: 50AM BLOOD ALT-8 AST-20 ___ 10: 10AM BLOOD UricAcd-5.2 ___ 01: 10PM BLOOD UricAcd-5.1 ___ 06: 50AM BLOOD UricAcd-7.1* <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild/Fever 2. DiphenhydrAMINE 25 mg PO ONCE MR1 headache Duration: 1 Dose 3. Docusate Sodium 100 mg PO BID 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 5. NIFEdipine (Extended Release) 60 mg PO DAILY RX *nifedipine 60 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills: *1 6. Prochlorperazine 10 mg PO Q6H: PRN headache RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 7. Omeprazole 20 mg PO Q12H <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> primary cesarean section HTN <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> per instruction sheets
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Ms. ___ is a ___ year old G1P1 with a history of congenital pulmonic stenosis who underwent a primary low transverse cesarean section on ___ for arrest of dilation. Her post operative and post partum course were complicated by gestational hypertension and obstructive acute kidney injury (___). Regarding her history of congenital pulmonic stenosis, patient had no issues. She was kept on telemetry one day postpartum, which was discontinued given lack symptoms. Regarding her gestational hypertension, patient was initially noted to have mild range blood pressures intrapartum. She also reported a headache that improved after Tylenol, motrin, compazine. Labs were notable for Cr 1.6 on ___. This was attributed to an obstructive ___ rather than pre-eclampsia. Her ___ rapidly improved after delivery, where her final creatinine was 0.9 (___). Patient's urine P:C was not able to be analyzed as it was contaminated. Throughout her hospital stay, Ms. ___ needed to be started on antihypertensive medications given slowly rising BPs. She initially started with labetalol 200mg TID (___), then labetalol 600mg q8hr (___). Given a non sustained severe range on ___, labetalol was discontinued and nifedipine 30mg QD was started. In the ___ of ___, patient continued to have higher range BPs and so her nifedipine was uptitrated to 60mg BID. By post operative day 8, patient had stable vitals. She mets all her post operative milestones and thus was discharged to home with precautions.
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10920368-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Latex <ATTENDING> ___. <CHIEF COMPLAINT> nausea, vomit, diarrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> On admission: ___ yo G2P1 at 6w1d by LMP with nausea, vomiting, and diarrhea since ___. She was seen in Gyn Triage on ___ and was hydrated and able to tolerate PO. She then went home but has had dry heaves and continued diarrhea (orange-brown, nonbloody) each time she drinks or eats anything. She last tried a little water at 3: 30am. She is also feeling some heartburn and upper abdominal cramping pain from throwing up so much. She denies any vaginal bleeding, fever, chills, chest pain, SOB, dizziness. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP (___) - A+/Ab- - TVUS ___ by radiology showed likely IUP with ___, hint of YS, no fetal pole or HR yet. Repeat US scheduled ___ OBHx: - G1: SVD, 6#15 - G2: current GynHx: - Denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - Dystonia - Hypothyroidism - Rheumatoid arthritis - Fibromyalgia PSH: - LSC CCY Meds: Levothyroxine 25 mcg MTWT, PNV, Propranolol for HA All: Latex <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Physical Exam on admission: VS: T 98.0 HR 121 BP 125/88 RR 20 Gen: NAD HEENT: MM dry CV: RRR, slightly tachycardic Pulm: CTAB Abd: +BS, Obese, soft, mild epigastric tenderness, no rebound or guarding Ext: nontender Physical Exam on discharge: VS: AVSS Gen: NAD CV: RRR Pulm: CTAB Abd: +BS, Obese, soft, no epigastric tenderness with palpation, no rebound or guarding Ext: nontender <PERTINENT RESULTS> ___ 02: 46PM BLOOD WBC-12.8* RBC-4.07* Hgb-12.4 Hct-38.2 MCV-94 MCH-30.4 MCHC-32.4 RDW-13.8 Plt ___ ___ 02: 46PM BLOOD Neuts-80.0* Lymphs-14.3* Monos-4.9 Eos-0.6 Baso-0.2 ___ 07: 42AM BLOOD ___ PTT-31.9 ___ ___ 07: 42AM BLOOD ___ ___ 02: 46PM BLOOD Glucose-199* UreaN-9 Creat-0.7 Na-138 K-3.5 Cl-105 HCO3-25 AnGap-12 ___ 02: 46PM BLOOD ALT-164* AST-69* AlkPhos-77 Amylase-49 TotBili-0.5 ___ 02: 46PM BLOOD Lipase-102* ___ 02: 46PM BLOOD Calcium-9.0 Phos-2.3* Mg-1.7 ___ 07: 42PM BLOOD %HbA1c-5.2 eAG-103 ___ 07: 42AM BLOOD TSH-1.8 ___ 07: 42AM BLOOD Free T4-1.2 ___ 04: 50PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE ___ 04: 50PM BLOOD HCV Ab-NEGATIVE ___ 04: 50PM BLOOD HEPATITIS E ANTIBODY (IGG)-neg ___ 04: 50PM BLOOD HEPATITIS E ANTIBODY (IGM)-neg . ___ 08: 35AM BLOOD WBC-12.5* RBC-4.53 Hgb-13.7 Hct-43.0 MCV-95 MCH-30.1 MCHC-31.7 RDW-13.9 Plt ___ ___ 08: 35AM BLOOD Neuts-78.3* Lymphs-14.7* Monos-4.7 Eos-1.8 Baso-0.4 ___ 08: 35AM BLOOD Glucose-75 UreaN-5* Creat-0.6 Na-138 K-4.5 Cl-107 HCO3-20* AnGap-16 ___ 08: 35AM BLOOD ALT-126* AST-43* ___ 08: 35AM BLOOD Calcium-8.3* Phos-2.0* Mg-2.1 . ___ 07: 27AM BLOOD WBC-12.6* RBC-4.61 Hgb-14.3 Hct-43.3 MCV-94 MCH-31.1 MCHC-33.1 RDW-13.7 Plt ___ ___ 08: 30AM BLOOD Neuts-81.1* Lymphs-13.5* Monos-4.0 Eos-1.3 Baso-0.1 ___ 07: 27AM BLOOD Glucose-109* UreaN-6 Creat-0.7 Na-138 K-4.0 Cl-106 HCO3-20* AnGap-16 ___ 07: 27AM BLOOD ALT-139* AST-60* ___ 07: 27AM BLOOD Lipase-119* ___ 07: 27AM BLOOD Calcium-9.1 Phos-2.1* Mg-2.0 . Imaging ___: transabdominal US: Normal abdominal ultrasound. ___: early OB US: Single live IUP measuring size one week less than dates. <MEDICATIONS ON ADMISSION> -Propranalol 10 BID (for headaches and recently elevated BPs) -Synthroid 25' ___, ___' ___ -was taking Prednisone and sulfasalazine for Rheumatoid arthritis <DISCHARGE MEDICATIONS> 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain: do not take more than 4000 mg of acetaminophen within 24 hrs. 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for Dyspepsia. 3. propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO MON, TUE, WED, ___ (). 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO FRI, SAT, SUN (). 6. loperamide 2 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for diarrhea: Do not take more than 16 mg of loperamide within 24 hrs. . Disp: *30 Capsule(s)* Refills: *0* 7. 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: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> nausea/vomit/diarrhea/epigastric pain/elevated lipase and liver function enzymes likely due to viral gastric illness <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 antepartum service for nausea, vomit, diarrhea, and epigastric pain. We obtained labs and followed them throughout your hospital stay because lipase and liver function enzymes were elevated. Stool cultures were sent and all results were negative except Norovirus (it was pending at the time of discharge, you can call ___ for the result in a few days). You also had a right upper quadrant ultrasound, which did not show any abnormalities. You had a pelvic ultrasound to evaluate your pregnancy on ___, it showed a single intrauterine pregnancy with fetal heart rate of 127 beats per minute. Throughout your hosptial stay, you received IV fluid, eletrolytes were repleted as needed, Imodium was started for the diarrhea after your lab tests showed reassuring result, and your diet was advanced slowly to a BRAT diet. Please stay hydrate and call if any concerns.
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___ G2P1 with diarrhea,epigastric pain and transaminitis of unknown etiology, admitted to the antepartum service with GI consultation. The patient was uncomfortable , but did not appear acutely ill. Pt had diarrhea but nausea/vomit improved with bowel rest. She was tender in the midepigastrium, this was improved with PPI. Her labs were consistent with a mild hepatitis but all viral hepatitis serologies were negative. Pt's abdominal ultrasound was negative and no evidence of any serious liver or pancreatic disease. Of note, she stoppped her RA meds including sulfasalazine and prednisone 2.5 mg when she learned she was pregnant at the advice of her rheumatology specialist. Her RA has not flared. Her symptoms were most likely due to viral infection. Her labs were followed throughout her hospital stay because lipase and liver function enzymes were elevated. Stool cultures were sent and all results were negative except Norovirus (it was pending at the time of discharge). Throughout her hosptial stay, pt received IV fluid and eletrolytes were repleted as needed, Imodium was started for the diarrhea after lab tests showed reassuring result, and her diet was advanced slowly to a BRAT diet. Given labs were stable and pt was able to tolerate the BRAT diet on hospital day #6, she was discharged home and instruction to follow up as outpatient.
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10920406-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Adenomyosis, endometrioma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparoscopy, laparoscopic total hysterectomy, left salpingo-oophorectomy, right salpingectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ woman with a history of dysfunctional uterine bleeding and imaging studies which suggest the possibility of adenomyosis. The patient had her most recent ultrasound on the ___ and this revealed a complex cyst in the left ovary, which "likely represented a hemorrhagic corpus luteum or the possibility of an endometrioma. Ms. ___ does continue to report having pelvic discomfort as well as upper abdominal "bloatedness". <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: She denies any history of asthma, hypertension, thromboembolic disorder, or mitral valve prolapse. She is up-to-date with respect to mammography. PAST SURGICAL HISTORY: She has had three to ? four laparoscopies for endometriosis as well as infertility. She had an RSO in ___. She also had three cesarean sections, 3, 5, and ___ years ago. She denies any history of abnormal Pap smears. OB/GYN HISTORY: Her last Pap smear was obtained in ___ and was normal. She did receive infertility medications for a year and a half and was on oral contraceptives for ___ years because of endometriosis. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports a paternal grandfather with lung cancer as well as two uncles on her upper grandfather on her father's side with lung cancer. No other family history of cancer. <PHYSICAL EXAM> GENERAL: She appears her stated age, in no apparent distress. HEENT: Normocephalic, atraumatic. Oral mucosa without evidence of thrush or mucositis. Eyes. Sclerae are anicteric. NECK: Supple, no masses, no evidence of thyromegaly. LYMPHATICS: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. CHEST: Lungs clear bilaterally. HEART: Regular rate and rhythm. I appreciate no murmurs today. BACK: No spinal or CVA tenderness. ABDOMEN: Soft, nontender, nondistended. There is no palpable mass. Previous incisions are noted. EXTREMITIES: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. PELVIC: Normal external genitalia. The inner labia minora is normal. The urethral meatus is normal. Speculum was placed and normal vaginal canal was seen. Walls of vagina are smooth. The cervix is normal. Bimanual exam reveals a normally sized anteverted uterus, mildly tender to palpation, no palpable masses. There is no evidence of rectal mass on exam. <PERTINENT RESULTS> ___ 05: 20PM HCT-28.8* <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *40 Tablet(s)* Refills: *0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *30 Tablet(s)* Refills: *2* 4. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp: *40 Tablet(s)* Refills: *0* 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal BID (2 times a day) as needed. Disp: *20 Suppository(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Adenomyosis and endometrioma <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or return to the hospital if you have: -Increased pain -Redness or unusual discharge from your incision -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -No intercourse, tampons, or douching for 6 weeks -No heavy lifting or vigorous activity for 6 weeks -You can shower and clean your wound, but do not use perfumed soaps or lotions. Be sure to pat completely dry after washing. -You may resume your regular diet and home medications
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Ms. ___ is a ___ yr old woman who was admitted after undergoing exploratory laparoscopy, laparoscopic total hysterectomy, left salpingo-oophorectomy, right salpingectomy, and cystoscopy for adenomyosis and left ovarian cyst noted to be benign on frozen pathology examination. Pt has a history of iron deficiency anemia and felt lightheaded on POD#0. Although it was felt to be likely secondary to anesthesia, a hct was checked and found to be 28.8. There was no baseline hct on record. PO iron was started, which the patient will continue upon discharge. Due to significant nausea and pain control issues on POD#1, pt remained in house until POD#2, at which point she was stable for discharge home.
| 1,130
| 164
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10921265-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> D+C <HISTORY OF PRESENT ILLNESS> ___ G5P1 five weeks postpartum with normal vaginal bleeding "like a period" until this week and has had three large gushes of blood over the past week. The first two were minor, but yesterday at 3pm she had heavy, flowing blood and clots for some time and felt dizzy and lightheaded. No CP/SOB/palpitations. Went to outside hospital ED where her Hct was 22% and an ultrasound suggested retained products of conception. Her bleeding stabilized on its own and she was transfered to ___ for further management. Of note, after her vaginal delivery 5 weeks ago, pt required manual removal of the placenta. Hematocrit was 20.8% at the time of discharge from the hospital. Pt refused blood transfusion at that time. Has not been taking her prescribed iron. <PAST MEDICAL HISTORY> OBHx: SAB x 2, TAB x 2, SVD noted above GYNhx: regular menses, no STI's, no abnl paps (though h/o HPV/ warts), infertility PMH: depression PSH: D&C x 2, hand surgery, diagnostic laparoscopy <SOCIAL HISTORY> ___ <FAMILY HISTORY> None contributory <PHYSICAL EXAM> <PHYSICAL EXAM> Vitals: Temp: 98 HR: 85 BP: 108/55 Resp: 12 O(2)Sat: 100% on RA General: Asleep, arousable CV: RRR Lungs: CTAB Abd: soft, nontender Ext: NT Pelvic: small amt of dried blood on perineum, pad moderately stained, uterus small, AV, mobile, nontender, external os ~fingertip dilated, no blood in vault; SSE deferred as not bleeding at the time of exam <PERTINENT RESULTS> ___ 11: 50PM GLUCOSE-95 UREA N-10 CREAT-0.8 SODIUM-139 POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-22 ANION GAP-11 ___ 11: 50PM WBC-9.2# RBC-2.46* HGB-6.9* HCT-20.5* PLT COUNT-369 ___ 11: 50PM NEUTS-61.8 ___ MONOS-5.6 EOS-4.0 BASOS-0.5 ___ 11: 50PM ___ PTT-23.4 ___ ___ 07: 02AM WBC-6.5 RBC-2.27* HGB-6.2* HCT-19.3* PLT COUNT-354 ___ 06: 12AM HGB-6.3* calcHCT-19 ___ TUVS: Hyperechoic heterogenous endometrium measuring up to 2.2cm with increased color flow most compatible with retained products. <MEDICATIONS ON ADMISSION> PNV, ibuprofen <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> retained POC D+C <DISCHARGE CONDITION> stable Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Take your medications as prescribed. Do not drive while taking Percocet. Nothing in vagina (no tampons, no douching, no intercourse) for 3 weeks.
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Pt's pelvic ultrasound demonstrated retained products of conception in the context of manual removal of placenta and chorioamnionitis at delivery five weeks ago. Her lab result showed blood loss anemia with HCT of 19.3. Recommended to pt to transfuse 2 units pRBCs, and discussed rationale behind transfusing at hematocrit of <21%, her dizziness with ambulation, and risks of blood transfusion. Pt refused and understood that should she lose more blood either before or during her D&C, she would likely need the transfusion. In order to remove the retained products of conception, pt undergone D&C. The surgery was uneventful, please see Dr. ___ report for details. Pt recovered well from the procedure, and she was discharged 4 hours later in stable condition: afebrile, minimum vaginal bleeding, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty.
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10922167-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right upper quadrant and epigastric pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ F G1PO who presented at 29 weeks +5d gestation age presents with epigastric and abdominal pain since the night prior. She ate pizza for dinner and around 11 ___ developed pain associated with 3 bouts of non-bilious non-bloody emesis. She vomited again several hours later and she presented to the ED. Her LFT's and lipase are WNL. <PAST MEDICAL HISTORY> PMH: small liver hemangiomas, myocarditis ___, Fibroid, ovarian cysts PSH: ear surgery/infections, rhinoplasty ___: prenatal vitamins <ALLERGIES> NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Initial PE T 98 BP 111/64 HR 110 RR 18 CV: rrr w/o m/g/r Chest: CTA B Abd: gravid, soft, tender with light palpation of lower sternum to epigastric area, not worse with deep palpation, no rebound or guarding. Back: - CVAT, tender/sore R mid (same as past) Ext: -edema B EFM: 135 ___, mod variability, +accels, no decels, reactive. Toco: no contractions <PERTINENT RESULTS> ___ 07: 05AM BLOOD WBC-9.6 RBC-3.23* Hgb-10.7* Hct-30.9* MCV-96 MCH-33.2* MCHC-34.7 RDW-13.9 Plt ___ ___ 06: 20AM BLOOD WBC-13.4* RBC-3.64* Hgb-11.7* Hct-34.4* MCV-95 MCH-32.0 MCHC-33.9 RDW-13.6 Plt ___ ___ 07: 05AM BLOOD Neuts-73.6* Lymphs-16.8* Monos-7.3 Eos-1.9 Baso-0.5 ___ 06: 20AM BLOOD Neuts-90.5* Lymphs-6.6* Monos-2.4 Eos-0.3 Baso-0.2 ___ 06: 30AM BLOOD Glucose-75 UreaN-5* Creat-0.4 Na-141 K-3.8 Cl-107 HCO3-26 AnGap-12 ___ 06: 20AM BLOOD Glucose-143* UreaN-7 Creat-0.4 Na-141 K-4.1 Cl-103 HCO3-24 AnGap-18 ___ 06: 20AM BLOOD ALT-17 AST-20 AlkPhos-124* TotBili-0.2 ___ 06: 30AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.7 ___ 06: 20AM BLOOD Albumin-3.7 Calcium-9.3 Phos-5.0* Mg-1.7 ___ 08: 30AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08: 30AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 08: 30AM URINE Hours-RANDOM Creat-55 TotProt-12 Prot/Cr-0.2 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth every twelve (12) hours Disp #*28 Tablet Refills: *0 PNV <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cholecystitis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted for management of suspected cholecystitis. You have recovered well and the surgery team believes you are stable to be discharged home.
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On ___ Ms. ___ was admitted to the antepartum service. A consultation with general surgery was obtained and they believed that Ms. ___ had cholecystitis. Ampicillin/ sulbactam was started and she was kept NPO with IVF. Fetal status remained reassuring. Ms. ___ remained afebrile and her pain improved. Her diet was slowly advanced to a low fat diet which she tolerated well. She was then transitioned to PO antibiotics. She was then discharged home with close follow up scheduled.
| 1,029
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10924951-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Headache, feeling unwell <MAJOR SURGICAL OR INVASIVE PROCEDURE> 24 hour urine collection <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 32+6 WGA with multiple complaints. She has been seen multiple times with contractions and is currently home on bedrest. Over the past few days, she has felt generally unwell. Her symptoms are vague but when asked she describes CP, SOB, RUQ pain, and HA unresponsive to Tylenol. She has also felt more "puffy" in her face and lower extremities. Denies visualize changes. She still has contractions but they are non-painful and at her baseline. +AFM. No VB, LOF. PNC: 1) Dating: EDC ___ 2) Labs: A+, antibody neg, RPR NR, rubella immune, HbsAg NR 3)Issues with this pregnancy: 1. preterm contractions, 2. short cervix and funneling. Was getting serial cervical lengths but stopped after dilated. Last EFW 1832g (34%). 3. Elevated GLT, nl GTT <PAST MEDICAL HISTORY> OB Hx: G1P0 Gyn Hx: Regular menses q28 days. H/o abnormal Pap s/p LEEP in ___. Denies STIs. History of uterine fibroids (right anterior ~4cm and left anterior also ~4cm). PMH: Asthma, h/o wrist fracture PSH: LEEP <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> VS: 98.4 164/87 157/70 160/70 150/70 50 18 Gen: NAD Abd: gravid, soft, nontender SVE: ___ Ext: NT, trace edema b/l EFM: 145 ___, mod variability, +accels, no decels, reactive. Toco: about 3 contractions per hour TAUS: BPP ___, vtx, AFI 12.4 cm, fundal/posterior placenta. <PERTINENT RESULTS> ___ 11: 36AM ALT(SGPT)-54* AST(SGOT)-32 ___ 11: 36AM URIC ACID-3.7 ___ 11: 36AM WBC-12.1*# RBC-3.74* HGB-11.8* HCT-33.9* MCV-91 MCH-31.5 MCHC-34.8 RDW-12.0 ___ 11: 36AM PLT COUNT-167 ___ 11: 36AM CREAT-0.5 ___ 11: 37AM URINE HOURS-RANDOM CREAT-36 TOT PROT-6 PROT/CREA-0.2 <MEDICATIONS ON ADMISSION> PNV, s/p Macrobid for UTI, Tylenol prn <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Gestational Hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedrest. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor if you develop headache not relieved with Tylenol, visual changes, abdominal pain, facial/extremity swelling, >5 painful contractions's in an hour, vaginal bleeding, leakage of fluid, decreased fetal movement or any other concerning symptoms.
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Ms. ___ was admitted to the antepartum service for blood pressure monitoring and a 24 hour urine collection. Her labs were repeated and stable. Her blood pressures were labile and ranged from normal to those seen on admission. Her 24 hour urine was negative with 180 mg of protein. She was diagnosed with gestational hypertension and discharged home on bedrest.
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10925025-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Keflex / Penicillins / Dilaudid (PF) / Morphine Sulfate <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G0 with a history of left sided ovarian torsion presents to gyn triage with acute onset of LLQ pain at 2pm. This pain is sharp/stabbing and constant, not unlike previous torsion episode. At that time, she underwent laparoscopic detorsion but not LSO. Endorses pain with "bumps in road" in transit to triage. She denies F/C, bowel/bladder complaints. Does have nausea, no emesis. No VB, LMP "4 weeks ago". <PAST MEDICAL HISTORY> Ob/gyn hx: h/o multiple ovarian cysts on US's taken for discomfort. h/o left-sided torsion with lsc detorsion as noted. LMP 4 weeks ago. compliant with OCPs. denies h/o abnl pap, STD. presents with male partner. ___: denies PSHx: ___ lsc ovarian detorsion, wrist & knee surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> on admission: T 97.6, HR 95 -> 83, BP 135/82, RR 18, O2 sat 98% RA * tearful, appears uncomfortable, partner at bedside * ___ * CTAB * abdomen soft, nondistended, +TTP in LLQ and midline pelvis, no R/G, no increased pain with shaking of bed * pelvic: normal-appearing cervix without abnormal discharge, no blood in vault * BME: no CMT, no fundal tenderness, +TTP LLQ, no masses noted on discharge: remains afebrile, VSS NAD, comfortable, in no pain ___ CTAB abdomen soft, NT, ND, +bs no vaginal bleeding no edema, extremities warm <PERTINENT RESULTS> ___ 05: 21AM BLOOD WBC-8.1 RBC-4.02* Hgb-12.3 Hct-35.7* MCV-89 MCH-30.7 MCHC-34.6 RDW-12.4 Plt ___ ___ 10: 31PM BLOOD WBC-13.5*# RBC-4.28 Hgb-13.2 Hct-37.8 MCV-88 MCH-30.9 MCHC-35.0 RDW-12.2 Plt ___ ___ 05: 21AM BLOOD Neuts-51.9 ___ Monos-6.0 Eos-4.2* Baso-0.9 ___ 10: 31PM BLOOD HCG-LESS THAN 5 <MEDICATIONS ON ADMISSION> ___ OCP, K, Mg <DISCHARGE MEDICATIONS> none <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> You were in the hospital for abdominal pain and monitored for question of left ovarian torsion. While in the hospital your pain resolved. Please continue to monitor your pain and associated symptoms and call your doctor immediately if they worsen or are associated with the following: 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. ___ is a ___ yo G0 with h/o left sided ovarian torsion who presents with acute onset severe LLQ pain. Afebrile and hemodynamically stable. Gives history of peritoneal signs in transit to triage; exam here notable for LLQ TTP but no acute abdomen. US nondiagnostic for torsion but cannot exclude intermittent torsion. UA neg, hcg neg; slight leukocytosis and thrombocytosis c/w acute phase reactant. She is admitted for serial abdominal exams and analgesia prn. Overnight, her pain greatly improved with minimal pain medication requirement. On hospital day 2, she was well-appearing, in no pain, and remained hemodynamically stable and afebrile. Her white count fell to 8.1. Therefore, she was discharged to home in good condition with follow-up.
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10925136-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Chocolate/Cocoa / Sulfa(Sulfonamide Antibiotics) / bee stings <ATTENDING> ___ <CHIEF COMPLAINT> Fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> robot-assisted total laparascopic hysterectomy <HISTORY OF PRESENT ILLNESS> ___ G2, P2, 0, 0, 3 (twins), premenopausal ___ female with MVP, migraines, fibromyalgia, chronic fatigue syndrome and known uterine fibroids. She presents today to discuss fibroid treatment options in the setting of worsening menometrorrhagia, dysmenorrhea and anemia over the last eight to nine months. Sonohysterogram (___) confirmed an enlarged uterus measuring 12.2 x 7.3 x 8.8 cm with multiple fibroids, one of which had a 30% submucosal component. Normal ovaries bilaterally. <PAST MEDICAL HISTORY> OB History: G2, P1, 1, 0, 3. 1. ___, preterm cesarean delivery for twins. 2. ___, VBAC. GYN History: Menarche age ___. LMP ___. Irregular menses every two to four weeks with seven days of heavy flow and increasing dysmenorrhea for the last eight to nine months. The patient denies any dyspareunia, pain with full bladder or bowel movement. Denies history of abnormal Pap. Last Pap ___, negative for SIL. Last mammogram ___, BI-RADS 1, negative for malignancy. Not currently sexually active, as she is having a difficult relationship with her husband. She is heterosexual, reports three sexual partners throughout life, status post a tubal sterilization for contraception. Denies history of STDs. Medical Problems: 1. Uterine fibroids. 2. Mitral valve prolapse. 3. Fibromyalgia. 4. Chronic fatigue syndrome. 5. Migraines with no aura. Surgical History: 1. ___, diagnostic laparoscopy at ___. 2. ___, C-section for twins. 3. ___, tubal ligation. 4. ___, sinus surgery. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Reports a maternal aunt and cousin with breast cancer. No other GYN cancers in the family. Her mother with diabetes. <PHYSICAL EXAM> General: Pleasant, moderately overweight ___ female, alert & oriented x3, no acute distress. BP 142/81, P 91, WT 230 pounds, HT 5 feet 6 inches. HEENT: normocephalic/atraumatic, anicteric sclera Neck: supple, full range of motion, no thyromegaly or nodules Lymphatic: no palpable neck lymphadenopathy Back: no CVA tenderness Lungs: clear to auscultation bilaterally, good inspiratory effort CV: regular rate and rhythm, no murmurs/rubs/gallops Abd: +bowel sounds, soft, non-tender, non-distended, no R/G Extremities: no clubbing/cyanosis/edema Pelvic: Grossly normal external female genitalia. On bimanual examination, there is an enlarged ___ size fibroid uterus with mild tenderness at the midline consistent with uterine tenderness on deep palpation. No CMT suggesting significant pain. No palpable adnexal masses. On speculum examination, there is a normal midline cervix with a nabothian cyst at 12 o'clock with no unusual bleeding, lesions or discharge. Normal-appearing vaginal vault. No evidence of prolapse. <PERTINENT RESULTS> None. <MEDICATIONS ON ADMISSION> iron 325 BID, gabapentin 300 qhs <DISCHARGE MEDICATIONS> 1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp: *120 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> symptomatic uterine 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. * 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 12 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incisions; no scrubbing of incisions. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor 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 Your blood pressures were mildly elevated while you were in the hospital. Please follow up with your primary care doctor about this.
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Ms. ___ was admitted to the GYN service post-operatively. Please see operative note for full details. She was initially planning to go home on post-op day 0 (POD 0) but was admitted for urinary retention. Post-operatively she did well. By post-operative day one she was able to void spontaneously, control her pain with oral pain medications, ambulate and tolerate a regular diet. She was discharged home in good condition on POD1 with follow-up.
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